Care of patient with altered level of consciousness
● Altered Level of Consciousness
○ Not oriented, does not follow commands, or needs persistent
... [Show More] stimuli to achieve ;
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
○ Persistent vegetative state: devoid of cognitive function but has sleep-wake
cycles
○ Locked-in syndrome: inability to move or respond except for eye movements due
to a lesion affecting the pons
● Level of consciousness
○ Change in LOC is the the most sensitive indicator of neurological status
○ Alert - awake, responsive. Assessment of orientation is a separate assessment
○ Lethargic- sleepy
○ Stuporous- aroused only with vigorous continuous stimulation
○ Comatose- unconscious, can’t arouse.
● Assessment of patient with altered LOC
○ Assessment
○ Respirations
○ EYES- pupils
■ Pupil assessment
● What does PERRLA mean?
○ Pupils Equal Round Reactive to Light and Accommodation
● How do you assess for direct and consensual pupillary response?
● How do you assess for accommodation?
○ Corneal reflex
■ Corneal reflex-(direct and consensual) assesses cranial nerve V sensory
○ Swallowing reflex
○ Response of extremity to noxious stimuli
○ DTR, pathological reflexes (Babinski)
■ Babinski- dorsiflexion of big toe. pathologic response
● Fanning is bad
○ Posturing
■ indicates a deterioration of condition: decorticate, decerebrate
● Decorticate is worse (flexion)
○ Glascow coma scale
■ Eye, verbal, motor response
● Max score 15
● The Care of the Patient with Altered Level of Consciousness— Diagnoses
○ Ineffective airway clearance
○ Risk of injury
○ Deficient fluid volume
○ Impaired oral mucosa
○ Risk for impaired skin integrity and impaired tissue integrity (cornea)
○ Ineffective thermoregulation
○ Impaired urinary elimination and bowel incontinence
○ Disturbed sensory perception
○ Interrupted family processes
● Collaborative Problems/Potential Complications
○ Respiratory distress or failure
○ Pneumonia
○ Aspiration
○ Pressure ulcer
○ Deep vein thrombosis (DVT)
○ Contractures
■ Positioning to prevent contractures
● Prevent shoulder adduction (frozen shoulder) by padding under
arm with pillow
● Position prone to prevent hip flexion contractures
● Nursing Interventions for Unconscious / Comatose patient
○ A major nursing goal is to compensate for the patient's loss of protective reflexes
and to assume responsibility for total patient care.
○ Assess/maintain airway **** Avoid hypoxia and hypercarbia!!
■ Frequent monitoring of respiratory status including auscultation of lung
sounds
■ Positioning to prevent accumulation of secretions and prevent obstruction
of upper airway—HOB elevated 30°, lateral or semi prone position
(NEVER flat on back).
■ Gentle Suctioning, oral hygiene, and CPT when necessary
■ Tongue, secretions may obstruct
■ May require mechanical intubation/ventilation
○ Maintaining fluid status- euvolemia desired
■ Assess fluid status by examining tissue turgor and mucosa, lab data, and
I&O.
■ Administer IVs, tube feedings, and fluids via feeding tube as required—
monitor ordered rate of IV fluids carefully.
○ Maintaining body temperature
■ Adjust environment and cover patient appropriately.
■ Use minimum amount of bedding, administer acetaminophen, use
hypothermia blanket, give a cooling sponge bath, and allow fan to blow
over patient to increase cooling.
■ Monitor temperature frequently and use measures to prevent shivering.
■ Consider- Why does hyperthermia occur? Why would it be deleterious for
a patient with a brain injury?
○ Protection if prone to seizures
■ padded size rails.
○ Mouth care [Show Less]