12 Questions
How is alertness typically measured in a patient with an altered LOC?
By observing the patient's ability to open the eyes spontaneously
Why is verbal response evaluation challenging in intubated patients?
They cannot speak due to the intubation
What is one way to test motor response in a patient who is not responding to commands?
Applying a painful stimulus to the nail bed
In assessing motor response, what does 'abnormal posturing' refer to?
A non-purposeful, rigid posture
Why is assessing verbal response significant in patients with altered LOC?
To assess their orientation to time, person, and place
What is a common barrier to evaluating alertness in patients with severe neurologic dysfunction?
Intubation or tracheostomy
What is considered a purposeful response when a patient withdraws to a painful stimulus?
The patient can cross the midline from one side of the body to the other
In the context of neurologic impairment, what type of posturing may be observed?
Decorticate or decerebrate posturing
What parameter cannot be assessed when a patient has been given neuromuscular blocking agents?
Motor response
Which of the following would be a potential nursing diagnosis for a patient with impaired tissue integrity of the cornea?
Risk for impaired skin integrity related to prolonged immobility
Which of the following potential complications is directly associated with respiratory function?
Pneumonia
In what condition does the most severe neurologic impairment result in?
Flaccidity
Study Notes
Assessment of Altered LOC
- Assessment of altered LOC begins with evaluating verbal response, including orientation to time, person, and place
- Patients are asked to identify day, date, or season, as well as their location and the people present
- Additional questions, such as "Who is the president?" or "What is the next holiday?", help determine processing of information
- Verbal response cannot be evaluated if the patient is intubated or has a tracheostomy
Alertness and Eye Opening
- Alertness is measured by the patient's ability to open their eyes spontaneously or in response to a vocal or noxious stimulus
- Patients with severe neurologic dysfunction cannot open their eyes
- Periorbital edema or trauma may prevent eye opening and should be documented
Motor Response
- Motor response includes spontaneous, purposeful movement, movement only in response to painful stimuli, or abnormal posturing
- Patients who do not respond to commands are tested by applying a painful stimulus to the nail bed or by squeezing a muscle
- A purposeful response is when the patient withdraws or pushes away from the stimulus, crossing the midline of their body
- Inappropriate or nonpurposeful responses are random and aimless
Nursing Diagnoses and Collaborative Problems
- Nursing diagnoses may include:
- Ineffective airway clearance
- Risk for injury
- Deficient fluid volume
- Risk for imbalanced nutrition
- Impaired oral mucous membrane
- Risk for impaired skin integrity
- Risk for impaired tissue integrity of cornea
- Ineffective thermoregulation
- Impaired urinary elimination
- Bowel incontinence
- Ineffective health maintenance
- Interrupted family processes
- Potential complications may include:
- Respiratory distress or failure
- Pneumonia
- Aspiration
- Pressure ulcer
- Venous thromboembolism (VTE)
Learn about the initial steps in assessing a patient with altered level of consciousness by evaluating their verbal response, including orientation to time, person, and place. Discover the importance of asking specific questions to determine the patient's processing of information.
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