Level of consciousness comes first
If you learn one neurological rule, learn this: the earliest indicator of neurological deterioration is a change in level of consciousness. Restlessness, irritability, confusion, difficulty rousing, or a subtle change described by family as 'not himself' all outrank pupil changes and vital sign changes in exam priority terms.
The Glasgow Coma Scale quantifies this with three components — eye opening, verbal response and motor response — scored from a total of three to fifteen. A score of eight or below indicates coma and an airway that generally requires protection. On the exam, a falling score across serial assessments is more meaningful than any single number.
Pupil changes are later and more localising. A unilaterally dilated, sluggish or fixed pupil suggests herniation compressing the oculomotor nerve and is an emergency. Posturing is later still: decorticate posturing with arms flexed inward indicates cortical damage, and decerebrate posturing with arms extended indicates deeper brainstem involvement and a worse prognosis.
- •Earliest sign: any change in level of consciousness
- •GCS of 8 or below generally means the airway needs protection
- •Unilateral dilated pupil suggests herniation — emergency
- •Decerebrate posturing is worse than decorticate posturing
Increased intracranial pressure
Raised intracranial pressure produces a predictable progression. Early findings are decreasing consciousness, headache that worsens in the morning or with straining, nausea and projectile vomiting without preceding nausea, and visual disturbances. Late findings are Cushing's triad — rising systolic pressure with a widening pulse pressure, bradycardia and irregular or Cheyne-Stokes respirations — along with posturing and fixed pupils.
Nursing actions are largely about not making it worse. Elevate the head of the bed to about thirty degrees unless contraindicated, keep the head and neck in neutral midline alignment to preserve venous drainage, avoid extreme hip flexion, cluster care to allow rest, minimise suctioning and keep each pass brief, and prevent Valsalva manoeuvres by managing constipation and coughing.
Know what raises pressure so you can eliminate wrong options: neck flexion or rotation, hip flexion, coughing and straining, suctioning for prolonged periods, hypercapnia, hypoxia, fever and clustering multiple stimulating activities together. Any answer option describing one of these is almost certainly the wrong action.
| Feature | Ischaemic stroke | Haemorrhagic stroke |
|---|---|---|
| Mechanism | Clot obstructing cerebral blood flow | Bleeding into brain tissue or subarachnoid space |
| Onset | Often sudden, may progress over minutes | Abrupt, often with severe headache |
| Classic report | Weakness or speech loss on waking | 'Worst headache of my life' |
| Thrombolytics | May be eligible within the treatment window | Absolutely contraindicated |
| Nursing focus | Time of onset, swallow screen, perfusion | Blood pressure control, quiet environment, ICP precautions |
Stroke assessment and recovery care
In suspected stroke, the critical piece of information is the exact time the client was last known to be well, because eligibility for thrombolytic therapy depends on it. A client found with symptoms on waking is dated from the time they went to sleep, not from when they woke. Establishing that time is the priority action in many stem variations, alongside obtaining an urgent non-contrast head scan to distinguish ischaemic from haemorrhagic before any clot-dissolving therapy.
Safety after stroke centres on swallowing and mobility. No food, fluid or oral medication should be given until a swallow screen is passed, because aspiration pneumonia is a leading cause of death after stroke. Position the client upright for meals, use thickened liquids if prescribed, and place food on the unaffected side of the mouth.
For deficits, adapt rather than correct. Approach a client with homonymous hemianopsia from the unaffected side initially and teach scanning; place the call bell within reach of the unaffected hand; support the affected arm to prevent subluxation; and for expressive aphasia allow ample time, use yes-or-no questions and picture boards, and never finish the client's sentences.
- •Time last known well determines thrombolytic eligibility
- •No oral intake until the swallow screen is passed
- •Approach from the unaffected side and teach visual scanning
- •Expressive aphasia: give time, use closed questions and picture boards
Seizure precautions and neuro safety
Seizure items have a fixed answer set. During a seizure, stay with the client, turn them to the side, protect the head, loosen restrictive clothing, remove nearby hazards, and time the event. Do not restrain the client and do not insert anything into the mouth. Afterwards, maintain a side-lying position, assess airway and vital signs, orient the client, allow rest, and document the duration, characteristics and postictal state.
Precautions before a seizure occurs include padded side rails in the raised position, the bed in the lowest position, oxygen and suction available at the bedside, and the client not left unattended in high-risk settings such as a bath. Status epilepticus — continuous seizure activity or repeated seizures without recovery — is a medical emergency requiring immediate airway management and intravenous medication.
Neuro content connects strongly to prioritisation, because a client with declining consciousness almost always outranks stable clients in first-to-see items. Practise these in mixed sets so you build the reflex of scanning for consciousness changes across every client described.