Neurological Nursing: Stroke, Seizures, and Brain Injury
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.
Learning notice: This chapter is an educational overview, not a bedside protocol or patient-specific treatment instruction. Contact emergency services for suspected stroke or seizure emergencies, and follow current institutional protocols and the treating team’s orders for all medications and interventions.
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 range; 9–12: moderate range; ≤8: severe impairment requiring immediate airway and emergency assessment. A GCS score alone does not diagnose brain death or automatically determine intubation.
Stroke Recognition and Management
FAST acronym: Face drooping, Arm weakness, Speech difficulty, Time to call emergency services.
Ischemic stroke: For eligible patients within 4.5 hours of symptom onset, current guidance supports intravenous thrombolysis with alteplase or tenecteplase. Selected patients with unknown onset or later presentation may qualify under advanced-imaging criteria. Endovascular treatment for large-vessel occlusion is also based on imaging and clinical selection and can apply to some patients within 24 hours.
Hemorrhagic stroke (15%): blood vessel ruptures into brain. tPA is contraindicated. Management: blood pressure control, reversal of anticoagulation, neurosurgical evaluation.
Nursing priorities: Establish the last-known-well time, monitor neurological change, withhold oral intake until swallowing is assessed, and protect airway, oxygenation, and aspiration risk. Blood-pressure targets, assessment frequency, and positioning vary with treatment and patient status and must follow the institution’s stroke protocol.
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
Key source
- American Heart Association/American Stroke Association. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke.
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