Neurological Nursing

Neurological Nursing

Neurological conditions require rapid assessment and intervention, making them a favorite testing area on the NCLEX. This guide covers stroke, seizures, increased intracranial pressure, spinal cord injury, and cranial nerve assessment. For a condensed reference, visit the Neurological Nursing Cheat Sheet.

Stroke (Cerebrovascular Accident)

Stroke is the sudden interruption of blood flow to the brain, causing neurological deficits. Time is critical: "Time is brain." Every minute of untreated large vessel ischemic stroke, approximately 1.9 million neurons are lost.

Ischemic Stroke (87% of all strokes): Caused by a thrombus or embolus blocking a cerebral artery. Symptoms depend on the affected area but commonly include unilateral weakness or paralysis, facial drooping, speech difficulties (aphasia), visual field deficits, and altered mental status. Use the FAST mnemonic for recognition: Face drooping, Arm weakness, Speech difficulty, Time to call 911.

tPA (Alteplase) Criteria: Tissue plasminogen activator dissolves the clot and restores blood flow. It must be administered within 3-4.5 hours of symptom onset. Inclusion criteria: confirmed ischemic stroke with measurable neurological deficit. Key exclusions include active internal bleeding, recent surgery (within 14 days), history of hemorrhagic stroke, uncontrolled hypertension (greater than 185/110), platelet count less than 100,000, and INR greater than 1.7. During and after administration, monitor for bleeding (intracranial hemorrhage is the most serious complication), perform frequent neurological assessments, and avoid invasive procedures.

Hemorrhagic Stroke (13% of strokes): Caused by rupture of a cerebral blood vessel (intracerebral hemorrhage or subarachnoid hemorrhage). Often presents with sudden severe headache ("worst headache of my life" in subarachnoid hemorrhage), nausea, vomiting, and rapid deterioration in consciousness. tPA is absolutely contraindicated. Treatment focuses on blood pressure control, surgical intervention if indicated, and management of increased ICP.

NIH Stroke Scale (NIHSS): A standardized tool used to quantify stroke severity. Assesses level of consciousness, gaze, visual fields, facial palsy, motor function (arms and legs), limb ataxia, sensory function, language, dysarthria, and extinction/inattention. Scores range from 0 (no deficit) to 42 (severe stroke). Higher scores indicate greater severity and help guide treatment decisions.

Seizures

Seizures result from abnormal, excessive electrical discharges in the brain. They are classified as:

• Generalized Seizures: Involve both hemispheres. Types include tonic-clonic (grand mal) -- characterized by loss of consciousness, muscle rigidity (tonic phase), followed by rhythmic jerking (clonic phase), and a postictal period of confusion and fatigue. Absence (petit mal) seizures involve brief staring episodes lasting 5-10 seconds, common in children.
• Focal (Partial) Seizures: Originate in one area of the brain. Simple partial (no loss of consciousness, localized motor or sensory symptoms), complex partial (altered consciousness, automatisms such as lip smacking or picking at clothes).

Seizure Management:

• During a seizure: Maintain airway, turn patient to the side (recovery position), do not restrain or place objects in the mouth, protect from injury (pad side rails, remove harmful objects), time the seizure, and note characteristics.
• After a seizure: Maintain airway, assess neurological status, reorient the patient, document seizure type, duration, and any preceding aura.
• Antiepileptic drugs (AEDs): Phenytoin (Dilantin) -- monitor therapeutic levels (10-20 mcg/mL), assess for gingival hyperplasia, administer IV slowly (no faster than 50 mg/min in adults) with cardiac monitoring, never mix with dextrose solutions. Valproic acid, levetiracetam (Keppra), and carbamazepine are other common AEDs.

Status Epilepticus: A seizure lasting longer than 5 minutes or two or more seizures without regaining consciousness. This is a neurological emergency. Treatment priority: maintain airway, administer IV benzodiazepine (lorazepam is first-line), followed by IV phenytoin or fosphenytoin loading dose. Prepare for intubation if seizures persist. Monitor for respiratory depression, aspiration, and cerebral hypoxia.

Increased Intracranial Pressure (ICP)

Normal ICP is 5-15 mmHg. Increased ICP results from an increase in the volume of brain tissue (tumor, edema), blood (hemorrhage), or cerebrospinal fluid (hydrocephalus) within the rigid skull (Monro-Kellie hypothesis).

Signs of Increased ICP:

• Early signs: Headache (worse in the morning), altered level of consciousness (restlessness, confusion, lethargy), pupillary changes (sluggish reaction, unilateral dilation), nausea and vomiting (often projectile without nausea).
• Late signs: Cushing's triad -- hypertension (widening pulse pressure), bradycardia, and irregular respirations (Cheyne-Stokes or ataxic breathing). This is a medical emergency indicating brainstem herniation.
• Other late signs: Fixed and dilated pupils, decerebrate or decorticate posturing, loss of brainstem reflexes.

Interventions for Increased ICP:

• Elevate the head of bed 30 degrees with the head in midline position (promotes venous drainage).
• Maintain a quiet, dimly lit environment. Minimize stimulation.
• Avoid activities that increase ICP: straining (Valsalva maneuver), coughing, suctioning for more than 10 seconds, hip flexion, prone position.
• Administer osmotic diuretics (mannitol) to reduce cerebral edema. Monitor serum osmolality (hold if greater than 320 mOsm/kg).
• Hypertonic saline (3% NaCl) may be used as an alternative to mannitol.
• Monitor ICP via external ventricular drain (EVD) or intraparenchymal monitor. Cerebral perfusion pressure (CPP) = MAP - ICP. Maintain CPP greater than 60-70 mmHg.

Glasgow Coma Scale (GCS)

The GCS is a standardized neurological assessment tool that evaluates three components:

Response	Score Range	Best Response
Eye Opening	1-4	4 = Spontaneous
Verbal Response	1-5	5 = Oriented
Motor Response	1-6	6 = Obeys commands

Total GCS ranges from 3 (deep coma) to 15 (fully alert). A score of 8 or less indicates severe brain injury and the need for intubation to protect the airway. Document and trend GCS scores to detect changes in neurological status.

Spinal Cord Injury (SCI)

Spinal cord injuries are classified by the level and completeness of injury. Higher injuries result in greater functional loss:

• Cervical (C1-C8): Quadriplegia/tetraplegia. Injuries at C3-C5 affect diaphragm function (phrenic nerve) and may require mechanical ventilation. Remember: "C3, 4, 5 keeps the diaphragm alive."
• Thoracic (T1-T12): Paraplegia with varying trunk control.
• Lumbar/Sacral: Variable lower extremity weakness, bowel and bladder dysfunction.

Spinal Shock: Temporary loss of all neurological function below the level of injury occurring immediately after SCI. Presents with flaccid paralysis, absent reflexes, loss of sensation, urinary retention, paralytic ileus, and hypotension. May last days to weeks. Return of the bulbocavernosus reflex signals the end of spinal shock.

Autonomic Dysreflexia: A life-threatening emergency occurring in injuries at T6 or above. Triggered by noxious stimuli below the level of injury (most commonly a distended bladder or impacted bowel). Symptoms include severe hypertension (can cause stroke), pounding headache, bradycardia, flushing and diaphoresis above the level of injury, and pale and cool skin below the injury. Immediate interventions: sit the patient upright (lowers BP), identify and remove the trigger (check for full bladder -- catheterize if needed, check for fecal impaction), loosen restrictive clothing, and administer antihypertensives if BP remains elevated. This is a priority NCLEX topic.

Cranial Nerve Assessment (I-XII)

Assessment of the twelve cranial nerves is a fundamental neurological nursing skill:

1. I - Olfactory: Sense of smell. Test each nostril separately with familiar scents.
2. II - Optic: Visual acuity and visual fields. Use Snellen chart and confrontation test.
3. III - Oculomotor: Pupil constriction, eyelid elevation, and most extraocular movements. Test pupillary light reflex (PERRLA).
4. IV - Trochlear: Downward and inward eye movement. Test by asking patient to look down and inward.
5. V - Trigeminal: Facial sensation (3 divisions: ophthalmic, maxillary, mandibular) and mastication. Test with light touch and cotton wisp; assess jaw clenching.
6. VI - Abducens: Lateral eye movement. Test by asking patient to look laterally.
7. VII - Facial: Facial expression and taste on the anterior two-thirds of the tongue. Ask patient to smile, frown, raise eyebrows, puff cheeks.
8. VIII - Acoustic (Vestibulocochlear): Hearing and balance. Test with whisper test, Weber, and Rinne tests.
9. IX - Glossopharyngeal: Taste on the posterior one-third of the tongue and gag reflex (along with CN X). Test swallowing and gag reflex.
10. X - Vagus: Swallowing, speech, and parasympathetic functions. Assess voice quality (hoarseness), uvula midline, and gag reflex.
11. XI - Spinal Accessory: Shoulder shrug (trapezius) and head turning (sternocleidomastoid). Test by asking patient to shrug shoulders and turn head against resistance.
12. XII - Hypoglossal: Tongue movement. Ask patient to stick out tongue (should be midline) and push tongue against cheek against resistance.

NCLEX Neurological Question Tips

Neurological assessment questions frequently test your ability to recognize changes in level of consciousness as the earliest indicator of neurological deterioration. Altered LOC is always the priority finding. Know the difference between ischemic and hemorrhagic stroke interventions. Understand that autonomic dysreflexia is a medical emergency requiring immediate action. Remember positioning principles: elevate HOB 30 degrees for increased ICP, logroll for spinal cord injury. For additional study, visit the Physiological Study Guide, review the Physiological Glossary, and practice with Physiological Flashcards.