5.4 Neurological Nursing: Unconscious Patient, Head Injury, Raised ICP & Epilepsy

5.4 Neurological Nursing: Unconscious Patient, Head Injury, Raised ICP & Epilepsy

Quick Answer: Neurological nursing questions centre on observation and airway protection. Record neurological observations—Glasgow Coma Scale (GCS), pupils, limb power and vital signs—and report a fall of 2 or more GCS points, a new unequal or unreactive pupil, or Cushing's triad (rising systolic pressure with widening pulse pressure, bradycardia and irregular breathing). Nurse the unconscious patient in the recovery or 30° head-up position with a clear airway, protect eyes, mouth, skin and joints, and never leave a convulsing patient: protect the head, do not restrain, put nothing in the mouth and treat seizures lasting 5 minutes or more as status epilepticus.

---

Neurological Observations

Frequency follows the doctor's order and the patient's stability—often every 15–30 minutes initially in acute head injury, then hourly as the patient stabilises. A GCS of 8 or less signals an unprotected airway and the need for urgent airway support (section 10.1).

Raised Intracranial Pressure (ICP)

Causes: head injury, haemorrhage, tumour, meningitis, cerebral oedema. Signs: headache, vomiting, falling level of consciousness, pupil changes, papilloedema and, late, Cushing's triad.

Nursing measures:

• Elevate the head of the bed 30° with the head and neck in neutral alignment (no tight collars or neck flexion) to help venous drainage;
• Maintain oxygenation and avoid hypoxia and hypercapnia;
• Avoid activities that raise ICP: straining at stool (give prescribed laxatives), vigorous coughing, prolonged suctioning (limit each pass), extreme hip flexion, clustering many procedures together;
• Keep the patient normothermic and control pain and agitation;
• Maintain accurate fluid balance; give prescribed osmotic therapy (e.g., mannitol) and monitor urine output and electrolytes.

Head Injury

Relatives taking home a patient with a minor head injury should return urgently if there is increasing drowsiness, repeated vomiting, severe headache, confusion, seizures, weakness or fluid from the nose or ears.

Care of the Unconscious Patient

1. Airway and breathing: recovery (lateral) position unless spinal injury is suspected; suction the mouth as needed; give oxygen as prescribed; have an oropharyngeal airway at hand.
2. Circulation and fluids: IV or nasogastric fluids and feeds as prescribed; fluid-balance chart.
3. Eye care: clean with sterile saline; keep lids closed or use prescribed lubricant to prevent corneal ulceration.
4. Mouth care: at least 2–4 hourly to prevent parotitis and infection; the patient takes nothing orally.
5. Skin and pressure areas: reposition at least every 2 hours (section 8.3).
6. Elimination: urinary catheter care or continence care; bowel chart and laxatives to prevent constipation.
7. Musculoskeletal: passive range-of-motion exercises and positioning to prevent contractures and foot drop.
8. Safety: side rails, seizure precautions and no unattended hot-water bottles.
9. Communication: explain every procedure aloud—hearing may be preserved—and support the family.

Epilepsy and Seizures

Seizure types: generalised tonic-clonic, absence (brief staring spells, usually in children), and focal seizures with or without impaired awareness.

During a tonic-clonic seizure:

• Stay with the patient, note the time the seizure started and call for help;
• Protect the head with something soft and move dangerous objects away;
• Do not restrain limbs and do not put anything in the mouth;
• Loosen tight clothing; after jerking stops, turn the patient into the recovery position and check airway and breathing;
• Record duration, type of movements, incontinence and the post-ictal state.

Status epilepticus (a convulsion lasting 5 minutes or more, or repeated seizures without recovery in between) is an emergency:

1. Airway, oxygen, suction, and check blood glucose (give dextrose if low);
2. First-line benzodiazepine as prescribed—e.g., IV diazepam (adult 10 mg) or rectal diazepam (0.5 mg/kg in children) when IV access is not available;
3. If seizures continue, a loading dose of phenytoin or phenobarbital per protocol, with cardiorespiratory monitoring.

Long-term care and teaching:

• Take anti-epileptic drugs exactly as prescribed—never stop suddenly;
• Know the drug risks: sodium valproate is teratogenic (women of childbearing age need specialist advice); phenytoin causes gum overgrowth (good oral hygiene); carbamazepine can cause rash and low white cells;
• Avoid triggers such as sleep deprivation, alcohol and missed doses; no swimming alone and no working at heights or near open fires while seizures are uncontrolled;
• Challenge stigma: epilepsy is a brain disorder, not contagious and not a spiritual curse, and people with epilepsy can go to school and work.

Meningitis on the Medical Ward

Cerebrospinal meningitis surveillance and CSF findings are covered in section 13.2. On the ward, nurse the patient in a quiet, dimly lit room, keep droplet precautions for the first 24 hours of effective antibiotics for meningococcal disease, give antibiotics exactly on time, monitor neuro-observations and fluid balance, treat fever and pain, and watch for seizures and raised ICP.

Exam Traps at a Glance

• A lucid interval after head injury points to an extradural haematoma.
• Clear fluid from the nose after head injury: no nasogastric tube, no nasal suction.
• Never put a spoon or finger into a convulsing patient's mouth.
• Hypoglycaemia is a reversible cause of both coma and seizures—check glucose.