7.1 Neurologic Assessment & Stroke

The Focused Neurologic Examination

A med-surg neuro exam is built around five elements, and the exam loves questions about which finding changes first. Level of consciousness (LOC) is the single most sensitive indicator of neurologic status — a change in LOC is the earliest sign of deterioration, appearing before pupil changes, motor changes, or vital sign shifts. Assess arousal with the least stimulation necessary: voice, then gentle touch, then painful stimulus (trapezius squeeze, sternal rub, nail bed pressure).

The Glasgow Coma Scale (GCS) standardizes LOC scoring from 3 to 15 across eye opening (1-4), verbal response (1-5), and motor response (1-6). The best response is scored even if the other side is impaired. A GCS of 8 or below signals severe brain injury and generally indicates the patient cannot protect the airway — the classic board phrase is "GCS of 8, intubate." Document the score as components (E4 V5 M6 = 15), never just a number.

Pupils, Motor, Sensation, and Reflexes

• Pupils: Assess size in millimeters, equality, and reaction to light. PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) is the normal finding. A fixed, dilated pupil on one side suggests uncal herniation compressing cranial nerve III on that side — a neurosurgical emergency. Pinpoint pupils suggest opioid toxicity or pontine injury.
• Motor function: Grade strength 0 to 5 in all four extremities and compare sides. Ask the awake patient to squeeze your fingers, push against your hands, and lift each leg. Pronator drift (one palm turning downward and drifting when arms are held out, eyes closed) is an early sign of subtle motor weakness. A flaccid or posturing response matters: decorticate posturing (arms flexed toward the core) indicates damage above the brainstem, while decerebrate posturing (arms extended and rotated outward) indicates brainstem damage and carries a worse prognosis.
• Sensation: Test light touch distally and compare sides. Note dermatomal patterns after spinal injury.
• Deep tendon reflexes: Graded 0 (absent) to 4+ (hyperactive with clonus); 2+ is normal. Hyperreflexia suggests upper motor neuron lesions; absent reflexes suggest lower motor neuron or peripheral nerve problems.

Stroke: Ischemic Versus Hemorrhagic

Stroke is the interruption of cerebral blood flow causing rapid-onset focal neurologic deficit. About 87 percent of strokes are ischemic (thrombotic or embolic occlusion of a cerebral artery); the remainder are hemorrhagic (intracerebral or subarachnoid bleeding, often from hypertension or aneurysm rupture). Only non-contrast computed tomography (CT) reliably distinguishes them — and it must be done before any thrombolytic is given, because giving a clot-buster to a bleeding patient is catastrophic.

Recognition: BE-FAST

BE-FAST expands the older FAST mnemonic to catch posterior-circulation strokes:

• B – Balance: sudden loss of coordination or dizziness
• E – Eyes: sudden vision loss or double vision
• F – Face: facial droop (ask the patient to smile)
• A – Arms: unilateral weakness or drift
• S – Speech: slurred or garbled speech, or inability to understand
• T – Time: note last known well time and activate the stroke team immediately

"Last known well" — not when symptoms were discovered — anchors every treatment decision. A patient who wakes with a deficit was last known well at bedtime.

Alteplase (tPA): Window, Eligibility, and Monitoring

Alteplase (recombinant tissue plasminogen activator, tPA) is an intravenous fibrinolytic that must be started within 3 to 4.5 hours of last known well for eligible ischemic stroke patients. The dose is 0.9 mg/kg (maximum 90 mg), with 10 percent given as a bolus over 1 minute and the rest infused over 60 minutes.

Key eligibility and exclusion points the exam tests:

• Blood pressure must be lowered to below 185/110 mm Hg before alteplase and maintained below 180/105 mm Hg for 24 hours after (using agents such as labetalol or nicardipine)
• Non-contrast CT must show no hemorrhage
• Exclusions include recent major surgery or trauma, active bleeding, platelets below 100,000/mm³, INR above 1.7 on warfarin, recent therapeutic heparin use, and glucose below 50 mg/dL (correct hypoglycemia first — it mimics stroke)
• No antiplatelets or anticoagulants for the first 24 hours, until a follow-up CT excludes bleeding

Nursing care after alteplase: neuro checks and blood pressure per protocol (typically every 15 minutes for 2 hours, then every 30 minutes, then hourly), watch for intracranial hemorrhage (sudden neuro decline, severe headache, nausea — stop the infusion and call the provider) and angioedema (tongue or lip swelling, especially in patients on ACE inhibitors). Avoid invasive procedures — no intramuscular injections, indwelling catheters, or nasogastric tubes unless essential — for 24 hours. For large-vessel occlusions, mechanical thrombectomy can be performed up to 24 hours from last known well in selected patients.

The National Institutes of Health Stroke Scale (NIHSS) quantifies stroke severity from 0 (normal) to 42 (severe) by scoring consciousness, gaze, visual fields, facial palsy, motor function, ataxia, sensation, language, dysarthria, and neglect. It does not localize the lesion; it standardizes severity, guides treatment decisions (thrombectomy is typically considered at NIHSS of 6 or higher with a large-vessel occlusion), and tracks improvement or deterioration over time. Certified nurses perform it on admission and serially.

Post-Stroke Nursing Priorities

• Swallow screen before anything by mouth: Dysphagia is common and silent aspiration causes pneumonia. Keep the patient NPO until a swallow screen is passed; if failed, obtain a formal speech-language pathology evaluation. No water, ice chips, or oral medications until cleared.
• Aspiration prevention: Feed with the head of bed at 30 degrees or higher (ideally upright 90 degrees), tuck the chin while swallowing if directed, place food on the unaffected side of the mouth, allow small bites with rest between, and keep the patient upright for 30 to 60 minutes after eating.
• Positioning: Turn every 2 hours, support the affected arm on a pillow (never let it dangle — risk of shoulder subluxation), avoid pulling on the affected side during transfers, and maintain functional alignment.
• Complication prevention: Deep vein thrombosis prophylaxis (sequential compression devices; pharmacologic prophylaxis once hemorrhage is excluded), early mobilization with rehabilitation, skin care, and bowel/bladder programs.

Transient Ischemic Attack: The Warning Shot

A transient ischemic attack (TIA) produces stroke-like deficits that resolve completely, typically within minutes to an hour, with no infarction on imaging. It is not benign: about 10 to 15 percent of TIA patients suffer a stroke within 90 days, and the greatest risk is in the first 48 hours. The ABCD2 score (Age, Blood pressure, Clinical features, Duration, Diabetes) stratifies short-term risk. Management focuses on prevention: antiplatelet therapy (aspirin, clopidogrel), statins regardless of baseline cholesterol, blood pressure and diabetes control, carotid evaluation for revascularization, anticoagulation for atrial fibrillation, and smoking cessation. Teach patients that resolved symptoms still demand emergency evaluation.