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Questions and Answers
What is defined as altered level of consciousness?
What is defined as altered level of consciousness?
Which of the following refers to the primary pathophysiologic phenomena causing altered level of consciousness?
Which of the following refers to the primary pathophysiologic phenomena causing altered level of consciousness?
What clinical manifestation is typically associated with altered level of consciousness?
What clinical manifestation is typically associated with altered level of consciousness?
What is an important nursing intervention for a patient with altered level of consciousness?
What is an important nursing intervention for a patient with altered level of consciousness?
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Which complication may arise from altered level of consciousness?
Which complication may arise from altered level of consciousness?
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What is one objective for nursing care in a comatose patient?
What is one objective for nursing care in a comatose patient?
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During a nursing assessment, which response indicates a higher level of consciousness?
During a nursing assessment, which response indicates a higher level of consciousness?
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What is a key nursing intervention to prevent aspiration in a comatose patient?
What is a key nursing intervention to prevent aspiration in a comatose patient?
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Which of the following is a common complication associated with prolonged immobility?
Which of the following is a common complication associated with prolonged immobility?
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What nursing diagnosis is appropriate for a patient with impaired oral intake due to altered consciousness?
What nursing diagnosis is appropriate for a patient with impaired oral intake due to altered consciousness?
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What does the intervention of maintaining skin integrity involve for immobile patients?
What does the intervention of maintaining skin integrity involve for immobile patients?
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Which nursing intervention can help maintain corneal integrity in a comatose patient?
Which nursing intervention can help maintain corneal integrity in a comatose patient?
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Which of the following is least likely to be a risk factor for impaired skin integrity?
Which of the following is least likely to be a risk factor for impaired skin integrity?
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In assessing a patient’s neurological function, what is the significance of pupillary reaction?
In assessing a patient’s neurological function, what is the significance of pupillary reaction?
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What is a common intervention to assess airway clearance in a comatose patient?
What is a common intervention to assess airway clearance in a comatose patient?
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Which nursing objective relates to managing nutrition in a comatose patient?
Which nursing objective relates to managing nutrition in a comatose patient?
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Which of the following reflects a strategy to maintain hydration in a patient at risk of hypovolemia?
Which of the following reflects a strategy to maintain hydration in a patient at risk of hypovolemia?
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Which condition is a potential complication in a comatose patient due to immobility?
Which condition is a potential complication in a comatose patient due to immobility?
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What is a primary purpose of using the Glasgow Coma Scale (GCS) in patient assessment?
What is a primary purpose of using the Glasgow Coma Scale (GCS) in patient assessment?
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How is the eye-opening response scored in the Glasgow Coma Scale?
How is the eye-opening response scored in the Glasgow Coma Scale?
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Which score on the Glasgow Coma Scale indicates moderate head injury?
Which score on the Glasgow Coma Scale indicates moderate head injury?
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What could a sudden change in pupil size or response indicate in a patient?
What could a sudden change in pupil size or response indicate in a patient?
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Which cranial nerve damage might cause a patient to be unable to open their eyes?
Which cranial nerve damage might cause a patient to be unable to open their eyes?
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What is the appropriate action if a patient’s GCS score decreases by 2 points?
What is the appropriate action if a patient’s GCS score decreases by 2 points?
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Which option describes an appropriate method for assessing pupil reaction to light?
Which option describes an appropriate method for assessing pupil reaction to light?
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What does a 'flexion posturing' response indicate in the GCS assessment?
What does a 'flexion posturing' response indicate in the GCS assessment?
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What characteristic signifies a score of 3 on the Glasgow Coma Scale?
What characteristic signifies a score of 3 on the Glasgow Coma Scale?
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What does a dilated pupil that does not react to light typically suggest?
What does a dilated pupil that does not react to light typically suggest?
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Which is a contraindication for using supraorbital pressure during a GCS assessment?
Which is a contraindication for using supraorbital pressure during a GCS assessment?
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What is a key limitation of the Glasgow Coma Scale?
What is a key limitation of the Glasgow Coma Scale?
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Which condition is associated with pinpoint pupils?
Which condition is associated with pinpoint pupils?
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How should pupil size be measured during assessment?
How should pupil size be measured during assessment?
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Study Notes
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
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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.
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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.
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Corneal Integrity: Eye care; swabbing, artificial tears, minimizing risk of abrasion (caution with eye patches).
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Body Temperature: Remove excess bedding, monitor and maintain normal temperature per protocol and use hypothermia blankets or cool compresses.
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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.
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Mucosal Care: Mouth and nasal inspection. Mouth care twice daily. Clean nasal passages as needed. If on a ventilator, comprehensive mouth care.
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Skin Integrity: Total nursing care, turning every two hours, pressure relieving mattresses, 8-hourly perianal care. Hand/forearm splints, orthotics, skin care, passive exercises.
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Nutritional Support: IV fluids as prescribed, complete nutritional assessment, enteral feeding, monitor fluid electrolytes assessment, prevent overhydration, meticulous intake/output records.
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Prevent Further Injury: Implement seizure precautions, administer medications that decrease intracranial pressure, eye care to prevent corneal damage.
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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.
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Description
This quiz covers the nursing needs of patients with altered levels of consciousness, including the definitions and continuum of LOC. It explores the pathophysiology of altered LOC, highlighting neurological, toxicologic, and metabolic causes. Test your knowledge on this crucial aspect of patient care.
