Neurology Nursing Assessment for NCLEX: Glasgow Coma Scale, Pupil Checks & ICP
Master neurological nursing assessment for the NCLEX. Learn Glasgow Coma Scale scoring, pupil evaluation, ICP monitoring, and stroke assessment.
Neurological Nursing Assessment for NCLEX
Neurological assessment is a critical nursing skill frequently tested on the NCLEX. Understanding how to perform and interpret neurological assessments helps identify deterioration early and guide appropriate interventions.
Glasgow Coma Scale (GCS)
The GCS measures level of consciousness using three parameters. Eye Opening: Spontaneous (4), to voice (3), to pain (2), none (1). Verbal Response: Oriented (5), confused (4), inappropriate words (3), incomprehensible sounds (2), none (1). Motor Response: Obeys commands (6), localizes pain (5), withdrawal (4), abnormal flexion/decorticate (3), extension/decerebrate (2), none (1). Total score ranges from 3-15. A score of 8 or below indicates severe brain injury and the need for intubation. Document and trend scores to identify changes in neurological status.
Pupil Assessment
Assess pupil size, shape, equality, and reactivity to light. Normal pupils are equal, round, and reactive to light (PERRLA). A fixed and dilated pupil indicates increased intracranial pressure on the ipsilateral side. Bilateral fixed and dilated pupils suggest brainstem herniation. Pinpoint pupils may indicate opioid overdose or pontine hemorrhage. Unequal pupils (anisocoria) can be a normal variant but new onset requires urgent evaluation.
Increased Intracranial Pressure (ICP)
Normal ICP is 5-15 mmHg. Signs of increased ICP include headache, vomiting (often without nausea), altered level of consciousness, papilledema, and Cushing triad (hypertension, bradycardia, irregular respirations) which is a late and ominous sign. Nursing interventions include elevating the head of bed 30 degrees, maintaining the head in midline position, avoiding activities that increase ICP (coughing, straining, hip flexion), administering osmotic diuretics (mannitol) as ordered, and monitoring neurological status frequently.
Stroke Assessment
Use the FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call 911. For ischemic stroke, the window for tPA (alteplase) administration is within 3-4.5 hours of symptom onset. Assess for contraindications including recent surgery, bleeding disorders, and uncontrolled hypertension. For hemorrhagic stroke, tPA is contraindicated. Review with our clinical nursing flashcards and practice neurology assessment questions.