Neurologic Assessment, Stroke, Seizure, and Delirium

Neurologic Change Is a Priority Finding

On a medical-surgical unit, a neurologic change may be the first sign of stroke, hypoxemia, sepsis, medication toxicity, hypoglycemia, increased intracranial concern, or worsening chronic disease. CMSRN questions often ask which patient to see first. The safest choice is the patient with acute change from baseline: new facial droop, arm drift, slurred speech, severe headache, seizure activity, new agitation, sudden somnolence, or unequal pupils. Chronic weakness after an old stroke matters, but a new deficit matters more.

Bedside Neuro Assessment

A focused neurologic assessment should be fast, repeatable, and compared with baseline. Assess level of consciousness, orientation, speech, pupils, facial symmetry, limb strength, sensation if appropriate, coordination, and gait safety. Include vital signs, oxygen saturation, pain, recent medications, glucose per policy, and timing of symptom onset.

Stroke Recognition and Escalation

Stroke care is time-sensitive. The nurse does not decide whether the patient is eligible for thrombolytic therapy, but must preserve the timeline and activate the stroke process. Last known well is the last time the patient was at neurologic baseline, not when symptoms were discovered. If a patient woke with symptoms, last known well may be bedtime or the last witnessed normal time.

Scenario: At 0930, a patient who was joking during 0700 report now has right facial droop and cannot repeat a sentence. The nurse should call a stroke alert or rapid response according to policy, note last known well of 0700 if that is accurate, obtain vital signs, check glucose if protocol allows, keep the patient NPO, and prepare for urgent evaluation. The nurse should not walk the patient, give oral medications, or wait for family to confirm that the speech change is unusual.

Nursing details that matter include anticoagulant use, recent surgery or bleeding, blood pressure, glucose, oxygenation, and baseline deficits. Communicate clearly: new deficit, time last known well, current vital signs, blood glucose if obtained, anticoagulants, and code status if relevant.

Seizure Care

During a seizure, safety and oxygenation are the priorities. Move hazards away, protect the head, loosen restrictive clothing, time the event, observe movements and eye deviation, and call for help. Do not place anything in the mouth, restrain the limbs, or try to force oral medication. When possible, position the patient on the side to reduce aspiration risk. After the seizure, assess airway, breathing, oxygen saturation, vital signs, injuries, neurologic status, and return to baseline.

A first seizure, repeated seizures, seizure lasting longer than the facility threshold, pregnancy, head trauma, or failure to regain consciousness requires urgent escalation. For a patient with known seizures, missed antiseizure medication, low sodium, alcohol withdrawal, infection, or sleep deprivation may be relevant report data. Administer ordered rescue medication only according to order and competency.

Delirium Is Not Normal Aging

Delirium is acute, fluctuating disturbance in attention and awareness. It may be hyperactive, with agitation and pulling lines, or hypoactive, with quiet withdrawal and sleepiness. Hypoactive delirium is easy to miss and has high risk because the patient may not request help. CMSRN judgment treats new confusion as a symptom to assess, not a behavior to simply manage.

Common contributors include infection, hypoxia, pain, urinary retention, constipation, dehydration, sleep disruption, unfamiliar environment, alcohol withdrawal, anticholinergic medications, benzodiazepines, opioids, steroids, and electrolyte imbalance. Nursing actions include reorientation, glasses and hearing aids, sleep protection, mobilization, hydration as appropriate, toileting, pain control, medication review, fall precautions, and family presence when helpful. Restraints are not first-line care and can worsen delirium unless there is immediate danger and policy criteria are met.

Prioritization Across Neuro Patients

A stable patient awaiting physical therapy after a known stroke is lower priority than a patient with new unilateral weakness. A patient with chronic dementia who is pleasantly confused may need supervision, but a patient who was oriented yesterday and is now drowsy, febrile, and hypoxic needs immediate assessment. Use baseline, acuity, and reversibility. Acute neurologic change is a rapid assessment and escalation problem.