Nursing Care for Altered Consciousness Levels

Nursing Needs of Patients with Altered Level of Consciousness

• Altered Level of Consciousness (LOC): Present when a patient is disoriented, does not follow commands, or requires constant stimulation to remain alert.
• Continuum of LOC: A range of consciousness levels, from alert to confused, lethargic, obtunded, stuporous, and comatose.
• Coma: A clinical state of unarousable unresponsiveness, where there are no purposeful responses to internal or external stimuli, though non-purposeful responses to painful stimuli and brainstem reflexes might be present.

Pathophysiology

• Multiple Factors: Altered LOC results from a variety of causes.
• Neurological Issues: Head injuries, strokes.
• Toxicologic Issues: Drug overdoses, alcohol intoxication.
• Metabolic Conditions: Liver or kidney injury, diabetic ketoacidosis leading to cellular edema.
• Other Factors: Disruptions in chemical transmission within nerve cells, affecting neurotransmitters and brain structures.

Clinical Manifestations

• Decreased Alertness/Consciousness: Gradual reduction in awareness.
• Changes in Responses: Pupils (sluggish), eye opening, verbal, and motor responses show changes.
• Anxiety/Restlessness: Early indicators in altered LOC.
• Pupils Changes: Initially sluggish response. Progressing to fixed or no response to light in comatose patients.

Diagnostic Tests

• CT/MRI: Computed Tomography/Magnetic Resonance Imaging for brain scans.
• EEG: Electroencephalography to record brainwave activity.
• Angiography/Brain Scan: For visualizing blood vessels and brain structure.
• Transcranial Doppler: Helps evaluate blood flow in the brain.
• Lumbar Puncture: For cerebrospinal fluid analysis.
• Serum Glucose & Electrolytes: Blood tests for metabolic imbalances.
• Urine Osmolality: Assessing hydration and electrolyte balance.
• ABGs, Liver Function Tests, Toxicology: Additional tests for various causes.

Assessment

• Mental Status, Cranial Nerves, Cerebellar Function, Reflexes, and Motor/Sensory Function Evaluation: Comprehensive assessment of neurological function.
• GCS Assessment: Performing the Glasgow Coma Scale.
• Localized Signs: Presence of abnormal pupillary or motor responses suggest neurological disease.
• Intact Pupillary Light Reflexes: Suggesting a toxic or metabolic disorder instead of neurologic disease.

Medical Management (Determining Level of Involvement)

• GCS: Level of consciousness assessment.
• Neurological Manifestations: Posture, presence/absence.
• Pupil Size/Reactivity: Assessing light response.
• Reflexes: Deep tendon and superficial reflexes for brainstem involvement.
• Noxious Stimuli Response: Reactions to loud verbal stimuli, shaking, or painful stimuli.
• Trauma Evidence: Physical evidence of injury.
• Blood Test: Identifying metabolic disorders.
• Medical History: Comprehensive patient history.

Medical Management (Cont.)

• Interdisciplinary Care: Identification of underlying cause, preservation of function, and prevention of deterioration.
• ABCs (Airway, Breathing, Circulation): Airway management, ventilation (oral or nasal intubation, tracheostomy, mechanical ventilation).
• Circulatory Support: Monitoring blood pressure (BP), heart rate (HR), to ensure adequate cerebral perfusion.
• Fluid/Nutrient Management: Infusion of isotonic solutions (normal saline, Ringer's Lactate), IV 50% glucose (for hypoglycemia), tube feeding (NG tube/gastrostomy), total parenteral nutrition (TPN).

Medical Management (Cont.)

• Medications: Insulin, Furosemide (Lasix), mannitol (osmotic diuretic for cerebral edema), antibiotics (meningitis), antiseizure (IV lorazepam/diazepam), steroid therapy, muscular blocking agent (decrease ICP), naloxone (opioid overdose).

Surgical Management

• Cranial Vault Decompression: If coma is due to structural damage.
• Burr Holes: For subdural hematoma.
• Craniotomy: For tumor, abscess, or intracerebral hematoma removal.
• Shunt: To manage hydrocephalus.

Potential Complications

• Respiratory Distress/Failure: Can occur from a variety of factors.
• Pneumonia (hypostatic): In immobilized patients.
• Aspiration: A major risk.
• Pressure Ulcers: From prolonged immobility.
• Deep Vein Thrombosis (DVT): Development of blood clots.
• Contractures: Stiffening of joints.

Nursing Assessment (cont.)

• Glasgow Coma Scale (GCS): Assessment of eye opening, verbal response (orientation, comprehension), and motor response.
• Neurological Examinations: Detailed and comprehensive checks
• Respiratory Function: Assessing respiratory status.
• Pupillary Reaction: Checking pupil response to light.
• Reflexes: Testing for reflexes.
• Patient History: Onset, progression, symptom awareness, any infection, falls, trauma, recent medications (prescription, OTC, alcohol).
• Visual Changes: Reporting any vision changes.
• Other Body Systems: Respiratory, circulatory, hydration, fluid-electrolyte balance, skin integrity, and elimination.
• Laboratory Results: Including laboratory test results and values.
• Posturing Observations (Decorticate/Decerebrate): Observation/assessment for upper and lower extremity posturing patterns.

Nursing Diagnoses (cont.)

• Ineffective Airway Clearance: Related to lack of airway clearance.
• Risk for Suffocation: Related to loss of gag reflex.
• Deficient Fluid Volume: Related to taking fluids by mouth.
• Risk for Aspiration: Related to loss of gag reflex.
• Impaired Oral Mucous Membrane: Related to mouth breathing.
• Risk for Disuse Syndrome: Related to lack of voluntary movement.
• Risk for Impaired Skin Integrity: Related to prolonged immobility.
• Risk for Imbalanced Nutrition: Less than body requirements.
• Ineffective Thermoregulation: Damage to the hypothalamic center.
• Impaired Urinary Elimination: Related to impairment in neurological function.
• Bowel Incontinence: Related to impairment of neurological function.
• Interrupted Family Process: Related to health crisis.

Nursing Objectives

• Effective Breathing/Circulatory Support: Maintain adequate systemic blood pressure to perfuse the brain and maintain breathing pattern.
• Temperature Regulation: Keep body temperature in a normal range.
• Safety: Ensure safety measures are in place.
• Nutritional Support: Providing adequate nutrients.
• Bowel and Bladder Elimination: Maintaining regular bowel and urinary function.
• Preventing Complications: Action to prevent potential complications.

Nursing Interventions

• Airway Management: Initial airway management (oral airway if required). ETT insertion/ventilator support. Elevating head of bed to decrease risk of aspiration. Positioning in lateral or semi prone positions. Suctioning secretions.

• Perfusion/Hydration: Maintain hydration, monitor anti-hypertensive effects, monitor cardiac output & blood pressure. Removal of cathiters as soon as possible. Ensure regular toileting for eliminating unnecessary risks.

• Corneal Integrity: Eye care; swabbing, artificial tears, minimizing risk of abrasion (caution with eye patches).

• Body Temperature: Remove excess bedding, monitor and maintain normal temperature per protocol and use hypothermia blankets or cool compresses.

• Aspiration Risk: Monitor ABG, SPO2, assess breath sounds. Employ suctioning judiciously and when needed. Hyperoxygenate before during and after procedure. Hourly turning to encourage proper drainage of secretions. Nutritional support.

• Mucosal Care: Mouth and nasal inspection. Mouth care twice daily. Clean nasal passages as needed. If on a ventilator, comprehensive mouth care.

• Skin Integrity: Total nursing care, turning every two hours, pressure relieving mattresses, 8-hourly perianal care. Hand/forearm splints, orthotics, skin care, passive exercises.

• Nutritional Support: IV fluids as prescribed, complete nutritional assessment, enteral feeding, monitor fluid electrolytes assessment, prevent overhydration, meticulous intake/output records.

• Prevent Further Injury: Implement seizure precautions, administer medications that decrease intracranial pressure, eye care to prevent corneal damage.

• Preventing Infection: Maintaining aseptic practice.

Glasgow Coma Scale (GCS)

• Components: Eye opening, verbal response, and motor response.
• Scoring: Assessing the quality of responses to stimuli (painful, verbal, and spontaneous) to provide a total score.
• Interpretation: Assessing changes in the GCS during the hospitalization and comparing to baseline scores to identify trends in a patient’s neurological state. Lower score implies more critical condition.
• Documentation: The documentation of a patient's GCS should accurately reflect the patient's response and any changes observed throughout the shift.
• Pupillary Assessment: Checking for equality, size, and reactions to light.
• Limb Movement Assessment: Evaluating strength and voluntary movements. Testing for presence of posturing.