Alterations in Neurological Function
Altered Level of Consciousness (LOC)
• Level of responsiveness and consciousness is the most important indicator
... [Show More] of
the patient's condition
• LOC is a continuum from normal alertness and full cognition (consciousness)
to coma
• Altered LOC is not the disorder but the result of a pathology
• Coma: unconsciousness, unarousable unresponsiveness (responding
inappropriately is not coma)
• Akinetic mutism: unresponsiveness to the environment, makes no movement
or sound but sometimes opens eyes - cant make a physical movement in
response to the env’t
• Persistent vegetative state: devoid of cognitive function but has sleep–wake
cycles - they just don’t respond in normal ways- cant understand or respond
to language
• Locked-in syndrome: inability to move or respond except for eye movements
due to a lesion affecting the pons (cant respond bc of a lesion affecting the
pons. Can communicate with eye movements)- “fully alive in your mind” as
opposed to Akinetic mutism
• Most important thing to think about with Neuro is LOC
• Most important indicator- tells us about neurological fcn (whether its CVA,
diabetic neuropathy, etc.)
• On a continuum-ex. A&O x3
• Its how we assess a patient
• Review GCS- Know cut offs
• Are they able to respond and if they can respond are they responding
appropriately?
• Orientation: Who your are. When it is in time.
The Care of the Patient With Altered Level of Consciousness
• Assess verbal response and orientation
• Alertness (are they looking around spontaneously?)
• Motor responses – fine and gross
• Fine
• Feed themselves
• Pick up a pencil
• Gross motors
• Push against (resistance), etc.
• Respiratory status
• May have a decrease is respiratory status ECHO
• Eye signs
• ECHO
• Reflexes
• Pain, touch (light, pressure, etc.)
• Postures
• Glasgow Coma Scale
Should you re- orient pt who is not A&O x3? If there’s a physical pathology that’s
preventing them from retaining the year month or day- then no.
They must be able to grasp the information and it must be productive.
Ex. someone having delirium or med. Rxn- then maybe
Collaborative Problems and Potential Complications ECHO
• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures
• Pts with RD or RF can have altered LOC
• Most imp thing to do as nurses it to help our pt. compensate (ex. turning and
positioning for pts that lack the ability to shift (to prevent PU))
Interventions ECHO
• A major nursing goal is to compensate for the patient's loss of protective
reflexes and to assume responsibility for total patient care. Protection also
includes maintaining the patient’s dignity and privacy.
• Maintaining an airway
• Frequent monitoring of respiratory status, including auscultation of
lung sounds
• Positioning to promote accumulation of secretions and prevent
obstruction of upper airway—head of bed (HOB) elevated 30 degrees;
lateral or semiprone position
• Suctioning, oral hygiene, and CPT
• CAB- cardiac, airway, breathing
Maintaining Tissue Integrity
• Assess skin frequently, especially areas with high potential for breakdown
• Frequent turning; use turning schedule
• Careful positioning in correct body alignment (esp pts with spinal
alignments, CVAs who have a weak side)
• Passive ROM (prevents contractures- maintains fcn)
• Breakdown in neuro fcn causes contraction
• Use of splints, foam boots, trochanter rolls, and specialty beds as needed
• Its your responsibility to figure out if mattress is appropriately
• MD orders it though
• Clean eyes with cotton balls moistened with saline
• Use artificial tears as prescribed
• Might need to close and keep eyes close
• May use eye patches- not used as much- because pts can open they’re
eyes underneath which results in corneal scratching from the patch
• Measures to protect eyes; use eye patches cautiously because the cornea may
contact patch [Show Less]
