Chapter 8: Neurological Nursing — Stroke, Seizures, and Brain Injury

Neurological emergencies demand rapid recognition and intervention. Minutes matter in stroke and seizure management. A thorough neurological assessment is the nurse’s most powerful tool for detecting deterioration before it becomes catastrophic.

Neurological Assessment

Glasgow Coma Scale (GCS)

Component	Response	Score
Eye Opening	Spontaneous	4
	To voice	3
	To pain	2
	None	1
Verbal	Oriented	5
	Confused	4
	Inappropriate words	3
	Incomprehensible sounds	2
	None	1
Motor	Obeys commands	6
	Localizes pain	5
	Withdraws	4
	Abnormal flexion (decorticate)	3
	Extension (decerebrate)	2
	None	1

GCS 13–15: mild injury; 9–12: moderate; ≤8: severe (intubation threshold). Minimum score: 3 (deep coma or brain death).

Stroke Recognition and Management

FAST acronym: Face drooping, Arm weakness, Speech difficulty, Time to call emergency services.

Ischemic stroke (85%): thrombus or embolus. Treatment: IV tPA (alteplase) within 4.5 hours of symptom onset if no contraindications; mechanical thrombectomy for large vessel occlusion up to 24 hours.

Hemorrhagic stroke (15%): blood vessel ruptures into brain. tPA is contraindicated. Management: blood pressure control, reversal of anticoagulation, neurosurgical evaluation.

Nursing priorities: Time of last known well (LKW), frequent neuro checks (q15–30 min initially), maintain BP per protocol, aspiration precautions (NPO until swallow screen), position HOB at 30°.

Increased Intracranial Pressure (ICP)

Normal ICP: 5–15 mmHg. Causes: head trauma, hemorrhage, tumor, hydrocephalus.

Early signs: headache (worst in morning), nausea, vomiting (projectile), papilledema, personality changes.

Cushing’s Triad (late/ominous): hypertension with widening pulse pressure + bradycardia + irregular respirations.

Nursing interventions: HOB 30°, neutral head/neck alignment, minimize suctioning (raises ICP), quiet environment, osmotic therapy (mannitol, hypertonic saline as ordered), avoid hypotension and hypoxia.

Seizures

Tonic-clonic (grand mal): loss of consciousness, muscle rigidity (tonic), rhythmic jerking (clonic), followed by postictal phase.

Absence: brief staring spells, no postictal phase.

Status epilepticus: seizure lasting > 5 minutes or two seizures without return to baseline — medical emergency.

Nursing during seizure: Do NOT restrain; protect from injury (pad rails, nothing in mouth); time the seizure; position laterally after for airway protection; administer lorazepam or diazepam as ordered for status epilepticus.

Multiple Sclerosis and Parkinson’s Disease

MS: autoimmune demyelination. Nursing: heat avoidance (worsens symptoms), fall prevention, fatigue management, bladder/bowel program, disease-modifying therapy education.

Parkinson’s: dopamine deficiency. Hallmarks: TRAP — Tremor (resting), Rigidity, Akinesia/Bradykinesia, Postural instability. Levodopa/carbidopa must be given on time (late doses cause acute symptom exacerbation). Fall risk is high.

Key Checklist

• Calculate GCS for a patient who opens eyes to pain, speaks confused sentences, and localizes pain (score and interpretation)
• Describe the window for tPA administration in ischemic stroke and list three contraindications
• List Cushing’s Triad and explain its clinical significance in ICP management