3.1 Stroke & Acquired Brain Injury

Neuro-rehabilitation is 25% of the CRRN exam, and stroke and acquired brain injury generate a large share of those scenario questions. The exam rewards nurses who can connect a lesion location to a predictable pattern of deficits and then to the correct safety intervention.

Stroke Syndromes and Deficits

A cerebrovascular accident (CVA), or stroke, is either ischemic (about 87% of cases, caused by clot or thrombus) or hemorrhagic (caused by vessel rupture). Rehabilitation nursing focuses on the residual deficits, which follow the lesion side and vascular territory.

Lateralization: Left vs. Right Hemisphere

Deficits appear on the side of the body opposite the brain lesion because motor and sensory tracts decussate.

Vascular Territories

• Middle cerebral artery (MCA) - the most common stroke; contralateral weakness greater in the face and arm than the leg, with aphasia (left) or neglect (right).
• Anterior cerebral artery (ACA) - contralateral weakness greater in the leg, with possible incontinence and behavioral change.
• Posterior circulation / brainstem - vertigo, diplopia, dysphagia, ataxia, and risk of locked-in syndrome with severe pontine lesions.

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Traumatic and Anoxic Brain Injury

Traumatic brain injury (TBI) results from external mechanical force; anoxic (or hypoxic) brain injury results from oxygen deprivation, such as after cardiac arrest or near-drowning. Anoxic injury is typically diffuse, so deficits are often global rather than focal.

TBI severity is initially classified using the Glasgow Coma Scale (GCS): 13-15 mild, 9-12 moderate, and 3-8 severe. The GCS measures eye, verbal, and motor responses. In rehabilitation, the focus shifts from acute survival to functional and cognitive recovery, where the Rancho scale becomes the primary tracking tool.

Rancho Los Amigos Levels of Cognitive Functioning

The Rancho Los Amigos (RLA) scale describes cognitive and behavioral recovery after brain injury. The original scale has eight levels; revised versions extend to ten. The rehabilitation nurse uses the level to set the environment, plan stimulation, and manage safety.

Rancho Levels and Nursing Priorities

Levels IV through VI demand the most intensive supervision. At Level IV (Confused/Agitated), the priority is a calm, low-stimulation environment and injury prevention - restraints are a last resort and behavioral and environmental strategies come first.

Cognitive and Communication Deficits

• Aphasia - impaired language. Expressive (Broca) aphasia limits speech output with relatively preserved comprehension; receptive (Wernicke) aphasia impairs comprehension with fluent but meaningless speech; global aphasia impairs both.
• Apraxia - inability to perform learned motor acts despite intact strength.
• Dysarthria - slurred speech from weak speech muscles; language content is intact.
• Executive dysfunction - poor planning, initiation, and judgment, common after frontal-lobe injury.

Nursing supports communication with short sentences, yes/no questions, gestures, communication boards, and coordination with speech-language pathology. The nurse does not pretend to understand unclear speech.

Dysphagia and Aspiration Risk

Dysphagia (impaired swallowing) is common after stroke and brainstem injury and is a leading cause of aspiration pneumonia. A bedside swallow screen - or keeping the patient nil per os (NPO) until a formal evaluation - is performed before any oral intake. Signs include coughing or wet voice with intake, pocketing food, and delayed swallow. Aspiration may be silent, so absence of coughing does not confirm a safe swallow.

Hemineglect (Unilateral Spatial Neglect)

Hemineglect is failure to attend to one side of space, most often the left after a right-hemisphere stroke. It is a perceptual deficit, not blindness. The patient may ignore food on one side of the plate, fail to dress one side, or collide with objects. Early nursing approach: place essentials and approach from the unaffected side for safety, then progressively retrain scanning toward the neglected side as the patient improves.

Rehabilitation Interventions

Recovery relies on neuroplasticity - the brain's ability to reorganize. Evidence-based rehabilitation nursing actions include early mobilization, task-specific repetitive practice, consistent routines, prevention of immobility complications (deep vein thrombosis, contractures, pressure injury), bowel and bladder retraining, and reinforcement of the interdisciplinary team's compensatory strategies across every shift.

Secondary Injury and Medical Vigilance

After the initial insult, the brain remains vulnerable to secondary injury from hypoxia, hypotension, increased intracranial pressure, seizures, and fever. The rehabilitation nurse protects the recovering brain by maintaining oxygenation and perfusion, implementing seizure precautions when indicated, controlling fever, and watching for signs of rising intracranial pressure (declining level of consciousness, worsening headache, vomiting, pupil changes). A new or sudden change in neurologic status is never assumed to be "just fatigue" — it is escalated.

Communication, Cognition, and Safety After Stroke

Stroke deficits cluster predictably by hemisphere, and tying them to the right safety action is the exam's favorite move. Left-hemisphere survivors are often aware of deficits, cautious, and aphasic — give extra time and use yes/no questions and communication aids. Right-hemisphere survivors are typically impulsive with poor safety judgment and left hemineglect, so they need close supervision and cueing to scan their environment. Emotional lability (involuntary crying or laughing) is neurologic, not a mood disorder, and families should be taught it is not deliberate.

Across both, dysphagia screening before oral intake and fall precautions are baseline rehabilitation nursing safety standards.