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Nur 265 Exam 3 Study Guide 2025
Increased Icp (939-940, Chart 941)
• Normal Icp 10-15 Mmhg, Pressures >20 Mmhg Impair Cerebral Circulation
• Iicp Is Leading Cause Of Death From Head Trauma In Pts Who Reach The Hospital Alive.
• Cerebral Perfusion Pressure (Cpp) O Blood Flow Required To Provide Adequate Oxygenation & Glucose For Brain
Metabolism O Maintenance Above 70 Mmhg O Cpp= Map-Icp
Map= (2xd) + S Map Needs To Be Atleast 80
3
• Compensation
o First Response – Csf Is Shunted Or Displaced Into The Spine (Compliance) O Next –
Reduction Of Blood Volume In The Brain (Autoregulation)
o As Icp Continues To Increase Cerebral Perfusion Decreases Leading To Brain Tissue
Ischemia, Edema, Vasodilation Then Acidosis Which Causes Further Increases Icp
o In Edema Remains Untreated The Brain May Herniate Into Spinal Canal – Death From Brain
Stem Compression
• Assessment Findings O Changes In Loc – First Sign Of Iicp Is Declining Loc & Includes Restlessness Or Confusion To
Stuporous
W/O Glucose & 02, Brain Shuts Down. Ex. Pt Knew Who You Were In Am & Now Don’t Remember
O Headache – Quite Environment May Have Photophobia So Keep Room Lights Very Low.
o Change In Speech Pattern – Aphasia, Slurred Speech O Changes In Pupil Size – 2 Cm
Change In Either Direction Is Significant, Dilated Or Constricted, Notify Dr
Normal Is 6 Mm. Getting Better If Going Back Toward Normal From Dilated Or Constricted
Uneven Pupils Tx As Iicp Until Proven Otherwise; Pinpoint - Brain Stem (Pons) Dysfunction O
Abnormal Posturing – Decorticate (Flexion) Or Decerebrate (Extensor)
Decorticate – Arms Drawn To Core, Legs Straight
Decerebrate – Arms Straight And Stiff, Pts Rarely Survive O Hyperthermia – Followed Later By
Hypothermia
When Hypothermic – Be Concerned, Pressure On Hypothalamus Located Next To Brain Stem O
Cardiac & Respiratory Rate/Rhythm Changes
Tachy First – Increased Hr & Rr Before Brady Hr & Rr O N/V – Common In Iicp
o Cushing’s Triad – Severe Htn, Widened Pulse Pressure, Bradycardia
Late Response & Indicates Severe Iicp 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
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o Oxygenation – Hyperventilate On A Vent To Decrease Co2 Which Causes Vasodilation O
Reduce cellul n (coma)
T
raumatic Brain Injury (946-957)
• Primary Brain Injury O Occurs At Time Of Injury
o Open – Head Fractured Or Penetrated; Closed – Blunt Trauma, Shaken Baby O Open Head
Injuries
Skull Fractures
• Linear Fx – Thin Line On X-Ray, No Tx Unless Underlying Brain Tissue Damaged
• Depressed Fx – Brain Damage From Bruising (Contusion), Laceration From Bone Fragments Basilar Skull Fx – Fx Of
Bones Of The Base Of Skull & Results In Csf Leak From Nose & Ears. O May Not Be Seen On Plain X-Ray, R/F Infection
W/ Csf Leak
o Manifested By Bruises Around Eyes(Raccoon Eyes) Or Behind Ears (Battle’s
Sign) O Has Potential For Hemorrhage If It Damages The Internal Carotid
o Closed Head Injuries
Caused By Blunt Force Trauma
Contusion – Bruising To Brain Tissue @ Site Of Impact (Coup) Or Opposite (Contercoup)
Laceration – Tearing Of The Cortical Surface Vessels, Lead To Secondary Hemorrhage,
Cerebral Edema And Inflammation
Diffuse Axonal Injury (Dai) – Tissue Of Entire Brain From High Speed Acel/Decel Mvc
• Impaired Cognitive Functioning, Results In Disorganization, Impaired Memory
• Severe Will Present With Immediate Coma, Survivors Require Lone-Term Care
o Classified As
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 Memory Loss Up To 24 Hrs.
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
o Glasgow Coma Scale
Score From 3-15; Score 3-8 In A Coma
A Change Of 2 Points Requires Immediate Notification To Hcp
• Secondary Brain Injury O Any Process That Occurs After The Initial Injury And
Worsen Or Negatively Influences Patient Outcomes.
While Trying To Recover From Initial Event, Something Else Happens (Ex: Meningitis)
O Most Common Result From Hypotension, Hypoxia, Iicp, & 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)
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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
• From Laceration Of Brain Tissue, Bleeding Is Slower Than Epidural, Highest Mortality Rate
• 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 Iicp O Brain Herniation
Uncus- Dilated Non-Reactive Pupils, Ptosis, Decreased Loc
Central – Down Shift Brain Stem – Cheyne-Stokes, Pinpoint & Nonreactive Pupils, Hemodynamic
Instability. Notify Physicial Immediately
• Etiology O Young Males, Play More Sports, Take More Risks When Driving
(Mvc) , Consume More Alcohol O Falls Most Common In Older Adults.
• 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
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Nur 265 Exam 3 Study Guide 2025
Increased Icp (939-940, Chart 941)
• Normal Icp 10-15 Mmhg, Pressures >20 Mmhg Impair Cerebral Circulation
• Iicp Is Leading Cause Of Death From Head Trauma In Pts Who Reach The Hospital Alive.
• Cerebral Perfusion Pressure (Cpp) O Blood Flow Required To Provide Adequate Oxygenation & Glucose For Brain
Metabolism O Maintenance Above 70 Mmhg O Cpp= Map-Icp
Map= (2xd) + S Map Needs To Be Atleast 80
3
• Compensation
o First Response – Csf Is Shunted Or Displaced Into The Spine (Compliance) O Next –
Reduction Of Blood Volume In The Brain (Autoregulation)
o As Icp Continues To Increase Cerebral Perfusion Decreases Leading To Brain Tissue
Ischemia, Edema, Vasodilation Then Acidosis Which Causes Further Increases Icp
o In Edema Remains Untreated The Brain May Herniate Into Spinal Canal – Death From Brain
Stem Compression
• Assessment Findings O Changes In Loc – First Sign Of Iicp Is Declining Loc & Includes Restlessness Or Confusion To
Stuporous
W/O Glucose & 02, Brain Shuts Down. Ex. Pt Knew Who You Were In Am & Now Don’t Remember
O Headache – Quite Environment May Have Photophobia So Keep Room Lights Very Low.
o Change In Speech Pattern – Aphasia, Slurred Speech O Changes In Pupil Size – 2 Cm
Change In Either Direction Is Significant, Dilated Or Constricted, Notify Dr
Normal Is 6 Mm. Getting Better If Going Back Toward Normal From Dilated Or Constricted
Uneven Pupils Tx As Iicp Until Proven Otherwise; Pinpoint - Brain Stem (Pons) Dysfunction O
Abnormal Posturing – Decorticate (Flexion) Or Decerebrate (Extensor)
Decorticate – Arms Drawn To Core, Legs Straight
Decerebrate – Arms Straight And Stiff, Pts Rarely Survive O Hyperthermia – Followed Later By
Hypothermia
When Hypothermic – Be Concerned, Pressure On Hypothalamus Located Next To Brain Stem O
Cardiac & Respiratory Rate/Rhythm Changes
Tachy First – Increased Hr & Rr Before Brady Hr & Rr O N/V – Common In Iicp
o Cushing’s Triad – Severe Htn, Widened Pulse Pressure, Bradycardia
Late Response & Indicates Severe Iicp 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
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
o Oxygenation – Hyperventilate On A Vent To Decrease Co2 Which Causes Vasodilation O
Reduce cellul n (coma)
T
raumatic Brain Injury (946-957)
• Primary Brain Injury O Occurs At Time Of Injury
o Open – Head Fractured Or Penetrated; Closed – Blunt Trauma, Shaken Baby O Open Head
Injuries
Skull Fractures
• Linear Fx – Thin Line On X-Ray, No Tx Unless Underlying Brain Tissue Damaged
• Depressed Fx – Brain Damage From Bruising (Contusion), Laceration From Bone Fragments Basilar Skull Fx – Fx Of
Bones Of The Base Of Skull & Results In Csf Leak From Nose & Ears. O May Not Be Seen On Plain X-Ray, R/F Infection
W/ Csf Leak
o Manifested By Bruises Around Eyes(Raccoon Eyes) Or Behind Ears (Battle’s
Sign) O Has Potential For Hemorrhage If It Damages The Internal Carotid
o Closed Head Injuries
Caused By Blunt Force Trauma
Contusion – Bruising To Brain Tissue @ Site Of Impact (Coup) Or Opposite (Contercoup)
Laceration – Tearing Of The Cortical Surface Vessels, Lead To Secondary Hemorrhage,
Cerebral Edema And Inflammation
Diffuse Axonal Injury (Dai) – Tissue Of Entire Brain From High Speed Acel/Decel Mvc
• Impaired Cognitive Functioning, Results In Disorganization, Impaired Memory
• Severe Will Present With Immediate Coma, Survivors Require Lone-Term Care
o Classified As
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 Memory Loss Up To 24 Hrs.
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
o Glasgow Coma Scale
Score From 3-15; Score 3-8 In A Coma
A Change Of 2 Points Requires Immediate Notification To Hcp
• Secondary Brain Injury O Any Process That Occurs After The Initial Injury And
Worsen Or Negatively Influences Patient Outcomes.
While Trying To Recover From Initial Event, Something Else Happens (Ex: Meningitis)
O Most Common Result From Hypotension, Hypoxia, Iicp, & 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)
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
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
• From Laceration Of Brain Tissue, Bleeding Is Slower Than Epidural, Highest Mortality Rate
• 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 Iicp O Brain Herniation
Uncus- Dilated Non-Reactive Pupils, Ptosis, Decreased Loc
Central – Down Shift Brain Stem – Cheyne-Stokes, Pinpoint & Nonreactive Pupils, Hemodynamic
Instability. Notify Physicial Immediately
• Etiology O Young Males, Play More Sports, Take More Risks When Driving
(Mvc) , Consume More Alcohol O Falls Most Common In Older Adults.
• 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
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