Altered Level of Consciousness (LOC)

Altered Level of Consciousness (LOC) Level of responsiveness and consciousness is the most important indicator of the patient's condition LOC is a continuum from normal alertness and full cognition (consciousness) to coma arouse

Altered Level of Consciousness (LOC) Altered LOC is not the disorder but the result of a pathology Coma: unconsciousness, unresponsiveness, and inability to

Altered Level of Consciousness (LOC) (cont.) Akinetic mutism: unresponsiveness to the environment, the patient makes no movement or sound but sometimes opens eyes

Altered Level of Consciousness (LOC) (cont.) Persistent vegetative state: patient is devoid of cognitive function but has sleepwake cycles Locked-in syndrome: patient is unable to move or respond except for eye movements due to a lesion affecting the pons

Assessment of the Patient With Altered LOC Verbal response and orientation Alertness Motor responses Respiratory status

Assessment of the Patient With Altered LOC Eye signs Reflexes Postures Glasgow Coma Scale

Decorticate Posturing

Decerebrate Posturing

Diagnosis of the Patient With Altered Level of Consciousness Ineffective airway clearance Risk of injury Deficient fluid volume Impaired oral mucosa Risk for impaired skin integrity and impaired tissue integrity (cornea)

Diagnosis of the Patient With Altered Level of Consciousness Ineffective thermoregulation Impaired urinary elimination and bowel incontinence Disturbed sensory perception Interrupted family processes

Collaborative Problems/Potential Complications Respiratory distress or failure Pneumonia Aspiration

Collaborative Problems/Potential Complications Pressure ulcer Deep vein thrombosis (DVT) Contractures

Planning the Care of the Patient With Altered LOC Goals include: Maintenance of clear airway Protection from injury Attainment of fluid volume balance Maintenance of skin integrity

Planning the Care of the Patient With Altered LOC Absence of corneal irritation Effective thermoregulation Accurate perception of environmental stimuli Maintenance of intact family or support system Absence of complications

Planning the Care of the Patient With Altered LOC A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care; protection includes maintaining the patients dignity and privacy

Interventions Maintain an airway Frequent monitoring of respiratory status including auscultation of lung sounds Position the patient to promote accumulation of secretions and prevent obstruction of upper airway: HOB elevated 30, lateral or semi prone position Provide suctioning, oral hygiene, and CPT

Maintaining Tissue Integrity Assess skin frequently, especially areas with high potential for breakdown Turn patient frequently; use turning schedule Carefully position patient in correct body alignment

Maintaining Tissue Integrity Perform passive range of motion Use splints, foam boots, trochanter rolls, and specialty beds as needed Clean eyes with cotton balls moistened with saline

Maintaining Tissue Integrity Use artificial tears as prescribed Implement measures to protect eyes; use eye patches cautiously as the cornea may contact patch Provide frequent, scrupulous oral care

Interventions Maintain fluid status 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

Maintain body temperature Adjust environment and cover patient appropriately If temperature is elevated, 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

Promoting Bowel and Bladder Function Assess for urinary retention and urinary incontinence May require indwelling or intermittent catherization Initiate bladder-training program

Promoting Bowel and Bladder Function Assess for abdominal distention, potential constipation, and bowel incontinence Monitor bowel movements Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated Diarrhea may result from infection, medications, or hyperosmolar fluids

Sensory Stimulation and Communication Talk to and touch the patient and encourage the family to talk to and touch the patient Maintain normal daynight pattern of activity

Sensory Stimulation and Communication Orient the patient frequently A patient aroused from coma may experience a period of agitation; minimize stimulation at this time Initiate programs for sensory stimulation

Sensory Stimulation and Communication Allow family to ventilate and provide support Reinforce and provide consistent information to family Provide referral to support groups and services for the family

Case Study, Management of Patients With Neurologic Dysfunction Objective: 4, 5 A 27-year-old male patient is transported to the emergency department after falling from the roof of his home. Upon arrival the patient is unconscious, responding only to deep pain stimuli. His Glasgow Coma Scale is 7 (Eye-opening 3, Motor 3, Verbal 1); his pupils are unequal with the left pupil more dilated than the right. He is orally intubated with a 7.5 ET tube, and is on Assist-Control ventilation. He is being evaluated for possible increased intracranial pressure.

What is the earliest sign of increased intracranial pressure? Discuss his care under the following needs Oxygen and transport Safety and protection Nutrition and psychological

References Black, J.M., &Hokanson Hawks,J.(2001)Medical Surgical Nursing. Clinical Management for Positive Outcomes. Elsiever Saunders. Smeltzer,S.C.,Bare,B.G.,Hinkle,J.L., Cheever,K.H.(2008)Brunner&Suddarths Text Book of Medical-Surgical Nursing. Lippincott,Williams&Wilkins.Philadelphia