9.4 Neurological Alterations

Neurological Alterations

Neuro questions hinge on change over time: a single value matters less than the trend. Level of consciousness is the most sensitive early indicator — restlessness and confusion appear before pupil changes or vital-sign shifts.

Level of Consciousness and the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) sums three responses; total ranges 3 (worst) to 15 (best).

Severity: 3–8 severe, 9–12 moderate, 13–15 mild. A score ≤8 means "can't protect the airway" — anticipate intubation. Decorticate posturing (flexion toward the core) is less ominous than decerebrate (extension); progressing from decorticate to decerebrate signals deterioration. Check pupils with PERRLA; a unilaterally dilated, fixed pupil suggests herniation.

Increased Intracranial Pressure (Normal 5–15 mmHg)

Caused by tumor, traumatic brain injury, hemorrhage, hydrocephalus, or infection.

Interventions: elevate the head of bed 30 degrees and keep the head midline to promote venous drainage; avoid coughing, straining, suctioning, and Valsalva; cluster care minimally and keep the room quiet; give osmotic diuretics (mannitol) as ordered; prevent hyperthermia and seizures, which raise metabolic demand. Cushing's triad is a late, ominous sign requiring immediate escalation.

Stroke (Cerebrovascular Accident)

Recognize with BE FAST: Balance loss, Eye/vision change, Face droop, Arm drift, Speech slurred, Time to call 911. Establishing the exact time of symptom onset is critical — it determines thrombolytic eligibility — and a CT scan must rule out hemorrhage before any clot-buster. Keep the patient NPO until a swallow screen passes (aspiration risk). Post-stroke care: approach a neglect patient from the unaffected side, perform ROM, use simple communication for aphasia, and support emotional lability.

Seizures

During: stay, clear the area, do not restrain, never put anything in the mouth, turn to the side when possible, loosen clothing, and time the seizure. Call for help if it exceeds 5 minutes or injury occurs. After (postictal): maintain airway and side-lying drainage, reorient, assess for injury, allow rest, and document type, duration, body parts involved, aura, incontinence, and recovery.

Meningitis

Inflammation of the meninges; bacterial is the most dangerous. Signs: fever, severe headache, nuchal rigidity, photophobia, altered mental status, and a petechial rash in meningococcal disease. Kernig's sign: pain/resistance straightening the knee with the hip flexed. Brudzinski's sign: neck flexion triggers involuntary hip/knee flexion. Place suspected bacterial cases on droplet precautions for at least 24 hours of effective antibiotics; close contacts may need prophylaxis.

Parkinson's Disease

Progressive dopamine deficiency. Cardinal signs spell TRAP: Tremor (resting, "pill-rolling"), Rigidity (cogwheel), Akinesia/bradykinesia, Postural instability (shuffling festinating gait). Give levodopa-carbidopa on time — its narrow therapeutic window means late doses cause "freezing." Prioritize fall prevention, dysphagia/aspiration assessment, and extra time for ADLs to preserve independence.

Serial Neuro Checks: The Core Skill

The single most tested neuro concept is that a declining trend drives action. A patient whose GCS slips, who becomes harder to rouse, or whose previously equal pupils turn unequal is deteriorating regardless of how the numbers look in isolation. The LPN/VN performs frequent checks, compares each to the last, and reports any decline to the RN before late signs such as Cushing's triad emerge. By the time bradycardia, widening-pulse-pressure hypertension, and irregular respirations appear, herniation may be imminent — the goal is to catch the change while it is still early and reversible.

Stroke Care Beyond the Acute Window

Once the thrombolytic window closes, nursing focus shifts to preventing complications and restoring function. Dysphagia is the most dangerous early problem: keep the patient NPO until a swallow screen passes, then start with thickened liquids and the chin-tuck technique, sitting fully upright. For a patient with homonymous hemianopsia or unilateral neglect, place needed items and approach from the unaffected side at first, then teach the patient to scan toward the neglected side. For expressive aphasia, allow time, use yes/no questions and picture boards, and never finish the patient's sentences.

Emotional lability is a brain-injury phenomenon, not deliberate behavior — respond with calm consistency.

Spinal Cord and Autonomic Dysreflexia

For injuries at or above T6, watch for autonomic dysreflexia, an emergency triggered by a noxious stimulus below the injury — most often a full bladder or impacted bowel. It presents with pounding headache, severe hypertension, bradycardia, flushing and sweating above the lesion, and pallor below. The immediate actions: sit the patient upright to lower blood pressure, then find and remove the trigger (check for a kinked or full catheter first). This sequence — raise the head, then remove the cause — is the tested answer.

Increased ICP Don'ts Worth Memorizing

Avoid hip flexion, neck flexion, prolonged suctioning, and clustering painful care, all of which spike intracranial pressure. Keep the environment quiet and the head midline, and never position a patient with rising ICP flat or in Trendelenburg.