Neuro: pressure, stroke, seizure

Brain tissue, blood, and cerebrospinal fluid share a fixed volume inside a rigid skull. When one rises, another must be displaced. Compensation works quietly until it is exhausted, and then perfusion drops fast. Every neurological item on this exam turns on how early the candidate notices.

Rising intracranial pressure

• The earliest sign is a change in level of consciousness: restlessness, confusion, difficulty rousing, a patient who was oriented at the start of the shift and is now vague.
• Headache, vomiting that arrives without preceding nausea, and pupil changes follow.
• Cushing's triad, a rising systolic with a widening pulse pressure, bradycardia, and irregular respirations, is late and ominous.
• Nursing actions: head of bed at thirty degrees, head midline to keep venous drainage open, no hip flexion, activities spaced rather than clustered, suctioning kept brief, and coughing and straining prevented.

Stroke: the clock

Time last known well is the single most valuable piece of data the nurse collects, and it is collected from whoever saw the patient last, not from the patient. Sudden unilateral weakness, facial droop, slurred or absent speech, and sudden vision loss all trigger the stroke pathway. Imaging separates ischemic from hemorrhagic before any clot-directed therapy is considered; that decision belongs to the provider. The nurse keeps the patient nothing by mouth until a swallow screen is passed, because aspiration is the complication the exam builds items around.

Seizure: the don'ts

• Do not restrain the patient, do not force anything into the mouth, do not leave the bedside.
• Do turn the patient to the side, protect the head, loosen restrictive clothing, time the event, and keep suction and oxygen at hand.
• Continuous seizure activity beyond five minutes is status epilepticus and is an emergency.

Margin noteconsciousness drops before the vital signs move.

Watch outCushing's triad means herniation is near. Escalate immediately.

TakeawayIn neuro, the first abnormal finding is almost always a change in how the patient is behaving, not a number.

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