Assesment, Interpretation and

Manganement of Altered
Consciousness

Dwi Kartika Rukmi

kartikarukmi@ymail.com
Definisi

Consciousness can be defined as a state

of awareness of self and the environment,
implying arousal in the brain and
perceptual processing of an experience
 Kesadaran
Arousal: determinasi dari fungsi RAS melalui
komunikasi neuron antara kortek dan talamus

Cognition/awareness: fungsi simultan dari

dua hemisfer dan keadaan RAS yang intact
 Sleep
 Sleep is a regularly occurring state of inactivity during which
consciousness is lost and responses to external stimuli are
reduced
 Kesadaran akan hilang dalam kondisi tidur dan koma, dengan
kondisi yang berbeda.
 Saat tidur, otak tetap aktif dan uptake oksigen sama dengan
saat sadar.
 Tidur ada dua fase:
1. NREM: thalamocortical cells are inhibted resulting in reduced
cortical stimulation
2. REM: cerebral cortex is highly active, almost identically to that
of an awake state, but the peri-locus ceruleus sup- presses
muscle tone (atonia), preventing the body from reacting to such
cortical activity
 Suprachiasmatic Nucleus
 The suprachiasmatic
nucleus is the
timekeeper of
consciousness,
maintaining
wakefulness and sleep
cycles.
 It is stimulated by light
on the retina being
transmitted to the
hypothalamus
 Consciousness Area

 Sensory input from multiple pathways is channelled

through the reticular formation and onwards to the
thalamus and cerebral cortex
Neural Pathways in Control
Consciousness
 ASSESSMENT OF CONSCIOUSNESS

 Five keys assessing neurologic system:

1. Level of consciousness/LOC (arousal
and cognition)
2. Pupil reaction

3. Motor function

4. Sensory function

5. Vital signs
AVPU

 Popular in recent years as a rapid

assessment of LOC
 It inadequate for patient with neurologic
condition
 Its difficult for nurse to extent the alteration of
consciousness
Glasgow Coma Scale (GCS)

 The gold standard for assessment of

consciousness throughout the world is the
Glasgow Coma Scale (GCS)
 The GCS was first developed as a 14 point
objective scale, then adapted into a 15 point
scale, with the addition of ‘abnormal flexion’
to the motor response category
 High accuracy in assess of LOC
 Interpretation of GCS
 Score what you see, always document the patient’s actual
response.
 The lower of GCS means the lower of LOC
 GCS of 8 or below, with no eye opening is in a coma
 Head injury: 13-15 (mild), 9-12 (moderate), 3-8 (severe)
 Has role play in decision at time of resuscitation: GCS 3/15 with
fixed dilated pupils indicates that the patient has no realistic
chance of survival, whereas GCS 3/15 without fixed dilated
pupils is an indicator for aggressive resuscitation
 GCS also effective in allocating triage priority in emergency care
situations
 ALTERED STATES OF
Etiology CONSCIOUSNESS
 ALTERED STATES OF
CONSCIOUSNESS
 Coma
 Persistent/permanent vegetative
state
 Minimally conscious state (MCS)
 Locked-in syndrome
 Cataplexy and sleep states
COMA
 Coma is an altered state of consciousness
characterised by absence of arousal or conscious
awareness.
 Sleep-wake cycles are absent
 Must last for more than one hour before the term
coma is applied.
 Outcome from coma is related to the cause, and is
independent of the patient’s initial presentation,
length of time in the coma, or ‘depth’ of the coma
Prognosis of Coma
Persistent vegetative state (PVS)
 Persistent vegetative state (PVS) is a chronic
neurological syndrome that is characterised by
preserved wakefulness, but voluntary interaction with
the environment is absent, and there is complete loss
of all cognitive functioning.
 ’Persistent’ refers to the vegetative state continuing
for at least one month, but this does not necessarily
imply permanency or irreversibility
 Permanent vegetative : PVS longer than 6 months 
considered to be irreversible
Persistent Vegetative State (PVS)
Minimally conscious state (MCS)

 10 times more common than PVS

 An individual who is in a MCS has a
limited, but definite, awareness of
themselves or environment,
distinguishing this state of
consciousness from a vegetative one
Minimally conscious state
(MCS)
 Locked-in syndrome
 Locked-in syndrome (pseudo-coma) is characterised by
quadriplegia and anarthria (partial or total loss of motor speech
control) and is commonly caused by ventral pontine and brain
stem lesions.
 Awareness of the environment is present, as is sustained eye
opening, aphonia or hypophonia and vertical or lateral eye
movement. Blinking responses are also present, with eye
movement being the only method of communication, as
patients have no limb movements or facial expressions.
 Communication can be difficult as the patient can become
exhausted trying to communicate by eye movements alone.
Locked-in syndrome
 Cataplexy and sleep states
 Cataplexy is a phenomenon that occurs when REM
sleep atonia (loss of muscle tone) intrudes into a
state of wakefulness, thereby affecting
consciousness.
 No loss of awareness, but unable to respond to the
environment due to the loss of motor tone
 Triggered by strong emotion: sadness, anger,
laughter
 Example: somnambulism (sleep walking), sleep
paralysis
 BRAIN STEM DEATH

 Brain stem death results from:

1. Raised intracranial pressure leading to
tonsillar herniation
2. Subsequent cerebrocirculatory arrest.

3. Isolated injury to the brain stem, such

as brain stem stroke/infarction.
 Brain stem death is accepted as death in
individual
 Death is defined as ‘the irreversible loss of
the capacity for consciousness, combined
with the irreversible loss of the capacity to
breathe’
 Death occurs when disorders are irreversible,
when treatment no longer effective.
Assessment of brain
stem death
 NURSING MANAGEMENT OF A PATIENT WITH
ALTERED CONSCIOUSNESS

 Immediate priorities in the patient who becomes

unconscious
1. Assess A (airway), B (breathing), C (circulation), D (disability),
E (exposure)
2. Determine the nursing care required :
 Maintenance airway
 Support of breathing (either through artificial ventilation or other
respiratory support)
 Support cardiovascular
 Evaluation of the extent of neurological compromise
 Assessment as to the cause of the loss of consciousness
 Preventing complications of bed rest
1. Pressure area care

 High risk of pressure area: male, older, unconscious

and post operative, low BMI, low albumin
 Assess with tool to determine risk of pressure ulcer
(ex: Braden scale)
 Intervention: turning position, use of pressure
relieving mattresses, management of continence and
optimisation of nutrition and hydration.
EBN: turning position every 4 hr + low-pressure foam
based mattresses are better than turning position every
2 hr +standard hospital mattress
2. Deep Vein Thrombosis
(DVT) Phrophylaxis
 Etiology DVT:
Hypercoagulability (systemic
or local), Venous stasis from
poor venous return, and Injury
to the venous intima
(specifically the endothelium)
 Virchow Triad
 See the guideline for prevent
DVT (see the box)
 Passive limb movements : can
help venous return to the
heart, while also helping to
prevent contractures and
muscular atrophy
3. Bladder and bowel care
Nursing care:
 Bladder care: catheter in early stage for
patient with urinary incontinence, late stage:
urinary sheaths or incontinence pads
 Bowel care: patients are greater risk for
constipation fibre enteral feed, adequate
hydration, use of laxatives as appropriate and
accurate assessment and documentation of
bowel function
4. Oral, aural and nasal hygiene
 Debris can build up around the oral cavity in the unconscious
patient, which can be exacerbated by unhumidified oxygen
therapy  increase oral flora that build up dental plaque
 Poor oral hygiene has also been associated with ventilator
acquired pneumonia (VAP) due to build up of bacteria within
plaque.
Nursing intervention:
 For unconscious patients, oral hygiene with a toothbrush and
toothpaste or water twice daily should suffice, and for ventilated
patients additional using antiseptics such as chlorhexidine is
recommended for this patient group
 Nasal mucosa and exter- nal aural canals may also require
cleansing to remove debris.
5. Eye care
 Unconscious patients will not have a protective blink reflex, and
the tears required to cleanse and hydrate the eyes will not be
spread over the surface of the cornea. Eyelid closure is also
often incomplete.
 Risk of corneal dehydration, keratitis, abrasions and in extreme
cases ulceration, perforation, scarring and possibly permanent
visual impairment
Nursing intervention:
 Cleanse of closed eyes with normal saline and gauze

 Maintain hydration through prescribed lubricating drops,

ointments, or polyethylene covers
 Keep the eye lids remain closed to prevent keratitis and
epithelial erosion
6. Communication needs of patients
and family
 Verbal communication and interaction received by
the unconscious patient is less than that received by
patients who are verbally responsive
 Communication needs to extend to the family
members who will often be experiencing a traumatic
situation. The need for family centred care that
emphasises better communication and involvement
of family in the process of care throughout
7. Psychological support for the
patient’s family
 Symptoms of depression and anxiety linked with
thoughts of the possible death of the patient often
occurs in family
 Nurses are ideally placed to offer support to families,
listen to their concerns and explain everything that is
happening. Relatives may feel helpless and can
appreciate opportunities to become involved in
patient care, but equally may be reluctant to get
involved and so should not be put under pressure to
participate.
 NURSING MANAGEMENT OF A PATIENT
WITH BRAIN STEM DEATH
 A patient who has been diagnosed with brain stem
death may still exhibit spinal reflex responses
(example: periodic leg movement) 
misinterpretation consider patient is alive.
 It is crucial for nurses to be proactive in assisting
relatives to understand the concept of brain stem
death  This has the potential to increase consent
for organ donation, but more importantly may help
the family in grieving for their loved one.
 Brain stem death with a GCS of 7 or less are
identified as having potential to be eventual organ
donors
REFERENCES
 Woodward, S.W., Mestecky,A.M.2011. Neuroscience
Nursing Evidence Based Practice. United Kingdom:
Wiley-Blackwell
 Wilkinson,I ., Lennox, G. 2005. Essential Neurology
(4 th edition). Oxford : Blackwell Publishing .
 Azoulay E, Pochard F (2003) Communication with
family members of patients dying in the intensive
care unit. Current Opinion in Critical Care 9(6): 545–
550.