Neurological Disorders

Stroke (CVA — Cerebrovascular Accident)

Time is brain — one of the most heavily tested neuro topics.

BE-FAST Screening

• Balance — sudden loss of balance or dizziness
• Eyes — sudden blurred or double vision
• Face — facial drooping (ask patient to smile)
• Arm — arm weakness or drift (ask to raise both arms)
• Speech — slurred or strange speech (ask to repeat a phrase)
• Time — call 911 immediately, note time of symptom onset

Ischemic vs Hemorrhagic Stroke

CauseIschemic (~87%)

Blood clot blocks cerebral artery (thrombus or embolus)

CauseHemorrhagic (~13%)

Ruptured blood vessel bleeds into brain

tPA (alteplase)Ischemic

YES — within 3–4.5 hours of symptom onset

tPA (alteplase)Hemorrhagic

ABSOLUTELY CONTRAINDICATED (would worsen bleeding)

BP managementIschemic

Allow permissive hypertension initially (brain needs perfusion)

BP managementHemorrhagic

Aggressively lower BP to reduce bleeding

CT scanIschemic

Must rule out hemorrhage BEFORE giving tPA

CT scanHemorrhagic

Shows blood in brain tissue

Left vs Right Brain Stroke

WeaknessLeft brain

Right-sided weakness/paralysis

WeaknessRight brain

Left-sided weakness/paralysis

LanguageLeft brain

Aphasia (speech/language deficits)

PerceptionRight brain

Neglect (unaware of left side of body/environment)

BehaviorLeft brain

Slow, cautious behavior; difficulty with math, reading, writing

BehaviorRight brain

Impulsive, poor judgment, safety risk; spatial-perceptual deficits

Key Nursing Interventions

• CT scan STAT before any treatment (rule out hemorrhage)
• Swallow assessment before ANYTHING PO — aspiration risk is major. NPO until cleared.
• HOB elevated 30 degrees
• Neuro checks frequently (NIH Stroke Scale)
• DVT prophylaxis (immobility risk)
• Speech therapy referral for aphasia/dysphagia
• Approach patient from the affected side to encourage awareness

Increased ICP & Head Injuries

Know the early vs late signs — Cushing's triad is always tested.

Early Signs of Increased ICP

• Headache (often worst in the morning)
• Restlessness, irritability, confusion
• Changes in level of consciousness (LOC) — most sensitive indicator
• Projectile vomiting (without nausea)
• Blurred vision, pupil changes

Late Signs (Ominous!)

• Cushing's Triad: hypertension with widening pulse pressure + bradycardia + irregular respirations — this is a LATE, life-threatening sign
• Posturing:
  • Decorticate = arms flexed toward core (less severe — think "toward the core")
  • Decerebrate = arms extended, internally rotated (more severe — think "away from body")
• Fixed, dilated pupils (unilateral = herniation on that side)
• Loss of consciousness → coma

Nursing Interventions for Increased ICP

• Elevate HOB 30 degrees — promotes venous drainage from the brain
• Keep head and neck in midline alignment (no flexion or rotation — impedes venous return)
• Avoid Valsalva maneuver (straining, coughing, bearing down) — increases ICP
• Reduce environmental stimuli (dim lights, minimize noise)
• Administer mannitol (osmotic diuretic — pulls fluid from brain tissue). Requires a Foley catheter for accurate I&O.
• Administer dexamethasone (corticosteroid — reduces cerebral edema)
• Monitor neurological status with Glasgow Coma Scale (GCS): Eye + Verbal + Motor = 3–15. Score of 8 or below = coma.
• Seizure precautions for ALL neuro patients

Seizures

Know what to do DURING a seizure and what seizure precautions look like.

Types of Seizures

Generalized tonic-clonicgrand mal

Loss of consciousness, stiffening (tonic) → rhythmic jerking (clonic). May have aura beforehand. Postictal phase (confusion, fatigue, sleepiness).

Absencepetit mal

Brief "staring spells" lasting 5–10 seconds. No postictal phase. Common in children. May be mistaken for daydreaming.

Focal (partial)

Starts in one area of the brain. May or may not involve altered consciousness. Can progress to generalized.

Status epilepticus

Continuous seizure lasting >5 minutes OR repeated seizures without regaining consciousness. MEDICAL EMERGENCY — can cause brain damage and death.

Nursing Care DURING a Seizure

• Protect from injury — clear area of hard/sharp objects, lower to floor if possible
• Turn on SIDE to maintain airway and prevent aspiration
• Time the seizure — duration is critical information
• Do NOT restrain the patient
• Do NOT put anything in the mouth (they will not swallow their tongue)
• Loosen restrictive clothing
• Do NOT attempt to give oral medications during a seizure
• Stay with the patient

Seizure Precautions

• Padded side rails up
• Suction and oxygen at bedside
• IV access maintained
• Bed in lowest position
• Anticonvulsant medications given on time (never skip doses)

Meningitis

Infection of the meninges — know the signs, the isolation, and the lumbar puncture.

Signs & Symptoms

• Nuchal rigidity (stiff neck — cannot touch chin to chest)
• Severe headache
• Photophobia (light sensitivity)
• High fever
• Kernig's sign: pain/resistance when extending the knee while hip is flexed
• Brudzinski's sign: involuntary flexion of hips/knees when neck is flexed
• Altered LOC, seizures in severe cases
• Petechial rash (especially with meningococcal meningitis — ominous sign)

Nursing Interventions

• Droplet precautions (bacterial meningitis) — private room, mask within 3 feet
• Antibiotics ASAP — do not delay for diagnostic tests
• Decrease environmental stimuli (dark, quiet room)
• Seizure precautions
• Monitor neurological status and vital signs frequently
• HOB elevated, neck in neutral position

Lumbar Puncture

• Confirm meningitis diagnosis via CSF analysis
• Position: side-lying, fetal position (opens spinal spaces)
• Post-procedure: lie flat for 1+ hours to prevent spinal headache
• Encourage fluids to replace CSF
• Monitor puncture site for leakage, redness, swelling

Parkinson's Disease

Know the classic triad and the priority safety concerns.

Parkinson's disease is a progressive degenerative disorder caused by loss of dopamine-producing neurons in the substantia nigra. There is no cure — treatment focuses on symptom management.

Classic Triad

• Tremor — resting tremor (pill-rolling), worse at rest, decreases with intentional movement
• Rigidity — cogwheel rigidity (jerky, ratchet-like resistance to passive movement)
• Bradykinesia — slowness of movement, shuffling gait, difficulty initiating movement

Other Features

• Mask-like facial expression (flat affect)
• Stooped, forward-leaning posture
• Shuffling, festinating gait (small steps, tendency to accelerate)
• Dysphagia (aspiration risk!)
• Soft, monotone speech
• Autonomic dysfunction (constipation, urinary issues, orthostatic hypotension)

Priority Nursing Concerns

• Fall prevention — #1 safety concern. Shuffling gait + rigidity + postural instability = high fall risk
• Aspiration prevention — swallow assessment, upright positioning during meals, thick liquids if needed
• Give medications ON TIME — timing is critical for symptom control (particularly levodopa/carbidopa)

Multiple Sclerosis (MS)

Demyelination of the CNS — unpredictable relapses and remissions.

MS is an autoimmune disease that destroys the myelin sheath surrounding nerves in the brain and spinal cord. This disrupts nerve impulse transmission. It follows a pattern of exacerbations (relapses) and remissions. Most common in young women (20–40 years old).

Signs & Symptoms

• Visual disturbances (optic neuritis — often the first symptom; diplopia)
• Muscle weakness, spasticity, fatigue (worsens with heat — Uhthoff's phenomenon)
• Numbness, tingling, paresthesias
• Bowel/bladder dysfunction (retention or incontinence)
• Cognitive changes, depression
• Intention tremor (tremor during purposeful movement — opposite of Parkinson's resting tremor)
• Lhermitte's sign: electric shock sensation down the spine when flexing the neck

Nursing Interventions

• Avoid heat — heat worsens symptoms (no hot baths, avoid sun exposure, cool environment)
• Energy conservation — plan activities, schedule rest periods, prioritize tasks
• Fall prevention (weakness, spasticity, balance issues)
• Assistive devices as needed
• Bladder program for urinary dysfunction
• Emotional support — chronic, unpredictable disease

Alzheimer's Disease

Progressive, irreversible cognitive decline — focus on safety and caregiver support.

Alzheimer's is the most common cause of dementia. It is progressive, irreversible, and terminal. Characterized by beta-amyloid plaques and neurofibrillary tangles in the brain.

The 5 A's of Alzheimer's

• Amnesia — memory loss (short-term first, then long-term)
• Aphasia — language difficulties
• Agnosia — inability to recognize familiar objects or people
• Apraxia — inability to perform learned motor tasks (dressing, eating)
• Altered perception — misinterpretation of environmental stimuli

Nursing Priorities

• Safety is #1 — wandering, falls, leaving stove on, medication errors, driving
• Consistent routine — reduces confusion and agitation
• Simple communication — short sentences, one-step instructions, calm tone
• Do NOT argue or try to reorient to reality — use validation therapy and redirection
• Provide a calm, structured environment — reduce stimulation during sundowning (late afternoon/evening agitation)
• Label rooms, use picture cues
• Caregiver support and respite — caregiver burnout is a major concern
• Monitor nutrition and hydration (patient may forget to eat)

Spinal Cord Injuries

Know the level of injury, the types of shock, and autonomic dysreflexia.

Levels of Injury

• Quadriplegia/Tetraplegia: Injury at C1–C7 → paralysis of all four extremities. C3–C5 injuries affect the diaphragm (phrenic nerve) → ventilator-dependent. Think: "C3, 4, 5 keeps the diaphragm alive."
• Paraplegia: Injury at T1 or below → paralysis of lower extremities. Upper body function preserved.

Spinal Shock vs Neurogenic Shock

What it isSpinal Shock

Temporary loss of all reflex activity below the injury

What it isNeurogenic Shock

Loss of sympathetic tone → cardiovascular collapse

SignsSpinal Shock

Flaccid paralysis, absent reflexes, loss of sensation, urinary retention, paralytic ileus

SignsNeurogenic Shock

Hypotension, bradycardia, warm/dry skin (vasodilation), hypothermia

DurationSpinal Shock

Days to weeks; resolves when reflexes return

DurationNeurogenic Shock

Acute — requires immediate treatment

TreatmentSpinal Shock

Supportive — monitor, prevent complications

TreatmentNeurogenic Shock

IV fluids, vasopressors, atropine for bradycardia

Autonomic Dysreflexia (MEDICAL EMERGENCY — T6 and above)

An exaggerated sympathetic response to a noxious stimulus below the level of injury. Most common trigger: full bladder or constipation.

• Signs: severe hypertension (can reach 300 systolic), pounding headache, bradycardia, flushing and sweating ABOVE the injury, pallor and goosebumps BELOW the injury, nasal congestion, blurred vision

Nursing Interventions for Autonomic Dysreflexia

Key Neuro Medications

The neurological medications most commonly tested on the exam.

tPA (alteplase)Ischemic stroke

Must give within 3–4.5 hrs. CONTRAINDICATED in hemorrhagic stroke. Monitor for bleeding.

Levodopa/Carbidopa (Sinemet)Parkinson's

Replaces dopamine. Take on empty stomach. Avoid high protein near doses. Don't stop abruptly.

Phenytoin (Dilantin)Seizures

Monitor levels (therapeutic: 10–20 mcg/mL). Gingival hyperplasia — good oral care. IV: give slowly (cardiac risk). Drug interactions.

Lorazepam (Ativan)Status epilepticus

First-line for active seizure. IV push. Monitor respiratory depression. Have flumazenil available (antidote for benzos).

MannitolIncreased ICP

Osmotic diuretic — pulls fluid from brain tissue. Requires Foley for I&O. Monitor electrolytes, renal function.

DexamethasoneCerebral edema

Corticosteroid to reduce brain swelling. Monitor glucose. Taper dose — do not stop abruptly.

Donepezil (Aricept)Alzheimer's

Cholinesterase inhibitor — improves cognition temporarily. Does NOT cure or stop progression. Give at bedtime. Side effects: GI upset, bradycardia.

Interferon beta (Avonex, Rebif)Multiple sclerosis

Immunomodulator — reduces relapse frequency. Injection. Flu-like side effects. Monitor liver function.

BaclofenSpasticity (MS, SCI)

Muscle relaxant. Do NOT stop abruptly (withdrawal → seizures, hallucinations). Can cause drowsiness.

Frequently Asked Questions

Common student questions on this topic.

Quick-Reference Cheatsheet

Every key point from this guide on a single printable page.