Stroke and neuro assessment

Stroke and spinal-cord items reward the nurse who protects the airway, knows the clock, and treats a pounding headache after T6 injury as an emergency, not a migraine.

Acute stroke: clock and airway

Sudden one-sided weakness, facial droop, or speech change is a stroke pathway until imaging and the neurologist say otherwise. The single most important historical fact for ischemic treatment is when the client was last known well.

BEFAST (Balance, Eyes, Face, Arms, Speech, Time) widens the public screen beyond classic FAST. Sudden ataxia, vision loss, facial droop, arm drift, and speech change all start the clock. Ischemic stroke is a blocked artery; hemorrhagic stroke is bleeding into brain tissue or spaces. You cannot tell them apart by kindness of symptoms alone. CT before IV thrombolysis exists because alteplase in a bleed worsens catastrophe. BP targets differ by pathway. Follow the order set rather than inventing a number.

• Activate the stroke response. ABCs and glucose check happen early (hypoglycemia mimics stroke).
• CT rules out hemorrhage before IV thrombolysis decisions.
• Know facility contraindications for alteplase (recent surgery, active bleed, uncontrolled severe hypertension, etc.) as listed in the protocol.
• After alteplase: neuro checks, bleed watch, avoid unnecessary invasive procedures for the protocol window.

Hemorrhagic stems emphasize BP control, ICP awareness, and no anticoagulants/thrombolytics. Neglect (ignoring one side of space) and aphasia change how you approach the bed and give teaching. Stand on the client’s intact side when needed, and keep communication simple for expressive or receptive aphasia.

Dysphagia and aspiration precautions

Stroke can weaken the muscles and sensation that keep food and liquid out of the airway. Aspiration is often silent until pneumonia or hypoxia shows up, so the exam treats oral intake after stroke as an airway decision, not a meal-tray courtesy.

1. Keep NPO until a swallow screen or speech evaluation clears oral intake.
2. Feed upright (high Fowler's); keep upright after meals as ordered.
3. Use ordered consistency (thin vs thickened). No straws unless cleared.
4. Have suction ready. Chin-tuck or other strategies only as taught for that client.

Why NPO until a screen clears them: the first sip can put thin liquid into the lungs before anyone hears a cough. Upright positioning uses gravity to keep the bolus moving down the esophagus; lying flat or leaning back for “comfort” invites pooling. Ordered consistency and straw rules exist because thin liquids and straw flow are harder to control when the swallow is weak. Suction readiness matters because even a cleared client can still cough or pocket food. Chin-tuck and other cues are client-specific strategies taught after evaluation: inventing your own maneuver is not the answer.

The distractor that looks kind is giving water for thirst, a favorite snack for morale, or a straw “so they do not spill.” Those moves skip the airway screen. Edge case: once speech therapy clears a diet level, follow that level exactly; do not upgrade to thin liquids because the client asks or looks thirsty.

Neuro and pain assessment

A focused neuro exam after stroke or spinal injury is how you catch change from *this* client’s baseline. Falling LOC, new confusion, or a sudden growth in deficit means the brain picture is evolving: report it now, do not wait for a perfect textbook late pattern.

GCS scores eye opening, verbal response, and best motor response so you can track LOC with a shared number instead of vague “more sleepy.” Orientation questions (person, place, time) are a separate check for confusion. A client can open eyes and still be disoriented. New unequal, fixed, or poorly reactive pupils are an emergency escalate cue on any neuro stem. Head-of-bed positioning, Cushing triad, and the full early-versus-late ICP map live in Increased ICP and head injury. Use that chapter when the stem turns on pressure mechanics rather than stroke swallow safety or a focused exam.

Pain assessment on this topic is honesty under pressure. Pain is what the client says it is; a calm face with a reported 8/10 still needs treatment. Infants and nonverbal clients cannot use a 0-10 self-report alone: use a behavioral tool (FLACC-style cues) and treat what the scale and clinical picture show. The distractor that looks objective is dismissing the number because vitals are stable or the client is joking between scores. Edge case: cardiopulmonary landmarks, refill time, and breath-sound meanings are owned by Acute coronary syndromes; keep this section on neuro change and pain truth, not a full systems review.

Spinal cord injury complications

Autonomic dysreflexia

In clients with injury typically at or above T6, a noxious stimulus below the injury can trigger massive hypertension. Classic picture: pounding headache, BP sky-high, bradycardia, flushing/sweating above the injury.

1. Sit the client up / elevate the head of bed.
2. Loosen tight clothing and abdominal binders.
3. Check bladder (kinked catheter, distention) and bowel/skin triggers.
4. Notify the provider; give ordered antihypertensives if the trigger cannot be cleared quickly.

Neurogenic shock

Early after SCI: hypotension with bradycardia and warm dry skin below the injury from lost sympathetic tone. This is not the cool-clammy hypovolemic picture.

Priority map