Acute Head Injury: What the Bedside Nurse Sees Before the Scan Confirms It

A nurse is doing a routine neuro check on a patient admitted after a fall with impact to her head six hours earlier. She sustained fractures of both arms. The head CT scan was within normal limits. The patient was oriented, moving all extremities, pupils equal and reactive.  She complained of a mild headache and requested to be left alone to sleep.

An hour later, the same patient is harder to rouse. She is not unconscious — just slower to answer, slower to open her eyes, slightly irritable when she does. The nurse could chalk it up to fatigue.

Instead, she notes it, checks the patient again in fifteen minutes, and finds the trend is real. She calls the hospitalist, who orders a repeat CT. It shows an expanding subdural hematoma. The patient goes to the OR before herniation sets in.

That nurse didn't have a new symptom to point to but rather a change in level of consciousness. And in acute head injury cases, the change is almost always the whole story.

Why the Trend Matters More Than the Snapshot

Head injury litigation rarely rests on whether a single assessment was documented correctly. It focuses on whether the clinical team recognized that a patient’s condition was headed in the wrong direction — and how quickly they acted on it.

The brain has a fixed amount of room inside the skull. When bleeding, swelling, or a growing mass lesion takes up space, something else must give. Early on, the body compensates. Once it cannot anymore, the pressure inside the skull rises sharply, and the deterioration that follows can happen fast. A patient can look reassuring at 2:00 and have a herniating brain by 3:15.

That's why a single normal exam tells the LNC very little. What tells you something is the comparison — this hour against the last one.

Nurses are usually the only people at the bedside often enough to catch that comparison in real time. Physicians round periodically. Nurses assess every hour, sometimes every fifteen minutes. Recognizing the trends is a nursing responsibility.

Acute Head Injury Charting

Level of consciousness. This is the single most sensitive indicator of a worsening head injury, and it changes before anything else does. Analyze the medical record to see if the staff noted the patient was harder to arouse than he was an hour ago, who needed more stimulus to respond, or whose answers were slower or less coherent — even if he's still "oriented times three".

Look at the Glasgow Coma Score (GCS). A drop from spontaneous eye opening to eye opening only with voice, or from voice to pain, is not a minor variation. It's often the first hard evidence of rising intracranial pressure, and it can precede a measurable drop in GCS score by a meaningful margin.

Pupillary response. A pupil that becomes sluggish, unequal, or fixed and dilated is a late and ominous sign, frequently associated with uncal herniation and compression of the third cranial nerve. By the time this appears, the window for intervention is narrowing. This is why waiting for pupil changes before escalating a concern is a mistake — pupils confirm what the level of consciousness has usually already been signaling.

Motor response and posturing. A patient who was purposefully moving a limb and is now only withdrawing from pain, or who develops decorticate or decerebrate posturing, is showing a critical change in the integrity of deeper brain structures. Asymmetry matters as much as the response itself — one side weaker or slower than the other is a localizing sign that deserves immediate attention, not a wait-and-see approach.

What This Means for Chart Review

When you're reviewing an acute head injury record for a case, don't just read each neuro check in isolation. Line them up. Look at the actual times between assessments, not just what was documented.

• Consider whether the staff treated a change in LOC as a subtle shift worth escalating, or did staff attribute this to fatigue, medication effect, or the patient being "difficult."
• Note how long elapsed between the first sign of deterioration and the repeat scan, the physician notification, or the transfer to a higher level of care.

That gap — between when the change was observable and when it was acted on — is often where the case focuses.

Learn This From Someone Who Has Published on It

Recognizing these patterns from a chart and explaining them credibly to an attorney or a jury, are two different skills. Mary Ann Seibold will be presenting on traumatic brain injury at the 14th LNC Success Online Conference, September 9–11. She is the author of Acute Head Injury, a book she published in 2026 with my help as her editor.

If you review acute head injury cases — or want to start — this is a chance to sharpen exactly the kind of clinical judgment that makes your case reviews and your testimony hold up.

Registration is open now.

Join us at the LNC Success Online Conference, September 9–11. Register here.