Key Takeaways
- GCS of 8 or below = severe injury requiring airway protection
- During seizures: protect from injury, time duration, position on side after
- Increased ICP: elevate HOB 30 degrees, head midline, avoid activities that raise ICP
- Stroke: BE FAST for recognition; tPA must be given within 4.5 hours for ischemic stroke
- Kernig's and Brudzinski's signs indicate meningeal irritation (meningitis)
Last updated: January 2026
Neurological Alterations
Neurological conditions can dramatically affect patient function and quality of life. LPN/VNs must perform accurate neurological assessments and recognize changes that require immediate intervention.
Neurological Assessment
Level of Consciousness (LOC): LOC is the most sensitive indicator of neurological change.
| Level | Description |
|---|---|
| Alert | Awake, oriented, responds appropriately |
| Lethargic | Drowsy but easily aroused |
| Obtunded | Difficult to arouse, confused when awake |
| Stuporous | Arouses only with vigorous stimulation |
| Comatose | Unresponsive to stimulation |
Glasgow Coma Scale (GCS):
| Response | Score |
|---|---|
| Eye Opening | |
| Spontaneous | 4 |
| To voice | 3 |
| To pain | 2 |
| None | 1 |
| Verbal Response | |
| Oriented | 5 |
| Confused | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| None | 1 |
| Motor Response | |
| Obeys commands | 6 |
| Localizes pain | 5 |
| Withdraws from pain | 4 |
| Flexion (decorticate) | 3 |
| Extension (decerebrate) | 2 |
| None | 1 |
Total Score: 3-15 (3 = worst, 15 = best)
- Severe injury: 3-8
- Moderate injury: 9-12
- Mild injury: 13-15
Pupil Assessment:
- PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation
- Unequal pupils (anisocoria): May indicate increased ICP, herniation
- Dilated, fixed pupil: Sign of brain herniation
Increased Intracranial Pressure (ICP)
Normal ICP: 5-15 mmHg
Causes:
- Brain tumor, abscess
- Traumatic brain injury
- Stroke (hemorrhagic or large ischemic)
- Hydrocephalus
- Encephalitis, meningitis
Signs and Symptoms:
| Early Signs | Late Signs |
|---|---|
| Headache (worse in AM) | Decreased LOC |
| Nausea/vomiting | Pupil changes (unilateral dilation) |
| Restlessness, confusion | Cushing's triad: bradycardia, hypertension, irregular respirations |
| Visual changes | Posturing (decorticate → decerebrate) |
| Seizures |
Nursing Interventions for Increased ICP:
- Elevate HOB 30 degrees (promotes venous drainage)
- Maintain head in midline (prevents jugular vein compression)
- Avoid activities that increase ICP: coughing, straining, suctioning, Valsalva
- Monitor neuro status frequently
- Maintain quiet, calm environment
- Administer osmotic diuretics (mannitol) as ordered
Stroke (Cerebrovascular Accident)
Types of Stroke:
| Type | Cause | Treatment Window |
|---|---|---|
| Ischemic (85%) | Clot blocking blood flow | tPA within 4.5 hours of symptom onset |
| Hemorrhagic (15%) | Bleeding in brain | Control bleeding, manage ICP |
Stroke Warning Signs (BE FAST):
- Balance: Sudden loss of balance
- Eyes: Sudden vision changes
- Face: Facial drooping
- Arm: Arm weakness, drift
- Speech: Slurred speech, difficulty speaking
- Time: Time to call 911
Stroke Complications and Care:
| Complication | Nursing Interventions |
|---|---|
| Dysphagia | NPO until swallow evaluation; aspiration precautions |
| Hemiplegia/paresis | ROM exercises, positioning, mobility training |
| Aphasia | Use simple communication, allow time, speech therapy |
| Neglect | Approach from unaffected side, teach scanning |
| Incontinence | Bladder training, toileting schedule |
| Emotional lability | Provide support, allow expression, consistency |
Seizures
Types of Seizures:
| Type | Description | Characteristics |
|---|---|---|
| Generalized Tonic-Clonic | Whole body involvement | Loss of consciousness, rigidity (tonic), jerking (clonic) |
| Absence | Brief loss of awareness | Staring, may not remember episode |
| Focal (Partial) | One area of brain | May or may not lose consciousness |
| Status Epilepticus | Continuous or rapidly recurring seizures | Medical emergency (> 5 minutes) |
Seizure Management:
-
During seizure:
- Stay with patient
- Protect from injury (clear area, don't restrain)
- Turn to side if possible (after tonic-clonic phase)
- Do NOT put anything in mouth
- Time the seizure
- Call for help if > 5 minutes or injury suspected
-
After seizure (postictal period):
- Maintain airway, position for drainage
- Reorient patient
- Assess for injuries
- Allow rest
- Document: type, duration, body parts involved, aura, postictal state
Meningitis
Meningitis is inflammation of the meninges (membranes covering brain and spinal cord).
Types:
- Bacterial: Most serious, requires immediate treatment
- Viral: Usually less severe, supportive care
- Fungal: Often in immunocompromised patients
Signs and Symptoms:
- Fever, headache
- Nuchal rigidity (stiff neck)
- Photophobia
- Altered mental status
- Kernig's sign: Unable to straighten leg when hip flexed
- Brudzinski's sign: Neck flexion causes hip/knee flexion
Meningitis Precautions:
- Bacterial meningitis: Droplet precautions until 24 hours of antibiotic therapy
- Private room, mask for close contact
- Prophylaxis for close contacts may be ordered
Parkinson's Disease
Parkinson's disease is a progressive movement disorder caused by dopamine deficiency.
Cardinal Signs (TRAP):
- Tremor: Resting tremor ("pill-rolling")
- Rigidity: Muscle stiffness, "cogwheel" rigidity
- Akinesia/Bradykinesia: Slow movement
- Postural instability: Balance problems, shuffling gait
Nursing Considerations:
- Medications must be given on time (levodopa has narrow window)
- Fall prevention (shuffling gait, balance issues)
- Swallowing assessment (dysphagia risk)
- Allow extra time for activities
- Maintain mobility and independence as long as possible
Test Your Knowledge
A patient's Glasgow Coma Scale score drops from 12 to 8. What does this indicate?
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B
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D
Test Your Knowledge
During a seizure, what is the priority nursing action?
A
B
C
D
Test Your Knowledge
A patient with suspected increased ICP should be positioned with:
A
B
C
D