Assessment of Altered Level of Consciousness

How is alertness typically measured in a patient with an altered LOC?

Why is verbal response evaluation challenging in intubated patients?

What is one way to test motor response in a patient who is not responding to commands?

In assessing motor response, what does 'abnormal posturing' refer to?

Why is assessing verbal response significant in patients with altered LOC?

What is a common barrier to evaluating alertness in patients with severe neurologic dysfunction?

What is considered a purposeful response when a patient withdraws to a painful stimulus?

In the context of neurologic impairment, what type of posturing may be observed?

What parameter cannot be assessed when a patient has been given neuromuscular blocking agents?

Which of the following would be a potential nursing diagnosis for a patient with impaired tissue integrity of the cornea?

Which of the following potential complications is directly associated with respiratory function?

In what condition does the most severe neurologic impairment result in?

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.