Chapter 61
Nursing Process
The Patient with an Altered Level of Consciousness
Assessment
Assessment of the patient with an altered LOC depends on the patient's circumstances,
but clinicians often start by assessing the verbal response. Determining the patient's
orientation to time, person, and place assesses verbal response. 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. Other questions such as,
―Who is the president?‖ or ―What is the next holiday?‖ may be helpful in determining
the patient's processing of information in the environment. (Verbal response cannot be
evaluated if the patient is intubated or has a tracheostomy, and this should be clearly
documented.)
Alertness is measured by the patient's ability to open the eyes spontaneously or in
response to a vocal or noxious stimulus (pressure or pain). Patients with severe
neurologic dysfunction cannot do this. The nurse assesses for periorbital edema
(swelling around the eyes) or trauma, which may prevent the patient from opening the
eyes, and documents any such condition that interferes with eye opening.
Motor response includes spontaneous, purposeful movement (eg, the awake patient can
move all four extremities with equal strength on command), movement only in
response to painful stimuli, or abnormal posturing (Hickey, 2003; Seidel, Ball, Dains,
et al., 2003). If the patient is not responding to commands, 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 recorded as
purposeful or appropriate (―patient withdraws to painful stimuli‖). This response is
considered purposeful if the patient can cross the midline from one side of the body to
the other in response to painful stimuli. An inappropriate or nonpurposeful response is
random and aimless. Posturing may be decorticate or decerebrate (Fig. 61-1; see also
Chapter 60). The most severe neurologic impairment results in flaccidity. The motor
response cannot be elicited if the patient has been administered pharmacologic
paralyzing agents.
In addition to LOC, the nurse monitors parameters such as respiratory status, eye signs,
and reflexes on an ongoing basis. Table 61-1 summarizes the assessment and the
clinical significance of the findings. Body functions (circulation, respiration,
elimination, fluid and electrolyte balance) are examined in a systematic and ongoing
manner.
Diagnosis
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses may include the following:
Ineffective airway clearance related to altered LOC
Risk of injury related to decreased LOC
Deficient fluid volume related to inability to take fluids by mouth
Impaired oral mucous membrane related to mouth-breathing, absence of
pharyngeal reflex, and altered fluid intake
Risk for impaired skin integrity related to immobility
Impaired tissue integrity of cornea related to diminished or absent corneal reflex
Ineffective thermoregulation related to damage to hypothalamic center
Impaired urinary elimination (incontinence or retention) related to impairment
in neurologic sensing and control