Management of Patient with Neurologic Disorders

Management of Patient with Altered Level of Consciousness

• An altered level of consciousness (LOC) is apparent

in the patient who is not oriented, does not follow
commands, or needs 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

• The level of responsiveness and consciousness is the

most important indicator of the patient’s condition.

Brunner and Suddarth’s Medical-Surgical Nursing

 Management of Patient with Altered Level of Consciousness

Level of Consciousness

COMA is a clinical state of unconsciousness in which the

patient is unaware of self or the environment for prolonged
periods (days to months or even years).

AKINETIC MUTISM is a state of unresponsiveness to the

environment in which 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 conscious
content, without cognitive or affective mental function.

Brunner and Suddarth’s Medical-Surgical Nursing

Management of Patient with Altered Level of Consciousness

Definition of terms
Management of Patient with Altered Level of Consciousness

Definition of terms
 Management of Patient with Altered Level of Consciousness

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 over- dose, alcohol intoxication)
• metabolic (hepatic or renal failure, diabetic ketoacidosis).

The underlying causes of neurologic dysfunction are disrupt-

tion in the cells of the nervous system, neurotransmitters, or
brain anatomy
Management of Patient with Altered Level of Consciousness

Pathophysiology
 Management of Patient with Altered Level of Consciousness

Clinical Manifestations
As the patient’s state of alertness and consciousness decreases, there
will be changes in the:

• pupillary response, eye opening response, verbal response, and

motor response.

• behavioral changes such as restlessness or increased anxiety.

• The pupils 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.

Brunner and Suddarth’s Medical-Surgical Nursing

 Management of Patient with Altered Level of Consciousness

Assessment and Diagnostic Findings

Evaluation of :

• mental status
• cranial nerve function
• cerebellar function (balance and coordination)
• Reflexes
• motor and sensory function.

Glasgow Coma Scale: eye opening, verbal response, and

motor response
 Glasgow Coma Scale

The patient’s responses are rated on a scale from 3 to 15. A

score of 3 indicates severe impairment of neurologic function; a
score of 15 indicates that the patient is fully responsive
Decorticate posture is an abnormal posturing in which a person is stiff
with bent arms, clenched fists, and legs held out straight. The arms are bent
in toward the body and the wrists and fingers are bent and held on the
chest.
Decerebrate posture is an abnormal body posture that involves the
arms and legs being held straight out, the toes being pointed
downward, and the head and neck being arched backward. The
muscles are tightened and held rigidly. This type of posturing usually
means there has been severe damage to the brain
 Management of Patient with Altered Level of Consciousness

PROCEDURES used to identify the cause of

unconsciousness include:
• scanning
• Imaging
• tomography (eg, computed tomography, magnetic
resonance imaging, positron emission tomography)
• electroencephalography

Laboratory tests include analysis of blood glucose,

electrolytes, serum ammonia, and blood urea nitrogen
levels, as well as serum osmolality, calcium level, and par
tial thromboplastin and prothrombin times.

Other studies may be used to evaluate serum ketones and

alcohol, drug levels, and arterial blood gas levels
 Management of Patient with Altered Level of Consciousness

Complications
Potential complications for the patient with altered
LOC include

• Respiratory failure
• Pneumonia
• Pressure ulcers
• Aspiration.
 Management of Patient with Altered Level of Consciousness

Medical Management
• Obtain and maintain a patent airway. The patient may be orally or nasally
intubated, or a tracheostomy may be performed- mechanical ventilator to
maintain adequate oxygenation.

• 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.
• Nutritional support, using either a feeding tube or a gastrostomy tube, is
initiated as soon as possible.
• Pharmacologic management of complications and strategies to prevent
complications.
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