NUR 265 Exam 3 Study Guide (2026) | Medical-Surgical Nursing | Galen

NUR 265
EXAM 3 STUDY GUIDE
Medical-Surgical Nursing
Galen College of Nursing

, Nur 265 Exam 3 Study Guide
Increased ICP (939-940, chart 941)
 Normal ICP 10-15 mmHg, pressures >20 mmHg impair cerebral circulation
 Assessment
o First sign of ICP is declining LOC; restlessness or confusion to Stuporous
o Headache – Quite environment may have photophobia so keep room lights very low.
o Aphasia, Slurred Speech
o Changes in pupil size – 2 cm change in either direction is significant, dilated or constricted, Notify Dr
 Uneven pupils ICP until proven otherwise; brain stem
o Decorticate (flexion) or Decerebrate (extensor)
o Hyperthermia – followed later by hypothermia
 When hypothermic – pressure on hypothalamus located next to brain stem
o N/V
o Cushing’s Triad – Severe HTN, Widened Pulse Pressure, Bradycardia
 Late response & indicates severe ICP w/loss of autoregulation, Imminent death
 Systolic BP increases bc decreased blood flow to brain
 Pressure on Vagus nerve and brainstem = bradycardia
 Managing IICP
o Elevate HOB 30-45 degrees (unless contraindicated)
 If hypotension, elevate HOB where CPP >70
o Maintain head in a midline neutral position
o Avoid sudden and acute hip or neck flexion during positioning – Log roll pt
o Avoid clustering of care (bath followed by linen change)
o Coughing and suctioning increase ICP
o Decrease cerebral edema – osmotic diuretics (mannitol) & fluid restriction
 Mannitol is hypertonic- pulling fluid into vascular space- will inc. fluid output & monitor BP for HTN
 Furosemide used in adjunct to reduce incidence of rebound from mannitol. Helps reduce edema &
blood volume, decrease Na uptake by the brain, & decrease production of CSF at choroid plexus.
o LOW CSF using intraventricular drain system
o Control fever w/antipyretics or cooling blanket – do not allow pt to shiver as will increase ICP
 When febrile every cell in body needs more 02 and glucose
o Oxygenation – Hyperventilate on a vent to decrease CO2 which causes vasodilation
o Reduce cellular metabolic demands – barbiturates (-bital, -barbital) and/or sedation (coma)

Traumatic Brain Injury (946-957)
o Glasgow Coma Scale
 Score from 3-15; score 3-8 in a coma
 A change of 2 points requires immediate notification to HCP

 Mild – GCS 13-15 (concussion)
 Blow to head, transient confusion, or feeling dazed or disoriented
 Loss of consciousness for up to 30 min, loss of memory before and after accident
 No evidence of brain damage, sx resolve w/i 72 hrs
 Sx: HA, N/V, Fatigue, Foggy, Balance off, Irritable, Sad, Nervous, Emotional, Visual probs
 Moderate – GCS 9-12
 Loss of consciousness 30 min – 6 hrs w/ memory loss up to 24 hrs.
 Short hospital stay to prevent secondary injury
 Severe – GCS 3-8
 Loss of consciousness >6 hrs
 High risk for secondary brain injury from cerebral edema, hemorrhage, reduced perfusion
 Pupil changes, Bradycardia, Papilledema, HTN w/wide PP, Nuchal rigidity if CSF leak
 Secondary Brain Injury
o Any process that occurs after the initial injury and worsen or negatively influences patient outcomes.
o Most common result from hypotension, hypoxia, ICP, & cerebral edema
 Damage to brain tissue due to delivery of O2 and glucose to brain is interrupted

,  Low blood flow and hypoxemia contribute to cerebral edema
o Hypotension & Hypoxia
 hypotension (MAP <70), hypoxia (PaO2 <80)
 Hypotension may be from shock & hypoxia from resp. failure, loss of airway, or impaired ventilation
o Increased Intracranial Pressure (IICP)
 See Increased ICP section above
o Hemorrhage
 Begins at moment of impact & potentially life threatening
 Epidural Hematoma – Arterial bleeding between dura and inner skull, from fx of temporal bone
 Have “lucid intervals” – Pt awake & talking then momentary unconsciousness
 Subdural Hematoma – Venous bleeding into space beneath dura & above arachnoid
 Acute SDH – w/i 48 hrs after impact
 Subacute SDH – 48 hrs – 2 weeks
 Chronic SDH – 2 weeks to several months
 A loss of consciousness from an epidural or subdural hematoma is a neurological emergency!
o Hydrocephalus – abnormal increase in CSF volume
 Caused by impaired reabsorption or blockage with outflow of CSF, leads to ICP
o Brain Herniation
 Central – Down shift brain stem – Cheyne-Stokes, Pinpoint & nonreactive pupils, hemodynamic
instability. NOTIFY PHYSICIAL IMMEDIATELY
 Assessment/Interventions
o Hx – Did pt lose consciousness? Drug or alcohol consumption? All screened for abuse/neglect
o Physical
 First priority is assessment of ABCs - Report any sign of respiratory problems immediately!
 Suspect neck injury until proven otherwise, stabilize w/ C-Collar and backboard
 Skin breakdown & pressure ulcer formation are concern with spine board & c-collar
 Once board removed, spinal precautions maintained until HCP indicates it is safe
o (1) Bedrest; (2) No neck flexion with a pillow or roll; (3)No thoracic or lumbar flexion
w/HOB elevation (reverse T acceptable); (4) Manual control of C spine anytime collar
removed; (5) Log roll
 Prevent secondary brain injury – O2 & lowering ICP, Vent if needed, do not want CO2 to rise as it
causes vasodilation & IICP.
o Vital Signs
 Monitor VS Q 1-2 hrs – May be hypotensive or hypertensive (IV fluids to maintain above 90)
 Central fever caused by hypothalamic damage – no sweating, high, last days-weeks
 Responds better to cooling (sponge bath, cool air)
 Fever from any cause is associated w/higher mortality rates
 Cushing’s Triad – HTN, Wide PP, & Bradycardia – late sign of IICP and indicates imminent death
 Hypotension and tachycardia indicate hypovolemic shock
o Neuro
 GCS
 Most important variable to assess w/any brain injury is LOC
 Dec or change in LOC is first sign of deterioration (behavior changes, restlessness, disorientation)
 Assess pupils
 Pinpoint - & nonresponsive – Brainstem dysfunction @ level of ponds
 Asymmetric, loss of light reaction, unilateral or bilateral dialed – herniation
o Late signs of IICP – severe HA, N/V, seizures, papilledema - always sign of IICP
 Motor response - Decorticate or Decerebrate posturing
o Psychosocial
 Personality changes – temper outbursts, depression, risk-taking, denial, talkative, outgoing
o Therapeutic Hypothermia
 Rapidly cool pt to 89.6 – 93.2 for 24-48 hrs after primary injury to reduce brain metabolism and reduce
secondary brain injury.
o Mechanical ventilation
 Maintain PaCO2 at 35 to 38 to prevent IICP from vasodilation from CO2
 Maintain PaO2 between 80-100 to prevent secondary injury