care of patient with altered level of consciouesness

Care for patients with altered level of consciousness

Unconsciousness is a condition in which there is a depression of cerebral function ranging from stupor to coma. Coma may be defined as no eye opening on stimulation, absence of comprehensible speech, and failure to obey commands. Altered state of consciousness may be caused by hypoxemia and a variety of neurologic and metabolic disorders. Diagnostic evaluation and management depend on the suspected or confirmed underlying cause.

Nursing Assessment:

1. Assess the patient’s level of responsiveness (arousal and awareness).
a. Responds to command or stimulation (press pen against side of patient’s nail bed for stimulation)
b. Eye opening
c. Verbal responses
d. Motor responses
2. Assess motor function for strength and symmetry.
3. Record the patient’s exact reactions. Use Glasgow coma scale for documentation (see next able).

The Glasgow Coma Scale (GCS)

Parameter Finding Score

Eye Opening Spontaneously
To speech
To pain
Do not open 4
3
2
1

Best verbal response Oriented
Confused
Inappropriate speech
Unintelligible speech
No verbalization 5
4
3
2
1

Best motor response Obeys command
Localizes pain
Withdraws from pain
Abnormal flexion
Abnormal extension
No motor response 6
5
4
3
2
1

4. Test brain stem reflexes to assess for brain stem dysfunction.
a. Pupil size, symmetry, and reaction to light.
5. Check respiratory rate and pattern (normal, Kussmaul’s, Cheyne-Stokes, apneic).
6. Check swallowing reflexes and deep tendon reflexes.

7. Examine head for signs of trauma, and mouth, nose, and ears for evidence of blood and CSF.
8. Monitor any change in neurologic status over time.

Nursing Diagnoses:

A. Ineffective Airway Clearance related to upper airway obstruction by tongue and soft tissues; inability to clear respiratory secretions
B. Risk for Fluid Volume Deficit related to inability to ingest fluids, dehydration from osmotic therapy (when used to reduce intracranial pressure)
C. Altered Oral Mucous Membranes related to mouth breathing, absence of pharyngeal reflex, inability to ingest fluid
D. Risk for Impaired Skin Integrity related to immobility or restlessness
E. Impaired Tissue Integrity of Cornea related to diminished/absent corneal reflex
F. Hypothermia related to damage to hypothalamic center
G. Altered Urinary Elimination (Incontinence or Retention) related to unconscious state
H. Bowel Incontinence related to unconscious state

Nursing Interventions:

A. Maintaining an Effective Airway:

1. Place the patient in a three-fourths prone or semiprone or lateral position—prevents the tongue from obstructing the airway, encourages drainage of respiratory secretions, and promotes oxygen and carbon dioxide exchange.
2. Keep the airway free of secretions with efficient suctioning—in the absence of the cough and swallowing reflexes, secretions rapidly accumulate in the posterior pharynx and upper trachea and can lead to fatal respiratory complications.

B. Attaining and Maintaining Fluid and Electrolyte Balance:

1. Monitor prescribed IV fluids carefully, because a large volume of fluid may aggravate cerebral edema.
2. Alternatively, use hyperalimentation or nasogastric feedings.
3. Measure urinary output and specific gravity.
4. Evaluate pulses (radial, carotid, apical, and pedal); measure blood pressure—these parameters are a measure of circulatory adequacy/inadequacy.
5. Maintain circulation; support the blood pressure and treat life-threatening cardiac dysrhythmias.

C. Maintaining Healthy Oral Mucous Membranes:

1. Remove dentures. Inspect patient’s mouth for dryness, inflammation, and the presence of crusting.
2. Cleanse the mouth with prescribed solution every 2 hours—to prevent parotitis (inflammation of parotid gland).
3. Apply lip emollient to prevent angular stomatitis and cheilitis.

D. Maintaining Skin Integrity:

1. Keep the skin clean, dry, and free of pressure—comatose patients are susceptible to the formation of pressure sores.
2. Clip the patient’s nails to prevent excoriation.
3. Turn the patient from side to side on a regular schedule—relieves pressure areas and helps clear lungs by mobilizing secretions; turning also provides kinesthetic (sensation of movement), proprioceptive (awareness of position), and vestibular (equilibrium) stimulation.
4. Reposition carefully after turning to prevent ischemic necrosis over pressure areas and pressure on nerves that can lead to compression neuropathies.
5. Put all extremities through range-of-motion exercises at least four times daily; contracture deformities develop early in unconscious patients.

E. Maintaining Corneal Integrity:

1. Protect the eyes from corneal irritation—the cornea functions as a shield. If the eyes remain open for long periods, corneal drying, irritation, and ulceration are likely to result.
a. Make sure the patient’s eye is not rubbing against bedding if blinking and corneal reflexes are absent.
b. Inspect the size of the pupils and condition of eyes with a flashlight.
c. Remove contact lenses if worn.
d. Irrigate eyes with sterile prescribed solution to remove discharge and debris.
e. Instill prescribed ophthalmic ointment in each eye—prevents glazing and corneal ulceration.
f. Instill artificial tears as prescribed.

2. Prepare for temporary tarsorrhaphy (suturing of eyelids in closed position) if unconscious state is prolonged.






F. Reducing Fever:

1. Look for possible sites of infections (respiratory, CNS, urinary tract, wound) when fever is present in an unconscious patient.
2. Control persistent elevations of temperature—increased metabolic demands will overburden brain circulation and oxygenation, resulting in cerebral deterioration.
a. Cool room to 18.3°C. However, an older patient requires a warmer temperature.
b. Remove bedding over the patient except light sheet or loincloth.
c. Use cool-water sponging and an electric fan blowing over the patient to increase surface cooling.
d. Consider use of hypothermia blanket if hyperthermia is of neurogenic origin. Esophageal or other core temperature is monitored continuously.


G. Promoting Urinary Elimination:

1. Palpate over the patient’s bladder at intervals to detect urinary retention and an overdistended bladder.
2. Insert an indwelling urethral catheter for short-term management.
3. Use intermittent bladder catheterization for distention as soon as possible—to minimize risk of infection.
4. Monitor for fever and cloudy urine; inspect the urethral orifice for suppurative drainage.
5. Initiate a bladder training program (see Urinary Incontinence) as soon as consciousness is regained.

H. Promoting Bowel Function:

1. Observe for constipation—from immobility and lack of dietary fiber.
a. Stool softener may be prescribed and given with tube feeding.
b. Glycerin suppository may be prescribed to stimulate bowel emptying.
2. Monitor for diarrhea—from infection, antibiotics, hyperosmolar fluids, and fecal impaction.
a. Perform a rectal examination if fecal impaction is suspected.
b. Use commercial fecal collection bags and meticulous skin care if patient has fecal incontinence.
3. Auscultate for bowel sounds; measure the girth of the abdomen with a tape measure to detect abdominal distention.
4. Palpate lower abdomen for distention.







Family Education and Support:

1. Develop a supportive and trusting relationship with the family or significant other(s).
2. Provide information and frequent updates on patient’s condition and progress.
3. Involve them in routine care and teach procedures that they can perform at home.
4. Demonstrate and teach methods of sensory stimulation to be used frequently.
a. Use physical touch and reassuring voice tone.
b. Talk in meaningful way even when patient does not seem to respond.
c. Orient patient periodically to person, time, and place.
5. Encourage adequate room lighting to prevent hallucinations for the semiconscious patient.
6. Teach family to recognize and report unusual restlessness that could indicate cerebral hypoxia or metabolic imbalance.
7. Enlist help of social worker, home health agency, or other resources to assist family with such issues as financial concerns, need for medical equipment in home, and respite care.

Evaluation:

A. Maintains clear airway; coughs up secretions
B. Absence of signs of dehydration
C. Intact, pink mucous membranes
D. No skin breakdown or erythema
E. Absence of trauma to cornea
F. Core temperature within normal limits
G. Catheterized at intervals for clear urine
H. Daily bowel movement stimulated with glycerin suppository