Altered Level of Consciousness Altered Level of Consciousness

IntroductionIntroduction

• An altered of consciousness (LOC) is apparent in the patient who is not oriented, does not follow commands, or need persistent stimuli to achieve a state of alertness. (LOC) is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. Coma is clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years).

• An altered of consciousness (LOC) is apparent in the patient who is not oriented, does not follow commands, or need persistent stimuli to achieve a state of alertness. (LOC) is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. Coma is clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years).

• Akinetic mutism is a state of unresponsiveness to the environment in the patient makes no movement or sound but sometimes opens the eyes.

• Persistent vegetative state is a condition in which the patient is described as wakeful but devoid of consciousness content, without cognitive or affective mental function. The level of responsiveness and consciousness is the most important indicator of the patient’s condition.

• Akinetic mutism is a state of unresponsiveness to the environment in the patient makes no movement or sound but sometimes opens the eyes.

• Persistent vegetative state is a condition in which the patient is described as wakeful but devoid of consciousness content, without cognitive or affective mental function. The level of responsiveness and consciousness is the most important indicator of the patient’s condition.

• Level I-conscious, cognitive, coherent (3 C’s)

• Level II-confused, drowsy, lethargic, obtunded, somnolent

• Level III-stuporous;responds only to noxious, strong or intense stimuli, e.g sternal pressure, trapezius pinch, pressure at the base of the nail or supraorbital area;very strong light or very loud sound.

• Level I-conscious, cognitive, coherent (3 C’s)

• Level II-confused, drowsy, lethargic, obtunded, somnolent

• Level III-stuporous;responds only to noxious, strong or intense stimuli, e.g sternal pressure, trapezius pinch, pressure at the base of the nail or supraorbital area;very strong light or very loud sound.

• Level IV

=Light coma-response is only by grimace or withdrawing limb from pain; primitive and disorganized response to painful stimuli.

=Deep coma-absence of response to even the most painful stimuli.

• Level IV

=Light coma-response is only by grimace or withdrawing limb from pain; primitive and disorganized response to painful stimuli.

=Deep coma-absence of response to even the most painful stimuli.

GLASGOW COMA SCALE

GLASGOW COMA SCALE

• The Glasgow Coma Scale is a tool for assessing the patient’s response to stimuli Score range from 3 (deep coma) to 15 (normal).

• The Glasgow Coma Scale is a tool for assessing the patient’s response to stimuli Score range from 3 (deep coma) to 15 (normal).

• Eye Opening response

• Eye Opening response

• Spontaneous 4

• To voice 3

• To pain 2

• None 1

• Spontaneous 4

• To voice 3

• To pain 2

• None 1

* Best Verbal response

* Best Verbal response

• Oriented 5

• Confused 4

• Inappropriate words 3

• Incomprehensible sounds 2

• None 1

• Oriented 5

• Confused 4

• Inappropriate words 3

• Incomprehensible sounds 2

• None 1

• Best Motor response

• Total

• Best Motor response

• Total

• Obeys command 6

• Localizes pain 5

• Withdraws 4

• Flexion 3

• Extension 2

• None 1

3 to 15

• Obeys command 6

• Localizes pain 5

• Withdraws 4

• Flexion 3

• Extension 2

• None 1

3 to 15

Altered LOC is not a disorder itself; rather, it is a function and symptom of multiple pathophysiologic phenomena. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose,alcohol intoxication), or metabolic (hepatic or renal failure, diabetic ketoacidosis).

Altered LOC is not a disorder itself; rather, it is a function and symptom of multiple pathophysiologic phenomena. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose,alcohol intoxication), or metabolic (hepatic or renal failure, diabetic ketoacidosis).

The underlying causes of neurologic dysfunction are disruption in the cells of the nervous system, neurotransmitters, or brain anatomy.

The underlying causes of neurologic dysfunction are disruption in the cells of the nervous system, neurotransmitters, or brain anatomy.

A disruption in the basis functional units (neurons) or neurotransmitters results in faulty impulse transmission, impeding communication within the brain or from the brain to other parts of the body. These disruptions are caused by cellular edema and other mechanism such as antibodies disrupting chemical transmission at receptor sites.

A disruption in the basis functional units (neurons) or neurotransmitters results in faulty impulse transmission, impeding communication within the brain or from the brain to other parts of the body. These disruptions are caused by cellular edema and other mechanism such as antibodies disrupting chemical transmission at receptor sites.

Intact anatomic structures of the brain are needed for proper function.

The two hemispheres of the cerebrum must communicate, via an intact corpus callosum, and the lobes of the brain (frontal, parietal, temporal and occipital) must communicate and coordinate their specific functions.

Intact anatomic structures of the brain are needed for proper function.

The two hemispheres of the cerebrum must communicate, via an intact corpus callosum, and the lobes of the brain (frontal, parietal, temporal and occipital) must communicate and coordinate their specific functions.

Additional anatomic structures of importance are the cerebellum and the brain stem.

The cerebellum has both excitatory and inhibitory actions and is largely responsible for coordination of movement.

Additional anatomic structures of importance are the cerebellum and the brain stem.

The cerebellum has both excitatory and inhibitory actions and is largely responsible for coordination of movement.

The brain stem contains areas that control the heart, respiration, and blood pressure. Disruptions in the anatomic structures are caused by trauma, edema, pressure from tumors as well as other mechanisms such as an increase or decrease in blood or cerebrospinal fluid (CSF) circulation

The brain stem contains areas that control the heart, respiration, and blood pressure. Disruptions in the anatomic structures are caused by trauma, edema, pressure from tumors as well as other mechanisms such as an increase or decrease in blood or cerebrospinal fluid (CSF) circulation

1. Alterations in LOC occur along a continuum, and the clinical manifestations depend or where the patient is along this continuum. As the patient’s state of alertness and consciousness decreases, there will be changes in the papillary response.

1. Alterations in LOC occur along a continuum, and the clinical manifestations depend or where the patient is along this continuum. As the patient’s state of alertness and consciousness decreases, there will be changes in the papillary response.

2. Initial changes may be reflected by subtle behavioral changes such as restlessness or increased anxiety

2. Initial changes may be reflected by subtle behavioral changes such as restlessness or increased anxiety

3. The pupils, normally round and quickly reactively to light, become sluggish (response is slower); as the patient becomes comatose, the pupils become fixed (no response to light). The patient in a coma does not open the eyes, respond verbally, or move the extremities in response to a request to do so.

3. The pupils, normally round and quickly reactively to light, become sluggish (response is slower); as the patient becomes comatose, the pupils become fixed (no response to light). The patient in a coma does not open the eyes, respond verbally, or move the extremities in response to a request to do so.

Assessment and Diagnostic Findings

Assessment and Diagnostic Findings

• The patient with an altered LOC is at risk for alterations in every body system. A complete assessment is performed, with particular attention to the neurologic system.

• The patient with an altered LOC is at risk for alterations in every body system. A complete assessment is performed, with particular attention to the neurologic system.

• The neurologic examination should be as complete as the LOC allows. It includes an evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. LOC, a sensitive indicator of neurologic function, is assessed base on criteria in the Glasgow Coma Scale; eye opening, verbal response (Bateman, 2001). The patient’s responses are rated on a scale from 3 to15

• The neurologic examination should be as complete as the LOC allows. It includes an evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. LOC, a sensitive indicator of neurologic function, is assessed base on criteria in the Glasgow Coma Scale; eye opening, verbal response (Bateman, 2001). The patient’s responses are rated on a scale from 3 to15

• A score of 3 indicates severe impairment of neurologic function; a score of 15 indicates that the patient is fully responsive.

• A score of 3 indicates severe impairment of neurologic function; a score of 15 indicates that the patient is fully responsive.

• If the patient is comatose, with localized signs such as abnormal papillary and motor responses, it is assumed that neurologic disease is present until proven otherwise. If the patient is comatose and papillary light reflexes are preserved, a toxic or metabolic disorder is suspected.

• If the patient is comatose, with localized signs such as abnormal papillary and motor responses, it is assumed that neurologic disease is present until proven otherwise. If the patient is comatose and papillary light reflexes are preserved, a toxic or metabolic disorder is suspected.

• Procedures is used to identify the cause of unconsciousness include scanning, imaging, tomography (eg, computed tomography magnetic resonance imaging positron emission tomography), and electroencephalography

• Procedures is used to identify the cause of unconsciousness include scanning, imaging, tomography (eg, computed tomography magnetic resonance imaging positron emission tomography), and electroencephalography

• Laboratory test include analysis of blood glucose, electrolytes, serum ammonia, and blood urea nitrogen levels as well as serum osmolality, calcium level, and partial thromboplastin and prothrombin times. Other studies may be used to evaluate serum ketones and alcohol, drug levels, and arterial blood gas levels.

• Laboratory test include analysis of blood glucose, electrolytes, serum ammonia, and blood urea nitrogen levels as well as serum osmolality, calcium level, and partial thromboplastin and prothrombin times. Other studies may be used to evaluate serum ketones and alcohol, drug levels, and arterial blood gas levels.

ComplicationsComplications

• Potential complications for the patient with altered LOC include; = respiratory failure- may develop shortly after the patient becomes unconscious = pneumonia, = pressures ulcers= and aspiration

• Potential complications for the patient with altered LOC include; = respiratory failure- may develop shortly after the patient becomes unconscious = pneumonia, = pressures ulcers= and aspiration

*If the patient cannot contain effective respiration, supportive care is initiated to provide adequate ventilation.

*If the patient cannot contain effective respiration, supportive care is initiated to provide adequate ventilation.

• The patient with altered LOC is subject to all the complications associated with immobility such as;

= pressure ulcers= venous stasis= musculoskeletal deterioration= and disturbed gastrointestinal functioning

• The patient with altered LOC is subject to all the complications associated with immobility such as;

= pressure ulcers= venous stasis= musculoskeletal deterioration= and disturbed gastrointestinal functioning

*Pressure ulcers may become infected and act as source of sepsis. Aspiration of gastric contents or feedings may occur, precipitating the development of pneumonia or airway conclusion.

*Pressure ulcers may become infected and act as source of sepsis. Aspiration of gastric contents or feedings may occur, precipitating the development of pneumonia or airway conclusion.

The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. Until the patient’s ability to breath on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation.

The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. Until the patient’s ability to breath on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation.

The circulatory status (blood pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain. An intravenous catheter is inserted to provide access for fluids and intravenous medications. Neurologic care focuses on the specific neurologic pathology, if any.nutritional support, using either a feeding tube or a gastrostomy tube, is initiated as soon as possible. In addition to measures to determine and treat the underlying causes of altered LOC, other medical interventions are aimed at pharmacologic management of complications and strategies to prevent complications.

The circulatory status (blood pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain. An intravenous catheter is inserted to provide access for fluids and intravenous medications. Neurologic care focuses on the specific neurologic pathology, if any.nutritional support, using either a feeding tube or a gastrostomy tube, is initiated as soon as possible. In addition to measures to determine and treat the underlying causes of altered LOC, other medical interventions are aimed at pharmacologic management of complications and strategies to prevent complications.

THE PATIENT WITH AN ALTERED LEVEL OF

CONSCIOUSNESS

THE PATIENT WITH AN ALTERED LEVEL OF

CONSCIOUSNESS

Assessment = assessing the with an altered LOC depends somewhat on each patient’s circumstances, but clinicians often start by assessing the verbal response

Assessment = assessing the with an altered LOC depends somewhat on each patient’s circumstances, but clinicians often start by assessing the verbal response

• The patient is asked to identify the day, date, or season of the year and to identify where he or she is or to identify the clinicians, or visitors present. Other questions such as, “who is the president?” or “what is the next holiday?” are also helpful in determining the patient’s processing of information in the environment

• The patient is asked to identify the day, date, or season of the year and to identify where he or she is or to identify the clinicians, or visitors present. Other questions such as, “who is the president?” or “what is the next holiday?” are also helpful in determining the patient’s processing of information in the environment

• (verbal response cannot be evaluated when the patient is intubated or has a tracheostomy, and this should be clearly documented.)

• (verbal response cannot be evaluated when the patient is intubated or has a tracheostomy, and this should be clearly documented.)

*Alertness is measured by the patient’s ability to open the eyes spontaneously o to a stimulus. Patient with severe neurologic dysfunction cannot do this. The should assess for periorbital edema or trauma, which may prevent the patient from opening the eyes, and document if this interferes with eye opening.

*Alertness is measured by the patient’s ability to open the eyes spontaneously o to a stimulus. Patient with severe neurologic dysfunction cannot do this. The should assess for periorbital edema or trauma, which may prevent the patient from opening the eyes, and document if this interferes with eye opening.

*Motor response includes spontaneous, purposeful movement (e g , the awake patient can move all four extremities with equal strength),movement only in response to noxious stimuli(e g, pressure/pain),or abnormal posturing if the patient is not responding to commands ,

*Motor response includes spontaneous, purposeful movement (e g , the awake patient can move all four extremities with equal strength),movement only in response to noxious stimuli(e g, pressure/pain),or abnormal posturing if the patient is not responding to commands ,

• the motor response is tested by applying a painful stimulus ( firm but gentle pressure)to the nailbed or by squeezing a muscle if the patient attempts to push away or withdraw, the response is recoreded as purposeful if the patient can cross from one side of the body to the other in response to noxious stimuli.

• the motor response is tested by applying a painful stimulus ( firm but gentle pressure)to the nailbed or by squeezing a muscle if the patient attempts to push away or withdraw, the response is recoreded as purposeful if the patient can cross from one side of the body to the other in response to noxious stimuli.

*In addition to LOC, the nurse monitors parameters such as..

=respiratory status,

=eye signs, and

=reflexes on an ongoing basis.

*In addition to LOC, the nurse monitors parameters such as..

=respiratory status,

=eye signs, and

=reflexes on an ongoing basis.

• Ineffective airway clearance related to altered level of consciousness

• Risk of injury related to decreased level of consciousness

• Deficient fluid volume related to inability to take in fluids by mouth

• Impaired oral mucous membranes related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake

• Risk for impaired skin integrity related to immobility

• Ineffective airway clearance related to altered level of consciousness

• Risk of injury related to decreased level of consciousness

• Deficient fluid volume related to inability to take in fluids by mouth

• Impaired oral mucous membranes related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake

• Risk for impaired skin integrity related to immobility

• Impaired tissue integrity of cornea related to diminished or absent corneal reflex

• Ineffective thermoregulation related to damage to hypothalamic center

• Impaired tissue integrity of cornea related to diminished or absent corneal reflex

• Ineffective thermoregulation related to damage to hypothalamic center

• Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control

• Bowel incontinence related to impairment in neurologic sensing and control and also related to transition in nutritional delivery methods

• Interrupted family process related to health crisis.

• Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control

• Bowel incontinence related to impairment in neurologic sensing and control and also related to transition in nutritional delivery methods

• Interrupted family process related to health crisis.

COMPLICATIONSCOMPLICATIONS

• Respiratory distress or failure

• Pneumonia

• Aspiration

• Pressure ulcer

• Deep vein thrombosis

• Respiratory distress or failure

• Pneumonia

• Aspiration

• Pressure ulcer

• Deep vein thrombosis

PLANNING AND GOALSPLANNING AND GOALS

• Maintenance of a clear airway• Protect from injury• Attainment of fluid volume balance• Achievement of intact oral mucous

membranes• Maintenance of normal skin integrity• Absence of corneal irritation• Attainment of effective thermoregulation• Effective urinary elimination

• Maintenance of a clear airway• Protect from injury• Attainment of fluid volume balance• Achievement of intact oral mucous

membranes• Maintenance of normal skin integrity• Absence of corneal irritation• Attainment of effective thermoregulation• Effective urinary elimination

• Maintaining the airway

• Protecting the patient

• Maintaining fluid balance and managing nutritional needs

• Providing mouth care

• Maintaining skin and joint integrity

• Preserving corneal integrity

• Maintaining the airway

• Protecting the patient

• Maintaining fluid balance and managing nutritional needs

• Providing mouth care

• Maintaining skin and joint integrity

• Preserving corneal integrity

• Achieving thermoregulation

• Preventing urinary retention

• Promoting bowel function

• Providing sensory stimulation

• Meeting families’ needs.

• Achieving thermoregulation

• Preventing urinary retention

• Promoting bowel function

• Providing sensory stimulation

• Meeting families’ needs.