Neurologic System, Stroke, and Head Injury

Vocabulary practice cards covering focused neurologic assessment, diagnostic procedures, stroke types and emergency management, head injuries, intracranial pressure dynamics, and related nursing care.

Level of Consciousness (LOC)

A measurement reflecting the patient's ability to arouse, respond, and interact with their environment.

Glasgow Coma Scale (GCS)

A standardized scoring tool used to assess level of consciousness across eye opening, best verbal, and best motor responses, ranging from $3$ (totally unresponsive) to $15$ (best response), with a score of $8$ or less indicating a comatose state.

PERRLA

An acronym describing a normal pupillary assessment finding: Pupils Equal, Round, Reactive to Light, and Accommodation.

Pronator Drift

A physical assessment technique where the patient extends both arms forward with palms up and closes their eyes; downward drift or pronation of one arm indicates subtle motor weakness.

Expressive Aphasia

A language impairment where the patient understands what they want to say but experiences difficulty producing language.

Nursing Strategies:

• ask simple questions

• allow plenty of response time

• use yes/no questions when helpful

• provide communication boards/picutres

• encourage gestures/writing if possible

• do not finish every sentence for the patient

Receptive Aphasia

A language impairment characterized by difficulty understanding language, even though the patient's speech output may remain fluent.

Nursing Strategies:

• use short, simple statements

• give one instruction at a time

• use gestures/visual cues

• repeat/rephrase as needed

• verify understanding

• actively listen and be patient

Dysarthria

A motor speech disorder caused by impaired muscle control used for speech production, resulting in slurred or hard-to-understand speech while language comprehension remains intact.

Noncontrast Head CT

The essential initial imaging modality for suspected acute stroke used primarily to rapidly rule out intracranial hemorrhage before administering reperfusion therapies.

Magnetic Resonance Angiography (MRA)

A specialized non-invasive magnetic resonance study that provides detailed visualization of cerebral blood vessels to detect stenosis, occlusions, or aneurysms.

Cerebral Angiography

An invasive vascular procedure in which a catheter is threaded through an artery into cerebral circulation to visualize vessels, diagnose aneurysms or arteriovenous malformations, and guide endovascular therapy.

Key nursing responsibilities include checking contrast allergy history, reviewing kidney function (BUN/creatinine), verifying consent, keeping NPO as ordered, and assessing baseline neuro status and peripheral pulses before the procedure; after the scan, nurses must monitor the access site for bleeding/hematoma, evaluate distal pulses and neurovascular status, track

Lumbar Puncture (LP)

A diagnostic procedure where a needle is inserted into the subarachnoid space (typically while side-lying with knees flexed) to collect cerebrospinal fluid (CSF) for analysis.

This procedure is used to diagnose conditions such as infections, inflammatory/demyelinating disorders, bleeding, and inflammatory diseases of the central nervous system, and to measure intracranial pressure.

Key Nursing Responsibilities:

• obtaining informed consent

• ensuring the patient is in the correct position

• monitoring vital signs during and after the procedure

• assessing the puncture site for complications

• Monitor for post-dural puncture headache (worse when upright, improves when lying down)

• providing post-procedure care, such as ensuring adequate fluid intake to prevent headaches.

Unsafe in patients with increased intracranial pressure due to risk of herniation.

Electroencephalogram (EEG)

A diagnostic procedure that records the electrical activity of the brain using scalp electrodes to evaluate seizures, epilepsy, or unexplained altered mental status.

Key nursing responsibilities:

• explain that the procedure is painless

• hair should be clean and free of styling products

• sleep deprivation may be ordered

• medications are adjusted only if prescribed

• patient may be exposed to flashing lights or hyperventilation during testing

External Ventricular Drain (EVD)

A device inserted into the lateral ventricles of the brain to monitor intracranial pressure and drain cerebrospinal fluid (CSF) to manage elevated ICP. This procedure is commonly used in cases of traumatic brain injury, hemorrhage, or hydrocephalus, providing both diagnostic and therapeutic benefits.

Nursing Priorities:

• maintain prescribed drainage level

• level system to ordered anatomical reference

• repositioning/ambulation requires nursing assistance to maintain drainage pressures

• monitor ICP

• monitor amount/color of CSF drainage (to look for signs of infection)

• assess neurologic status

• maintain strict aseptic technique

• monitor for infection

Craniotomy

A neurosurgical procedure where a portion of the skull (bone flap) is temporarily removed to access brain tissue and then replaced. Used to access the brain for tumors, hemorrhage, aneurysms, etc. Bone flap is replaced.

Craniectomy

A neurosurgical procedure where a portion of the skull is removed and not immediately replaced, providing space for severe cerebral swelling. This procedure is often indicated for conditions such as traumatic brain injury or large strokes, where removal of the skull can help relieve pressure on the brain.

Burr Holes

Small openings are drilled through the skull to drain hematomas or collections of fluid. Lower impact on the patient, but still a concern for infection.

Transient Ischemic Attack (TIA)

A temporary episode of focal neurological dysfunction caused by brain ischemia without acute tissue infarction, serving as an important warning sign for future stroke. Also known as a mini-stroke, it typically lasts less than 24 hours and may resolve quickly, indicating a need for urgent medical evaluation.

Thrombotic Ischemic Stroke

An ischemic stroke caused by a clot forming directly within a cerebral artery, frequently associated with underlying atherosclerotic disease. Ruptured plaque that cuts off blood supply.

Embolic Ischemic Stroke

An ischemic stroke caused by a clot or debris traveling from another part of the body (such as the heart or carotid arteries) and blocking a cerebral blood vessel. Atrial fibrillation is an important cause.

Lacunar Ischemic Stroke

An ischemic stroke resulting from the occlusion of small penetrating arteries deep within the brain is strongly linked to chronic hypertension and diabetes.

Ischemic Penumbra

The region of ischemic but structurally intact brain tissue surrounding an infarction core that remains viable if blood flow is rapidly restored.

BE FAST

A mnemonic identifying key signs of acute stroke: Balance loss, Eyes/vision changes, Face drooping, Arm weakness, Speech difficulty, and Time to call 911.

Last Known Well (LKW)

The precise time at which a patient was last observed or confirmed to be at their baseline normal neurological function, essential for establishing eligibility for reperfusion therapies, urgency and type of imaging, and treatment decision.

“When was the patient last known to be neurologically normal?” This information is critical in stroke care for determining treatment options.

NIH Stroke Scale (NIHSS)

A standardized 11-item clinical evaluation tool used to quantify acute stroke deficit severity, establish baseline impairment, and track neurological changes. Higher score = greater stroke. severity

Tenecteplase (TNK)

A weight-based IV thrombolytic agent administered as a single bolus for acute ischemic stroke reperfusion therapy. Must be given with 4.5 hours of stroke.

Alteplase (tPA)

A weight-based IV thrombolytic medication administered as an initial IV bolus followed by a 1-hour infusion for acute ischemic stroke reperfusion. Must be given with 4.5 hours of stroke.

Endovascular Thrombectomy (EVT)

An interventional procedure in which a catheter is advanced into cerebral vasculature to mechanically remove a blood clot causing a large-vessel occlusion.

Intracerebral Hemorrhage (ICH)

A subtype of hemorrhagic stroke involving direct blood vessel rupture and bleeding within brain tissue, frequently caused by chronic hypertension.

Presents as focal deficits, headache, decreased LOC, and nausea and vomiting.

Major concerns are hematoma, expansion, edema, and increased ICP

Treatment focus is control bleeding/ICP, surgery when indicated.

Subarachnoid Hemorrhage (SAH)

Bleeding into the subarachnoid space surrounding the brain, most often caused by a ruptured cerebral aneurysm, presenting with a sudden thunderclap headache.

Major concerns are rebleeding, vasospasm/delayed cerebral ischemia, and hydrocephalus

Treatment focus is secure aneurysm and prevent complications with surgical clipping or endovascular coiling, alongside supportive care.

Nimodipine

An enteral calcium channel blocker administered following aneurysmal subarachnoid hemorrhage to prevent or lessen delayed cerebral ischemia from vasospasm.

4-Factor Prothrombin Complex Concentrate (4-factor PCC)

An IV medication containing blood coagulation factors used for urgent reversal of warfarin-induced anticoagulation during acute bleeding emergencies.

Primary Brain Injury

Occurs at the moment of trauma.

Physical brain damage occurring at the direct moment of impact or trauma, such as contusions, direct tissue laceration, skull fractures, or axonal shearing.

CANNOT BE REVERSED

Secondary Brain Injury

Progressive brain damage unfolding after initial trauma caused by edema, hypoxia, hypotension, hypercapnia, elevated ICP, or impaired perfusion.

Concussion

A mild traumatic brain injury caused by mechanical forces that results in transient physical, cognitive, emotional, or sleep-related symptoms, occurring with or without loss of consciousness.

Seek immediate evaluation for:

• worsening headache

• repeated vomiting

• increased confusion/agitation

• increased drowsiness or inability to awaken

• new weakness/numbness

• slurred speech

• seizure

• one pupil larger than the other

• new loss of coordination

• loss of consciousness or worsening responsiveness

Epidural Hematoma

An accumulation of arterial blood between the skull and dura mater, often associated with skull fractures, classically marked by a brief loss of consciousness followed by a lucid interval and sudden deterioration.

NEUROSURGICAL EMERGENCY

May require rapid surgical evaluation, craniotomy/burr holes (for small bleeds), and ICP management.

Subdural Hematoma

A collection of venous blood between the dura mater and arachnoid mater caused by tearing of bridging veins, commonly seen in elderly individuals and patients with alcohol dependency.

• Acute: symptoms within 24hrs of injury. Progress rapidly, high M&M due to lots of bleeding

• Subacute: symptoms 2-10 days after injury. Slower bleed

• Chronic: symptoms appear weeks to months after injury, often subtle and progressively worsening. Can get walled off and become highly osmotic, causing expanding mass.

Diffuse Axonal Injury (DAI)

Widespread damage to nerve axons throughout the brain resulting from severe acceleration, deceleration, or rotational forces, often leading to immediate, prolonged coma.

Monro-Kellie Hypothesis

The doctrine stating that the skull is a rigid container holding brain tissue, blood, and CSF; an increase in volume of any one compartment must be offset by a decrease in another or ICP will rise.

Cerebral Perfusion Pressure (CPP)

The net pressure gradient driving blood flow to the brain cells, calculated as $\text{CPP} = \text{MAP} - \text{ICP}$, with a normal target range of $60 - 80\text{ mmHg}$.

Decorticate Posturing

An abnormal motor response to pain characterized by rigid leg extension and inward flexion of arms, wrists, and fingers toward the body's core, indicating damage above the brainstem. Arms toward the CORE

Decerebrate Posturing

An ominous motor posture characterized by rigid extension of legs, flexed wrists, and extended, pronated arms held straight at the sides, signaling brainstem involvement.

Generally indicates worse prognosis.

Cushing's Triad

A late sign of markedly increased intracranial pressure and impending brain herniation consisting of bradycardia, severe hypertension with a widening pulse pressure, and irregular respirations.

This is the body’s attempt to maintain blood flow to the brain by increasing the systemic arterial pressure.

Mannitol

An osmotic diuretic administered intravenously to pull fluid from hyper-edematous brain tissue into the intravascular space, lowering intracranial pressure.

CT with Iodinated Contrast

A diagnostic brain imaging study used to visualize vessels, tumors, and infections. Key nursing responsibilities include checking contrast allergy history, reviewing kidney function (BUN/creatinine), and ensuring IV access before the scan, followed by monitoring for allergic reactions, tracking renal function, and encouraging hydration afterwards.

MRI

A diagnostic imaging modality that provides detailed visualization of brain tissue without radiation, commonly used to evaluate ischemic injury, brain tumors, demyelinating disease, infection, and structural abnormalities.

• Nursing Responsibilities:

  • Before

    • screen for pacemakers/ICDS

    • aneurysm clips

    • cochlear implants

    • Ensure no metal implants or devices that may contraindicate use.

    • claustrophobia

  • During

    • patient must remain still

    • provide hearing protection

    • maintain communication

    • Sedation may be needed for severe claustrophobia

CT vs MRI

A comparison of primary neuroimaging modalities: CT is fast, involves radiation, and is excellent for detecting acute hemorrhage in emergencies with minimal device concerns; MRI is slower, radiation-free, requires strict safety screening for metallic implants, and provides superior brain tissue detail with greater sensitivity for early ischemic stroke.

Intracranial Pressure Monitoring

A procedure to measure the pressure within the skull, used to assess conditions like traumatic brain injury or stroke. It helps guide treatment decisions and monitor cerebral perfusion.

Normal ICP: 5-15 mm Hg

Increased ICP: Sustained elevation requires evaluation and treatment to prevent brain damage and optimize outcomes. Continuous monitoring allows for timely interventions.

Postoperative Neurosurgical Care

The management and monitoring provided after neurosurgery to ensure recovery, prevent complications, and support neurological function. This includes assessing vital signs, neurological status, and managing pain and potential infections.

• monitor BP closely

• prevent hypotension

• HOB generally elevated as prescribed

• maintain neutral head/neck alignment

• monitor LOC/GCS, pupils, motor strength, speech, and compare with preoperative baseline

Dysphagia

An impairment in swallowing function commonly caused by neurological injury, placing the patient at high risk for aspiration pneumonia.

Key Nursing & Safety Priorities:

• Keep patient strictly NPO until swallowing safety is formally evaluated

• Recognize that aspiration may be silent

• Monitor for clinical signs including coughing or choking with food/fluids, a wet or gurgling voice, drooling, food pocketing, or difficulty initiating a swallow

Protecting Affected Extremities after Stroke

Involves measures taken to safeguard and maintain the function of limbs affected by a stroke. This may include repositioning, range of motion exercises, and the use of supportive devices to prevent complications such as contractures and pressure ulcers.

• Upper Extremity

  • support affected arm during positioning/transfers

  • maintain appropriate alignment

  • avoid pulling on affected arm

  • monitor for shoulder pain/subluxation

  • encourage prescribed ROM

• Lower Extremity

  • Maintain proper positioning

  • Monitor skin and pressure areas

  • Use appropriate transfer assistance

  • Prevent foot drop/contractures as directed by therapy

• Sensory Loss

  • inspect skin frequently

  • protect from heat/cold

  • avoid pressure or injury

  • teach patient to visually inspect affected areas

Stroke Complications

Possible adverse effects that can occur after a stroke include physical, cognitive, and emotional challenges. Common complications include dysphagia, mobility issues, and risk of aspiration pneumonia. Other complications may involve aphasia, anosognosia, seizures, and changes in bladder or bowel control.

Nursing Prevention/Recognition:

• Regularly assess swallowing ability

• Implement mobility and rehabilitation strategies

• Monitor for cognitive and emotional changes

• Educate patient and family about potential complications and self-care strategies

High Yield Nursing Priorities for Stroke

Initial Assessment of Head Injury

First: Trauma priorities (Airway, Breathing, and Circulation) and Protect the cervical spine until injury is excluded.

Do a focused neurological assessment, look for evidence of head trauma, and record important history.

Cerebral Contusion

Bruising of the brain tissue. May cause local edema, hemorrhage, focal neurologic deficits, seizures, or increased ICP.

These may evolve/enlarge after the initial injury.

Increased ICP

Above 20 mmHg is considered pathologic and should be treated.

Initial symptoms: headache, projectile vomiting, papilledema

Late: Cushing’s Triad- bradycardia, hypertension (with widening pulse pressure), and irregular respiratory pattern.

Recognizing Increased ICP

Early findings:

• change in level of consciousness

• restlessness

• confusion

• increased drowsiness

• difficulty following commands

• headache

• N/V

Progressive Findings:

• Worsening LOC

• Pupillary changes

• New motor weakness

• Abnormal posturing

• Seizures

• Changes in respiratory pattern

Managing Increased ICP

1. promote venous drainage

   1. head of bed –30º

   2. Maintain neutral head and neck alignment

2. Reduce cerebral edema

3. Maintain oxygenation and ventilation

4. Maintain cerebral perfusion

5. Decrease cerebral metabolic demand

6. Remove blood/CSF/mass when necessary

Avoid unnecessary spikes caused by

• coughing, suctioning, straining, vomiting, agitation, pain, seizures, fever, hypoxia, etc

Nursing Strategies:

• Avoid prolonged excessive stimulation

• treat pain and agitation

• Prevent constipation/straining

• Control fever

• Maintain oxygenation

• Suction only when clinically necessary

• Allow recovery between stimulating activities

head of bed