1. The patient presented with an altered level of consciousness which can result from various neurologic, toxicologic, or metabolic causes that interrupt the brain's blood supply or normal function. 2. A complete assessment including Glasgow Coma Scale is performed to evaluate the patient's mental status, neurological exam, and determine the underlying cause. 3. The goals of treatment are to maintain an open airway, adequate oxygenation and ventilation if needed via intubation, monitor the patient's circulatory status, and treat any underlying conditions causing the altered consciousness.

1. MANAGEMENT OF PATIENTS
WITH ALTERED LEVEL OF
CONSCIOUSNESS
ALTERED LEVEL OF
CONSCIOUSNESS
Mr ANILKUMAR BR MS.C NURSING
LECTURER
Medical-surgical nursing

2. ∗ The human brain requires a constant
supply of oxygen and glucose for
normal function.
∗ Interruption of this supply will cause
loss of consciousness within a few
seconds and may also cause even
permanent brain damage
Introduction

3. ∗ Altered level of consciousness is not a
disorder itself, rather it is a result of
multiple pathophysiologic phenomena.
∗ The cause may neurogenic( HI,BT,CVA
etc.) toxicological ( alcohol, poison &
drug overdose) or metabolic ( hepatic,
renal failure)

4. ∗ Consciousness is a state of
wakefulness and awareness of self
and the environment.
What is consciousness

5. 1) Wakefulness
2) Awareness of self, environment
(including place) and Time
 Wakefulness is the ability to maintain
an awake state or to be easily aroused
from sleep.
 Awareness of self- means that client
can identify himself /or her self.
Consciousness is a state of being with two
important aspects

6. An altered level of consciousness (LOC) is
apparent in the patient who is not
oriented, does not follow commands,
commends persistent stimuli to achieve a
state of alertness.
Coma is a clinical state of unconsciousness in
which the patient is unaware of self or the
environment for prolonged periods (days to
Definition

7. Two types disorders can produce
unconsciousness
Etiological factors of
unconsciousness

8. ∗ Cerebral edema
∗ Brain tumor ( intracranial tumor)
∗ Brain abscess
∗ Focal brain dysfunction
∗ Cerebral hemorrhage
Structural lesions in the brain

9. ∗ Cerebral infaraction (Massive)
∗ Epidural hematoma
∗ Subdural hematoma
∗ Increase ICP
∗ Subarachnoid hemorrhage
Structural lesions in the brain

10. ∗ Disease of the organs ( heart, liver, lungs,
endocrine, kidney)
∗ Hypoxia and Hypoglycemia
∗ Hypo and hyperthermia
∗ Metabolic and Endocrine causes (diabetic coma,
hepatic coma, renal failure)
∗ Hypotension / Hypertensive crisis
∗ Infections ( Encephalitis and Meningitis
Metabolic disorders

11. ∗ Epilepsy and seizures
∗ Severe nutritional deficiency
∗ Toxicity: heavy metals, carbon
monoxide, drug(opiates, barbiturates
and alcohol)
Metabolic disorders

12. ∗ Altered level of consciousness is a symptom
of a multiple pathophysiologic causes such
as:
∗ Neurologic: head injury, stroke
∗ Toxicologic: drug overdose, alcohol
intoxication
∗ Metabolic: hepatic failure, renal failure,
diabetic ketoacidosis
∗ The underlying causes of neurologic
dysfunction are disruption in the cells of the
nervous system, neurotransmitters, or brain
anatomy
Pathophysiology

13. 1. Cellular brain oedema or disrupting
chemical transmission at receptor
site, result in faulty impulse
transmission and impeding
communication within the brain or
from the brain to other body parts
Continue

14. 1. Brain trauma, brain oedema, tumour
pressure, increase or decrease blood or
cerebrospinal fluid result in disruption in
anatomic structure of the brain and
faulty impulse transmission and
impeding communication within the
brain or from the brain to other body
part

15. ∗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.
Clinical manifestations

16. ∗ The pupils normally round and
quickly reactive to light , become
sluggish ( response in slower); as
the patients becomes comatose,
the pupils become fixed ( no
response to light).
Clinical manifestations

17. ∗ The patient in a coma does not open the
eyes, respond verbally, or move the
extremities.
Continue

18. ∗ The client with an ALOC is at risk
for alterations in every body
system.
∗A complete assessment is
performed, with particular
attention to the neurologic system.
Assessment and Diagnostic Findings

19. ∗ It includes an evaluation of mental
status, cranial nerve function, cerebellar
function ( balance and coordination)
reflexes ,and motor and sensory
function.
∗ GLASGOW COMA SCALE ( GCS)
Assessment and Diagnostic Findings

20. Eye opening
Glasgow Coma Scale (GCS)

21. ∗ CT-SCAN
∗ MRI
∗ PET
∗ SPECT
∗ EEG , MRI & PET as important technologies
in determining brain function through the
evaluation of metabolic and electrical
activity.
Other common diagnostic and
laboratory test

22. ∗Analysis of blood glucose levels
∗Electrolytes, serum ammonia, and
Liver functions test
∗ BUN, PTT and PT
∗ Other studies include alcohol and
drug concentrations and ABGs.
laboratory tests

23. Potential complications for the patient
with altered LOC include:
1.Respiratory distress or failure
2.Pneumonia
3.Pressure ulcers or bedsore
4.Aspiration.
Complications

24. ∗ Venous thromboembolism (VTE) or
DVT
∗ Contractures
complications

25. Pressure ulcer

26. Venous thromboembolism (VTE) or
DVT

27. Contractures

28. ∗ The first priority of treatment for clients with
ALOC is to obtain and maintain a patient airway.
∗ The client may be orally or nasally intubated, or
a tracheostomy may be performed.
∗ until the ability of the client breathe is
determined, a mechanical ventilator is used to
maintain adequate oxygenation and ventilation.
Medical management

29. Airway management in client with a ALOC

30. ∗ BP , HR is monitored to ensure
adequate perfusion to the body and
brain.
∗ IV lines are inserted to provide access
for IV fluids & medications.
∗ Nutritional support , via a feeding tube
(NG tube) or gastrostomy tube or TPN.
Medical management

31. ∗ Obtain and maintain a patent airway.
∗ Intubation, or a tracheostomy may be performed.
∗ Mechanical ventilator is used to maintain adequate
oxygenation.
∗ The circulatory status (blood pressure, heart rate) is
monitored to ensure adequate perfusion to the body
and brain.
Medical management

32. ∗Determine and treat the underlying
causes of altered LOC.
∗ Pharmacological management of
complications and strategies to
prevent complications.
Continue

33. NURSING PROCESSNURSING PROCESS
THE PATIENT WITH AN ALTEREDTHE PATIENT WITH AN ALTERED
LEVELLEVEL
OF CONSCIOUSNESSOF CONSCIOUSNESS

34. ∗ Level of responsiveness or consciousness
∗ Verbal response.
∗ Patient’s orientation to time, person, and place,
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, family
members, or visitors present.
∗ Assess alertness by the patient’s ability to open
the eyes spontaneously or to a stimulus.
∗ Periorbital edema or trauma, which may prevent
the patient from opening the eyes.
Assessment

35. ∗ Motor response includes spontaneous,
purposeful movement, movement only in
response to noxious stimuli, or abnormal
posturing (decorticate or decerebrate).
∗ Respiratory status and pattern of
respiration.
∗ Eye signs, and reflexes.
∗ Corneal reflex.
∗ Facial symmetry.
∗ Swallowing reflex.
∗ Deep tendon reflex.
Continue

36. ∗ Nursing assessment
- Assess eye opening ( level of responsiveness)
- Pupils reaction to light
- Assess neurologic function using the GCS
- Assess respiratory and cardiac functions
- Monitor frequent neurologic status over time
and report changes to health care provider, as
indicated.
Nursing management of clients with an
altered state of consciousness

37. ∗ Decreased Intracranial adaptive capacity
∗ Ineffective airway clearance related to
upper airway obstruction by tongue and
soft tissues, inability to clear respiratory
secretions.
∗ Risk for imbalanced fluid volume related
to inability to ingest fluids , dehydration
from osmotic diuretic therapy ( when used
to reduce increase ICP) .
Nursing Diagnosis

38. ∗ Risk for respiratory infection related to
prolong mechanical ventilation and
aspiration
∗ Impaired oral mucous membranes
related to mouth breathing, absence of
pharyngeal reflex, inability to ingest
fluid.
Nursing diagnosis

39. ∗ Risk for impaired or decrease skin integrity
related to immobility or restlessness.
∗ Impaired tissue integrity of cornea related
to diminished /absent of corneal reflexes
∗ Risk for Hypothermia related to infectious
process; damage of thermoregulation
Centre.
Nursing diagnosis

40. ∗ Impaired urinary and bowel elimination
related to unconscious state.
∗ Risk for imbalanced nutrition: less than
body requirements related to inability to
ingest nutrients to meet metabolic
needs.
∗ Interrupted family process related to
health crisis
Nursing diagnosis

41. Nursing interventions

42. ∗ Monitor frequent neurological status and maintain
hourly neurological chart
∗ Identify emerging trends in neurologic function and
communicate findings to medical staff
∗ Monitor the client response to medications and drugs.
∗ Monitor lab data if indicated ( Blood glucose, CSF, CBC
etc.)
∗ Institute measures to minimize risk for increased ICP,
cerebral edema, seizures.)
Minimizing secondary brain injury

43. ∗ Monitor lab data if indicated ( Blood glucose, CSF,
CBC etc.)
∗ Institute measures to minimize risk for increased ICP,
cerebral edema, seizures.)
∗ Monitoring temperature status ; maintain
normothermia, institute cooling procedures if
indicated.
Minimizing secondary brain injury

44. ∗ The most important aspect in managing the
patient with ALOC is to establish an adequate
airway and ensure ventilation.
∗ Keep the airway freeform secretions with
adequate suctioning
∗ If client need endotracheal intubation and
mechanical ventilation should be assist.
Maintaining an effective airway

45. ∗ Monitor prescribed IV fluids carefully for
e.g. monitor hourly intake and output
∗ Assess hydration status by examining skin
turgor & mucous membranes
∗ Monitor Pulse, BP
∗ Monitor fluid over load and pulmonary
edema carefully.
Attaining & Maintaining fluid &
electrolyte balance

46. ∗ Respiratory tract infection and UTI is most common
complications in a patient with prolong ALOC status
∗ Ventilator associated pneumonia ( VAP) and
aspiration pneumonia can be associated with prolong
endotracheal intubation and Mechanical ventilation.
∗ Adequate oral care and anticipate prevention of
aspiration such as proper position and suctioning is
essential to prevent respiratory tract infection
Prevent infection

47. ∗ Respiratory therapies such as CPT and PD
∗ Follow proper aseptic technique maintain adequate
urinary catheter care
∗ Monitor signs &symptoms of infection ( Elevation
body temp , increase WBC etc.)
Prevent infection

48. ∗ The mouth is inspected for dryness,
inflammation and crusting.
∗ Remove dentures
∗ Provide oral care and take precautions
during oral care because of risk for
aspiration ( side lying position is
preferable)
∗ Maintain hydration and prevent dryness
Maintaining healthy oral mucus
membranes and oral hygiene

49. ∗ Use oxygen therapy if indicated.
∗ Refer to Chest physical therapy such as
Postural drainage, chest percussion etc.
∗ Frequently monitor respiratory status
such as rate, rhythm, pattern etc.,
Maintaining an effective airway

50. ∗ Maintaining of skin integrity is quite challenging
in a patient with ALOC because of long term
immobility, negligence of providing frequent
positioning and nutritional factors can affect
level of skin integrity.
∗ Frequent turn the client from side to side and
provide positioning on a regular schedule to
relive pressure areas and help clear lungs by
mobilizing secretions
Maintain skin integrity

51. ∗ Perform ROM exercise of extremities at
least four times per day
∗ Use water bed and air bed to prevent
pressure ulcer
∗ Maintain adequate nutritional status.
∗ Keep the skin clean and moisture , well
lubricated
Maintain skin integrity

52. ∗ Some clients who are unconscious have
their eyes open and have inadequate or
absent corneal reflexes.
∗ The cornea may become infected,
irritated, dry, or scratched and leading
to ulcerations.
Maintain corneal integrity

53. ∗ Protect the eyes from corneal irritation as the cornea
functions as shield.
∗ Care full inspect the condition of the eyes with
penlight
∗ Remove the any contact lenses if worn
∗ Irrigate the eyes with sterile water
∗ Instill prescribed ophthalmic ointments and drops
∗ Apply eye patches when indicated
Maintain corneal integrity

54. ∗ Hypothermia & Hyperthermia is common in
unconscious clients in case of damage of
thermo regulating Centre of the brain
( hypothalamus) and also may be caused by
respiratory and urinary tract infections.
∗ Monitor client body temperature
∗ Take appropriate interventions to manage
thermo imbalance
Maintain thermoregulation functions

55. ∗ An Indwelling Urinary Catheter may be used for short
–term management
∗ Use intermittent bladder catheterization
∗ Monitor cloudy urine and fever
∗ Auscultate for bowel sounds; palpate and measure
lower abdomen for distention
∗ Treat constipation promptly if present
∗ Monitor for diarrhea caused by infection & antibiotics
Promote manage urinary and bowel
function

56. ∗ Always beds slide rails should be used
∗ Care taken invasive IV lines and tubes
∗ Frequent neurological assessment and frequent
orientation is essential
∗ prevent injury to the patient
Safety of the client

57. ∗ Develop a supportive and trusting relationship
with the family members of the patient.
∗ Provide information and frequent updates on
the clients condition and progress.
∗ Demonstrate and teach some of procedure
esp. procedure carried out in home setting
such as feeding technique, position change etc.
Family education and support