Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
♡ Exam 3: advanced med surg ♡
Neurological
Diagnostic tests:
o ALWAYS assess LOC when assessing Neuro
o Glascow Coma Scale= should be 15
o Pupil Assessment= pupil size
o Orientation to person, place and time= decreased LOC is a sign of
brain issue.
o Doll’s eyes= sign of brain issue
Glasgow coma scale
o A score of 10 or less indicates a need for emergency attention
o A score of 7 or less is generally interpreted as coma
o Normal we know is 15, if the number is going down that is a sign that
the patient is declining.
Posturing
o Abnormal posturing: means you know there’s a brain issue
o Decorticate posture – Flexor, Decerebrate posture – Extensor, damage
to midbrain/pons
Traumatic head injury
Death usually occurs at 3 points:
o Immediately with injury
o Within 2 hours after injury
o 3 weeks after injury
o Don’t want them to go to sleep if they hit their head
o Patients with visual issues are at risk for brain injury= due to falls or
hitting something.
o Brain injury depends on Force and type: car accident, baseball, bullet,
fell, sports.
Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
,Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
Categorization
o Direct blow to head
o Indirect from brain being jarred against interior of skull
o Coup-Contrecoup= get hit in front of head but injury is in the back of
the skull.
o Closed (skull isn’t open) vs Open (skull is open) = closed is worse
because of ICP.
o Primary (happened right away, occurs at time of injury and results from
physical stress within the tissue caused by blunt force) vs. secondary
(happened after some time)
Classification per GCS
o Mild–GCS 13-15: Concussion or Mild TBI - Feeling dazed AND possible
loss of consciousness for up to 30 minutes or loss of memory for
events before accident or focal neurological deficits. Resolves within 72
hours. (CAN have Tylenol, but CANNOT have melatonin, morphine,
alcohol, benzodiazepines, NSAIDS because causes bleeding, or any
other CNS depressants) should not see any drainage from nose (sign of
CSF leak, check by doing halo sign= glucose in drainage) or be
confused for days.
o Moderate-GCS 9-12 with up to 6 hr. loss of consciousness. Lasts up to
24 hours.
o Severe-GCS 3-8 with greater than 6 hr. loss of consciousness. Usually
require treatment in critical care. VERY WORRIED ABOUT THESE PTS.
o We want to catch pt in mild stage.
S/S or cues to look out for
o Amnesia (loss of memory) @ time of injury
o Headache
o Dizziness
o Seizure
o Loss of consciousness, sleepiness
o Restlessness or irritability= one of the first signs
Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
, Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
o Diplopia= double vision
o Sensitivity to light
o Sensitivity to sound
o Gait changes= unsteady
o MAKE SURE to do Neuro checks
Secondary brain injury
o Any processes that occur after the initial injury and worsen or
negatively influences patient outcomes.
o This is caused by pressure build up in the brain, didn’t log roll pt, didn’t
decrease stimuli, didn’t provide a quiet environment, didn’t limit
visitors, did cluster care.
o Takes 4-6 minutes for brain tissue to die.
o MAP must be at least 65
Nursing interventions
o First Priority: assessment of airway, breathing, circulation, ABC’s!
o Spinal precautions= make sure to log roll pt.
o Vital signs= high temp. Will cause pt to shiver, we don’t want that,
increases ICP.
o Full neurologic assessment
o PREVENT secondary brain injury
Major goals
o Patent airway!
o Fluid and electrolyte balance= especially sodium, low sodium=
seizures
o Adequate nutrition= look at albumin, if unconscious they are NPO=
TPN- change tubing + bag every 24 hours to prevent infection.
o Normal body temperature.
o Prevent secondary injury!
o HOB 30-35 degrees
Halo sign
Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
♡ Exam 3: advanced med surg ♡
Neurological
Diagnostic tests:
o ALWAYS assess LOC when assessing Neuro
o Glascow Coma Scale= should be 15
o Pupil Assessment= pupil size
o Orientation to person, place and time= decreased LOC is a sign of
brain issue.
o Doll’s eyes= sign of brain issue
Glasgow coma scale
o A score of 10 or less indicates a need for emergency attention
o A score of 7 or less is generally interpreted as coma
o Normal we know is 15, if the number is going down that is a sign that
the patient is declining.
Posturing
o Abnormal posturing: means you know there’s a brain issue
o Decorticate posture – Flexor, Decerebrate posture – Extensor, damage
to midbrain/pons
Traumatic head injury
Death usually occurs at 3 points:
o Immediately with injury
o Within 2 hours after injury
o 3 weeks after injury
o Don’t want them to go to sleep if they hit their head
o Patients with visual issues are at risk for brain injury= due to falls or
hitting something.
o Brain injury depends on Force and type: car accident, baseball, bullet,
fell, sports.
Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
,Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
Categorization
o Direct blow to head
o Indirect from brain being jarred against interior of skull
o Coup-Contrecoup= get hit in front of head but injury is in the back of
the skull.
o Closed (skull isn’t open) vs Open (skull is open) = closed is worse
because of ICP.
o Primary (happened right away, occurs at time of injury and results from
physical stress within the tissue caused by blunt force) vs. secondary
(happened after some time)
Classification per GCS
o Mild–GCS 13-15: Concussion or Mild TBI - Feeling dazed AND possible
loss of consciousness for up to 30 minutes or loss of memory for
events before accident or focal neurological deficits. Resolves within 72
hours. (CAN have Tylenol, but CANNOT have melatonin, morphine,
alcohol, benzodiazepines, NSAIDS because causes bleeding, or any
other CNS depressants) should not see any drainage from nose (sign of
CSF leak, check by doing halo sign= glucose in drainage) or be
confused for days.
o Moderate-GCS 9-12 with up to 6 hr. loss of consciousness. Lasts up to
24 hours.
o Severe-GCS 3-8 with greater than 6 hr. loss of consciousness. Usually
require treatment in critical care. VERY WORRIED ABOUT THESE PTS.
o We want to catch pt in mild stage.
S/S or cues to look out for
o Amnesia (loss of memory) @ time of injury
o Headache
o Dizziness
o Seizure
o Loss of consciousness, sleepiness
o Restlessness or irritability= one of the first signs
Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
, Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
o Diplopia= double vision
o Sensitivity to light
o Sensitivity to sound
o Gait changes= unsteady
o MAKE SURE to do Neuro checks
Secondary brain injury
o Any processes that occur after the initial injury and worsen or
negatively influences patient outcomes.
o This is caused by pressure build up in the brain, didn’t log roll pt, didn’t
decrease stimuli, didn’t provide a quiet environment, didn’t limit
visitors, did cluster care.
o Takes 4-6 minutes for brain tissue to die.
o MAP must be at least 65
Nursing interventions
o First Priority: assessment of airway, breathing, circulation, ABC’s!
o Spinal precautions= make sure to log roll pt.
o Vital signs= high temp. Will cause pt to shiver, we don’t want that,
increases ICP.
o Full neurologic assessment
o PREVENT secondary brain injury
Major goals
o Patent airway!
o Fluid and electrolyte balance= especially sodium, low sodium=
seizures
o Adequate nutrition= look at albumin, if unconscious they are NPO=
TPN- change tubing + bag every 24 hours to prevent infection.
o Normal body temperature.
o Prevent secondary injury!
o HOB 30-35 degrees
Halo sign
Med Surg (NUR170) Exam 3 Study Guide: Advanced Med Surg for Nursing Students
