Altered Loc

1. Altered Level of
Consciousness

2. Introduction
•An altered of consciousness (LOC) is
apparent in the patient who is not oriented, does
not follow commands, or need persistent stimuli
to achieve a state of alertness. (LOC) is gauged
on a continuum with a normal state of alertness
and full cognition (consciousness) on one end
and coma on the other end. Coma is clinical
state of unconsciousness in which the patient is
unaware of self or the environment for prolonged
periods (days to months or even years).

3. •Akinetic mutism is a state of unresponsiveness
to the environment in the patient makes no
movement or sound but sometimes opens the
eyes.
•Persistent vegetative state is a condition in
which the patient is described as wakeful but
devoid of consciousness content, without
cognitive or affective mental function. The level
of responsiveness and consciousness is the
most important indicator of the patient’s
condition.

4. •Level I-conscious, cognitive, coherent (3
C’s)
•Level II-confused, drowsy, lethargic,
obtunded, somnolent
•Level III-stuporous;responds only to
noxious, strong or intense stimuli, e.g
sternal pressure, trapezius pinch,
pressure at the base of the nail or
supraorbital area;very strong light or very
loud sound.

5. •Level IV
=Light coma-response is
only by grimace or
withdrawing limb from
pain; primitive and
disorganized response to
painful stimuli.
=Deep coma-absence of
response to even the
most painful stimuli.

6. GLASGOW
COMA SCALE

7. •The Glasgow Coma Scale is a tool
for assessing the patient’s response
to stimuli Score range from 3 (deep
coma) to 15 (normal).

8. •Eye Opening
response
•Spontaneous
4
•To voice
3
•To pain
2
•None
1

9. * Best Verbal
response
•Oriented
5
•Confused
4
•Inappropriate words
3
•Incomprehensible
sounds
2
•None
1

10. •Best Motor response
•Total
•Obeys command
6
•Localizes pain
5
•Withdraws
4
•Flexion
3
•Extension
2
•None
1
3 to 15

12. Altered LOC is not a disorder itself;
rather, it is a function and symptom
of multiple pathophysiologic
phenomena. The cause may be
neurologic (head injury, stroke),
toxicologic (drug overdose,alcohol
intoxication), or metabolic (hepatic or
renal failure, diabetic ketoacidosis).

13. The underlying causes of neurologic
dysfunction are disruption in the
cells of the nervous system,
neurotransmitters, or brain
anatomy.

14.  A disruption in the basis functional units
(neurons) or neurotransmitters results in
faulty impulse transmission, impeding
communication within the brain or from the
brain to other parts of the body. These
disruptions are caused by cellular edema
and other mechanism such as antibodies
disrupting chemical transmission at
receptor sites.

15. Intact anatomic structures of the brain are
needed for proper function.
The two hemispheres of the cerebrum
must communicate, via an intact corpus
callosum, and the lobes of the brain
(frontal, parietal, temporal and occipital)
must communicate and coordinate their
specific functions.

16. Additional anatomic structures of
importance are the cerebellum and
the brain stem.
The cerebellum has both excitatory
and inhibitory actions and is largely
responsible for coordination of
movement.

17. The brain stem contains areas that
control the heart, respiration, and
blood pressure. Disruptions in the
anatomic structures are caused by
trauma, edema, pressure from tumors
as well as other mechanisms such as
an increase or decrease in blood or
cerebrospinal fluid (CSF) circulation

19. •Alterations in LOC occur along a
continuum, and the clinical
manifestations depend or where
the patient is along this
continuum. As the patient’s state
of alertness and consciousness
decreases, there will be changes
in the papillary response.

20. 2.Initial changes may be reflected by
subtle behavioral changes such as
restlessness or increased anxiety

21. 3. The pupils, normally round and quickly
reactively to light, become sluggish
(response is slower); as the patient
becomes comatose, the pupils become
fixed (no response to light). The patient in
a coma does not open the eyes, respond
verbally, or move the extremities in
response to a request to do so.

22. Assessment and
Diagnostic Findings
•The patient with an altered LOC is at
risk for alterations in every body
system. A complete assessment is
performed, with particular attention to
the neurologic system.

23. •The neurologic examination should be as
complete as the LOC allows. It includes an
evaluation of mental status, cranial nerve
function, cerebellar function (balance and
coordination), reflexes, and motor and
sensory function. LOC, a sensitive
indicator of neurologic function, is
assessed base on criteria in the Glasgow
Coma Scale; eye opening, verbal response
(Bateman, 2001). The patient’s responses
are rated on a scale from 3 to15

24. •A score of 3 indicates severe
impairment of neurologic function; a
score of 15 indicates that the patient
is fully responsive.

25. •If the patient is comatose, with localized
signs such as abnormal papillary and
motor responses, it is assumed that
neurologic disease is present until
proven otherwise. If the patient is
comatose and papillary light reflexes are
preserved, a toxic or metabolic disorder
is suspected.

26. •Procedures is used to identify the
cause of unconsciousness include
scanning, imaging, tomography (eg,
computed tomography magnetic
resonance imaging positron emission
tomography), and
electroencephalography

27. •Laboratory test include analysis of blood
glucose, electrolytes, serum ammonia,
and blood urea nitrogen levels as well as
serum osmolality, calcium level, and
partial thromboplastin and prothrombin
times. Other studies may be used to
evaluate serum ketones and alcohol, drug
levels, and arterial blood gas levels.

28. Complications
•Potential complications for the
patient with altered LOC include;
= respiratory failure- may
develop shortly after the patient
becomes unconscious
= pneumonia,
= pressures ulcers
= and aspiration

29. *If the patient cannot contain
effective respiration, supportive care
is initiated to provide adequate
ventilation.

30. •The patient with altered LOC is
subject to all the complications
associated with immobility such as;
= pressure ulcers
= venous stasis
= musculoskeletal deterioration
= and disturbed gastrointestinal
functioning

31. *Pressure ulcers may become
infected and act as source of sepsis.
Aspiration of gastric contents or
feedings may occur, precipitating the
development of pneumonia or airway
conclusion.

33. ·The first priority of treatment for the
patient with altered LOC is to obtain
and maintain a patent airway. The
patient may be orally or nasally
intubated, or a tracheostomy may
be performed. Until the patient’s
ability to breath on his or her own is
determined, a mechanical ventilator
is used to maintain adequate
oxygenation.

34. ·The circulatory status (blood pressure, heart rate) is
monitored to ensure adequate perfusion to the body and
brain. An intravenous catheter is inserted to provide
access for fluids and intravenous medications.
Neurologic care focuses on the specific neurologic
pathology, if any.nutritional support, using either a
feeding tube or a gastrostomy tube, is initiated as soon
as possible. In addition to measures to determine and
treat the underlying causes of altered LOC, other
medical interventions are aimed at pharmacologic
management of complications and strategies to prevent
complications.

36. THE PATIENT WITH AN
ALTERED LEVEL OF
CONSCIOUSNESS
Assessment = assessing the with an
altered LOC depends somewhat on
each patient’s circumstances, but
clinicians often start by assessing
the verbal response

37. •The patient is asked to identify the day,
date, or season of the year and to identify
where he or she is or to identify the
clinicians, or visitors present. Other
questions such as, “who is the president?”
or “what is the next holiday?” are also
helpful in determining the patient’s
processing of information in the
environment

38. •(verbal response cannot be evaluated
when the patient is intubated or has a
tracheostomy, and this should be
clearly documented.)

39. *Alertness is measured by the patient’s
ability to open the eyes spontaneously o
to a stimulus. Patient with severe
neurologic dysfunction cannot do this. The
should assess for periorbital edema or
trauma, which may prevent the patient
from opening the eyes, and document if
this interferes with eye opening.

40. *Motor response includes spontaneous,
purposeful movement (e g , the awake
patient can move all four extremities with
equal strength),movement only in
response to noxious stimuli(e g, pressure/
pain),or abnormal posturing if the patient
is not responding to commands ,

41. •the motor response is tested by applying a
painful stimulus ( firm but gentle
pressure)to the nailbed or by squeezing a
muscle if the patient attempts to push
away or withdraw, the response is
recoreded as purposeful if the patient can
cross from one side of the body to the
other in response to noxious stimuli.

42. *In addition to LOC, the nurse
monitors parameters such as..
=respiratory status,
=eye signs, and
=reflexes on an ongoing basis.

44. •Ineffective airway clearance related to altered
level of consciousness
•Risk of injury related to decreased level of
consciousness
•Deficient fluid volume related to inability to take
in fluids by mouth
•Impaired oral mucous membranes related to
mouth breathing, absence of pharyngeal reflex,
and altered fluid intake
•Risk for impaired skin integrity related to
immobility

45. •Impaired tissue integrity of cornea
related to diminished or absent
corneal reflex
•Ineffective thermoregulation related to
damage to hypothalamic center

46. •Impaired urinary elimination (incontinence
or retention) related to impairment in
neurologic sensing and control
•Bowel incontinence related to impairment
in neurologic sensing and control and also
related to transition in nutritional delivery
methods
•Interrupted family process related to
health crisis.

47. COMPLICATIONS
•Respiratory distress or failure
•Pneumonia
•Aspiration
•Pressure ulcer
•Deep vein thrombosis

48. PLANNING AND GOALS
•Maintenance of a clear airway
•Protect from injury
•Attainment of fluid volume balance
•Achievement of intact oral mucous
membranes
•Maintenance of normal skin integrity
•Absence of corneal irritation
•Attainment of effective thermoregulation
•Effective urinary elimination

50. •Maintaining the airway
•Protecting the patient
•Maintaining fluid balance and
managing nutritional needs
•Providing mouth care
•Maintaining skin and joint integrity
•Preserving corneal integrity

51. •Achieving thermoregulation
•Preventing urinary retention
•Promoting bowel function
•Providing sensory stimulation
•Meeting families’ needs.