Neurologic

Neurologic critical care is a vital component of nursing practice, focusing on the assessment and management of life-threatening neurological conditions such as strokes, traumatic brain injuries, seizures, and increased intracranial pressure. For the NCLEX-RN®, understanding key concepts like the Glasgow Coma Scale, pupillary assessments, and nursing interventions ensures effective prioritization of care. Nurses must recognize early signs of neurological deterioration, implement safety measures, and manage airway and hemodynamics to optimize patient outcomes. Mastery of these skills is crucial for both exam success and clinical competence.

Learning Objectives

In studying “Critical Care: Neurologic” for the NCLEX-RN® exam, you should learn to recognize and manage life-threatening neurological conditions, including traumatic brain injuries (TBI), strokes, seizures, and increased intracranial pressure (ICP). Understand key neurological assessments, such as the Glasgow Coma Scale, pupillary response, and cranial nerve evaluation, to monitor patient status effectively. Evaluate nursing interventions to maintain airway patency, control ICP, and ensure seizure precautions. Analyze principles behind pharmacologic therapies, such as thrombolytics and anticonvulsants, and their clinical applications. Apply this knowledge to prioritize care, enhance patient safety, and interpret critical scenarios in NCLEX practice questions and case studies.

1. Key Neurological Conditions in Critical Care

Neurological emergencies in critical care require prompt recognition and management to prevent irreversible damage. Key conditions include:

• Traumatic Brain Injury (TBI):
  Causes include trauma from accidents or falls, categorized into concussion, contusion, or diffuse axonal injury. Nursing priorities include monitoring Glasgow Coma Scale (GCS) scores, observing for signs of increased intracranial pressure (ICP), and managing oxygenation and perfusion.
• Stroke:
  Ischemic strokes result from clots blocking blood flow, while hemorrhagic strokes involve ruptured vessels causing bleeding. FAST recognition (Face drooping, Arm weakness, Speech difficulties, Time to act) is crucial. Ischemic strokes often require thrombolytics, while hemorrhagic strokes focus on blood pressure control and surgical interventions.
• Seizures and Status Epilepticus:
  Seizures stem from abnormal brain electrical activity, while status epilepticus involves continuous seizures lasting over 5 minutes. Nursing interventions include ensuring patient safety, protecting the airway, administering anticonvulsants like lorazepam or phenytoin, and documenting seizure activity.
• Increased Intracranial Pressure (ICP):
  Increased ICP can result from trauma, hydrocephalus, or infections. Signs include Cushing’s triad (bradycardia, hypertension, irregular respirations), vomiting, and altered mental status. Treatment includes elevating the head of the bed, reducing stimuli, and administering medications such as mannitol or hypertonic saline.

2. Neurological Assessment and Monitoring

Accurate and frequent assessments are vital in critical care to detect early changes in neurological status.

• Glasgow Coma Scale (GCS):
  Evaluates eye-opening, verbal response, and motor response. Scores below 8 indicate severe impairment, necessitating immediate intervention.
• Pupillary Response:
  Pupils are assessed for size, equality, and reaction to light (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation). Sluggish or unequal pupils may indicate increased ICP or cranial nerve compression.
• Cranial Nerve Assessment:
  Focus on specific nerves based on symptoms:
  • CN III (Oculomotor): Pupil reaction.
  • CN VII (Facial): Facial asymmetry.
  • CN IX and X (Glossopharyngeal and Vagus): Swallowing and gag reflex.
• Vital Signs:
  Monitor patterns like Cushing’s triad or Cheyne-Stokes breathing, which may indicate brainstem dysfunction or impending herniation.

3. Nursing Interventions and Prioritization

Effective nursing interventions are central to managing critical neurological conditions.

• Airway Management:
  For patients with GCS ≤8, securing the airway through intubation is a priority. Monitor for respiratory patterns that indicate neurological compromise, such as apnea or agonal breathing.
• ICP Management:
  Nursing care includes:
  • Keeping the head of the bed elevated to 30° to improve venous drainage.
  • Avoiding activities that increase ICP, such as coughing or straining.
  • Administering osmotic diuretics (e.g., mannitol) and monitoring ICP values.
• Seizure Precautions:
  Maintain a safe environment by padding side rails, removing potential hazards, and ensuring IV access for emergency medication administration. Postictal care involves reorienting the patient and assessing for injuries.
• Psychosocial Support:
  Patients and families often experience anxiety and uncertainty. Provide clear explanations, involve families in care decisions, and ensure a compassionate approach to alleviate stress.

Examples

Example 1: Managing Increased Intracranial Pressure (ICP)

A patient with a traumatic brain injury (TBI) is admitted to the ICU. The nurse observes Cushing’s triad—bradycardia, hypertension, and irregular respirations. The priority is to elevate the head of the bed to 30 degrees to reduce ICP, avoid activities that increase pressure (e.g., suctioning, straining), and administer osmotic diuretics like mannitol as prescribed. Close monitoring of neurological status using the Glasgow Coma Scale (GCS) and reporting of pupil changes are critical interventions.

Example 2: Responding to an Acute Stroke

A 65-year-old patient arrives in the emergency department presenting with left-sided facial droop, slurred speech, and weakness in the right arm. The nurse identifies the symptoms of an ischemic stroke and ensures immediate action by initiating a stroke alert. Preparing the patient for a CT scan to rule out hemorrhage is crucial before administering tissue plasminogen activator (tPA) within the 3-4.5-hour therapeutic window. Time-sensitive interventions and continuous neuro checks are priorities.

Example 3: Managing Status Epilepticus

A patient with a history of epilepsy begins experiencing a prolonged seizure lasting over 5 minutes. The nurse ensures airway protection by positioning the patient on their side, administering oxygen, and ensuring the bed rails are padded. Emergency medications such as lorazepam (Ativan) or diazepam (Valium) are administered intravenously to terminate the seizure. Postictal monitoring for neurological recovery and vital signs stability is essential to prevent further complications.

Example 4: Caring for a Spinal Cord Injury (SCI)

A patient with a complete spinal cord injury at the T4 level is admitted following a motor vehicle accident. The nurse prioritizes stabilizing the spine by maintaining cervical immobilization and monitoring for neurogenic shock (hypotension, bradycardia). The nurse assesses for complications like autonomic dysreflexia, characterized by a sudden spike in blood pressure triggered by stimuli such as a full bladder. Immediate interventions include sitting the patient upright, loosening restrictive clothing, and identifying the cause.

Example 5: Managing a Post-Craniotomy Patient

A patient recovering from a craniotomy to remove a brain tumor is admitted to the ICU. The nurse monitors for complications such as infection (fever, meningitis symptoms), increased ICP, and cerebral edema. Nursing care includes maintaining strict aseptic technique for wound care, ensuring the head is midline and elevated, and administering prescribed corticosteroids to manage inflammation. Regular neurological assessments are performed to detect any deterioration in mental status or motor function.

Practice Questions

Question 1

A patient with a traumatic brain injury (TBI) is being monitored in the ICU. Which finding is most concerning and requires immediate intervention?

A. Pupils equal, round, and reactive to light.
B. Glasgow Coma Scale (GCS) score of 15.
C. Blood pressure of 190/90 mmHg with bradycardia.
D. Slight confusion noted during verbal responses.

Answer: C. Blood pressure of 190/90 mmHg with bradycardia.

Explanation:

• This is a classic sign of Cushing’s triad, which indicates increased intracranial pressure (ICP) and impending brain herniation.
• Cushing’s triad includes hypertension, bradycardia, and irregular respirations. These findings demand immediate intervention, such as reducing ICP through osmotic diuretics or other measures.
• Option A: Normal pupil findings are reassuring and not concerning.
• Option B: A GCS score of 15 is normal and does not indicate any immediate neurological deficit.
• Option D: Slight confusion may warrant monitoring, but it is less critical than signs of increased ICP.

Question 2

A nurse is caring for a patient with ischemic stroke scheduled for thrombolytic therapy. What is the highest priority before administering tissue plasminogen activator (tPA)?

A. Checking blood glucose levels.
B. Verifying the time of symptom onset.
C. Assessing for facial droop and arm weakness.
D. Monitoring blood pressure for hypertension.

Answer: B. Verifying the time of symptom onset.

Explanation:

• tPA is most effective when given within a 3–4.5-hour window from symptom onset. Administering tPA outside this window increases the risk of severe complications, such as hemorrhage.
• Option A: Blood glucose should be checked to rule out hypoglycemia as a stroke mimic but is not the top priority.
• Option C: Assessing stroke symptoms is essential, but confirming the time of onset is critical for tPA eligibility.
• Option D: Blood pressure management is necessary, but tPA administration takes precedence once eligibility criteria are met.

Question 3

A patient with a history of seizures experiences a tonic-clonic seizure lasting over 5 minutes. What is the nurse’s first priority action?

A. Insert an oral airway to prevent tongue injury.
B. Administer prescribed lorazepam IV.
C. Turn the patient onto their side to maintain airway patency.
D. Document the duration and characteristics of the seizure.

Answer: C. Turn the patient onto their side to maintain airway patency.

Explanation:

• Turning the patient onto their side prevents airway obstruction by allowing secretions to drain and reducing the risk of aspiration. This is the immediate priority during a seizure.
• Option A: Oral airways are contraindicated during an active seizure as they can cause further injury.
• Option B: Administering lorazepam is appropriate to stop the seizure but is done after ensuring airway safety.
• Option D: Documentation is important but occurs after ensuring patient safety and addressing the seizure.