Nursing Process: The Patient With an Altered Level of Consciousness

NURSING PROCESS: THE PATIENT WITH AN ALTERED LEVEL OF CONSCIOUSNESS

Assessment

Where to begin assessing the patient with an altered LOC de-pends somewhat on each patient’s circumstances, but clinicians often start by assessing the verbal response. Determining the pa-tient’s orientation to time, person, and place assesses verbal re-sponse. 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?”

are also helpful in determining the patient’s processing of infor-mation in the environment. (Verbal response cannot be evaluated when 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 to a stimulus. Patients with severe neurologic dysfunction cannot do this. The nurse should assess for peri-orbital edema or trauma, which may prevent the patient from opening the eyes, and document if this interferes with eye opening.

Motor response includes spontaneous, purposeful move-ment (eg, the awake patient can move all four extremities with equal strength), movement only in response to noxious stimuli (eg, pressure/pain), or abnormal posturing (Bateman, 2001). If the patient is not responding to commands, the motor response is tested by applying a painful stimulus (firm but gentle pres-sure) to the nailbed or by squeezing a muscle. If the patient at-tempts to push away or withdraw, the response is recorded as purposeful or appropriate (“patient withdraws to painful stim-uli”). This response is considered purposeful if the patient can cross from one side of the body to the other in response to nox-ious stimuli. An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decere-brate. The most severe neurologic im-pairment results in flaccidity. Occasionally, posturing cannot be elicited if the patient has been given 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 signifi-cance of the findings. Body functions (circulation, respiration, elimination, fluid and electrolyte balance) are examined in a sys-tematic 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 level of con-sciousness

·       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

·      Impaired tissue integrity of cornea related to diminished or absent corneal reflex

·      Ineffective thermoregulation related to damage to hypo-thalamic center

·      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 transitions in nutri-tional delivery methods

·      Disturbed sensory perception related to neurologic im-pairment

·      Interrupted family processes related to health crisis

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications may include:

·      Respiratory distress or failure

·       Pneumonia

·       Aspiration

·       Pressure ulcer

·       Deep vein thrombosis

Planning and Goals

The goals of care for the patient with altered LOC include main-tenance of a clear airway, protection from injury, attainment of fluid volume balance, achievement of intact oral mucous mem-branes, maintenance of normal skin integrity, absence of corneal irritation, attainment of effective thermoregulation, and effective urinary elimination. Additional goals include bowel continence, accurate perception of environmental stimuli, maintenance of in-tact family or support system, and absence of complications (Jacobson & Winslow, 2000).

Because the unconscious patient’s protective reflexes are im-paired, the quality of nursing care provided literally may mean the difference between life and death. The nurse must assume re-sponsibility for the patient until the basic reflexes (coughing, blinking, and swallowing) return and the patient becomes con-scious and oriented. Thus, the major nursing goal is to compen-sate for the absence of these protective reflexes.

Nursing Interventions

MAINTAINING THE AIRWAY

The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure venti-lation. Obstruction of the airway is a risk because the epiglottis and tongue may relax, occluding the oropharynx, or the patient may aspirate vomitus or nasopharyngeal secretions.

The accumulation of secretions in the pharynx presents a se-rious problem. Because the patient cannot swallow and lacks pharyngeal reflexes, these secretions must be removed to elimi-nate the danger of aspiration. Elevating the head of the bed to 30 degrees helps prevent aspiration. Positioning the patient in a lateral or semiprone position will also help as it permits the jaw and tongue to fall forward, thus promoting drainage of secretions.

Positioning alone is not always adequate, however. The pa-tient may require suctioning and oral hygiene. Suctioning is per-formed to remove secretions from the posterior pharynx and upper trachea. With the suction off, a whistle-tip catheter is lubricated with a water-soluble lubricant and inserted to the level of the pos-terior pharynx and upper trachea. Continuous suction is applied as the catheter is withdrawn using a twisting motion of the thumb and forefinger. This twisting maneuver prevents the suctioning end of the catheter from causing irritation, which increases se-cretions and causes mucosal trauma and bleeding. Before and after suctioning, the patient is hyperoxygenated and hyperventi-lated to prevent hypoxia (Hickey, 2003). In addition to these interventions, chest physiotherapy and postural drainage may be initiated to promote pulmonary hygiene, unless contraindicated by the patient’s underlying condition. Also, the chest should be auscultated at least every 8 hours to detect adventitious breath sounds or absence of breath sounds.

Despite these measures, or because of the severity of impair-ment, the patient with altered LOC often requires intubation and mechanical ventilation. Nursing actions for the mechanically ventilated patient include maintaining the patency of the endo-tracheal tube or tracheostomy, providing frequent oral care, mon-itoring arterial blood gas measurements, and maintaining ventilator settings.

PROTECTING THE PATIENT

For the protection of the patient, padded siderails are provided and raised at all times. Care should be taken to prevent injury from invasive lines and equipment, and other potential sources of injury should be identified (eg, restraints, tight dressings, envi-ronmental irritants, damp bedding or dressings, tubes and drains).

Protection also encompasses the concept of protecting the pa-tient’s dignity during altered LOC. Simple measures such as pro-viding privacy and speaking to the patient during nursing care activities preserve the patient’s humanity. Not speaking nega-tively about the patient’s condition or prognosis is also important, because patients in a light coma may be able to hear. The co-matose patient has an increased need for advocacy, and it is the nurse’s responsibility to see that these advocacy needs are met (Elliott & Wright, 1999; Villanueva, 1999).

MAINTAINING FLUID BALANCE AND MANAGING NUTRITIONAL NEEDS

Hydration status is assessed by examining tissue turgor and mu-cous membranes, assessing intake and output trends, and analyz-ing laboratory data. Fluid needs are met initially by giving the required fluids intravenously. However, intravenous solutions (and blood transfusions) for patients with intracranial conditions must be administered slowly. If given too rapidly, they may in-crease ICP. The quantity of fluids administered may be restricted to minimize the possibility of producing cerebral edema.

If the patient does not recover quickly and sufficiently enough to take adequate fluids and calories by mouth, a feeding tube will be inserted for the administration of fluids and enteral feedings (Day, Stotts, Frankfurt et al., 2001).

PROVIDING MOUTH CARE

The mouth is inspected for dryness, inflammation, and crusting. The unconscious patient requires conscientious oral care because there is a risk of parotitis if the mouth is not kept scrupulously clean. The mouth is cleansed and rinsed carefully to remove se-cretions and crusts and to keep the mucous membranes moist. A thin coating of petrolatum on the lips prevents drying, cracking, and encrustations. If the patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips.

MAINTAINING SKIN AND JOINT INTEGRITY

Preventing skin breakdown requires continuing nursing assess-ment and intervention. Special attention is given to unconscious patients because they cannot respond to external stimuli. Assess-ment includes a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin. Turning also provides kinesthetic (sensation of movement), proprioceptive (awareness of position), and vestibular (equilibrium) stimulation. After turning, the patient is carefully repositioned to prevent is-chemic necrosis over pressure areas. Dragging the patient up in bed must be avoided, because this creates a shearing force and friction on the skin surface.

Maintaining correct body position is important; equally im-portant is passive exercise of the extremities to prevent contrac-tures. The use of splints or foam boots aids in the prevention of footdrop and eliminates the pressure of bedding on the toes. Trochanter rolls supporting the hip joints keep the legs in proper alignment. The arms should be in abduction, the fingers lightly flexed, and the hands in slight supination. The heels of the feet should be assessed for pressure areas. Specialty beds, such as flu-idized or low-air-loss beds, may be used to decrease pressure on bony prominences.

PRESERVING CORNEAL INTEGRITY

Some unconscious patients have their eyes open and have inade-quate or absent corneal reflexes. The cornea is likely to become irritated or scratched, leading to keratitis and corneal ulcers. The eyes may be cleansed with cotton balls moistened with sterile nor-mal saline to remove debris and discharge. If artificial tears are prescribed, they may be instilled every 2 hours. Periocular edema (swelling around the eyes) often occurs after cranial surgery. Cold compresses may be prescribed, and care must be exerted to avoid contact with the cornea. Eye patches should be used cautiously because of the potential for corneal abrasion from the cornea coming in contact with the patch.

ACHIEVING THERMOREGULATION

High fever in the unconscious patient may be caused by infection of the respiratory or urinary tract, drug reactions, or damage to the hypothalamic temperature-regulating center. A slight eleva-tion of temperature may be caused by dehydration. The envi-ronment can be adjusted, depending on the patient’s condition, to promote a normal body temperature. If body temperature is elevated, a minimum amount of bedding—a sheet or perhaps only a small drape—is used. The room may be cooled to 18.3°C (65°F). However, if the patient is elderly and does not have an el-evated temperature, a warmer environment is needed.

Because of damage to the heat-regulating center in the brain or severe intracranial infection, unconscious patients often develop very high temperatures. Such temperature elevations must be con-trolled because the increased metabolic demands of the brain can overburden cerebral circulation and oxygenation, resulting in cere-bral deterioration (Hickey, 2003). Persistent hyperthermia with no identified clinical source of infection indicates brain stem damage and a poor prognosis.

Strategies for reducing fever include:

·      Removing all bedding over the patient (with the possible ex-ception of a light sheet or small drape)

·      Administering repeated doses of acetaminophen as pre-scribed

·      Giving a cool sponge bath and allowing an electric fan to blow over the patient to increase surface cooling

·      Using a hypothermia blanket

Frequent temperature monitoring is indicated to assess the re-sponse to the therapy and to prevent an excessive decrease in tem-perature and shivering.

PREVENTING URINARY RETENTION

The patient with an altered LOC is often incontinent or has uri-nary retention. The bladder is palpated or scanned at intervals to determine whether urinary retention is present, because a full bladder may be an overlooked cause of overflow incontinence. A portable bladder ultrasound instrument is a useful tool in bladder management and retraining programs (O’Farrell, Vandervoort, Bisnaire et al., 2001).

If there are signs of urinary retention, initially an indwelling urinary catheter attached to a closed drainage system is inserted. A catheter may be inserted during the acute phase of illness to monitor urinary output. Because catheters are a major factor in causing urinary tract infection, the patient is observed for fever and cloudy urine. The area around the urethral orifice is in-spected for drainage. The urinary catheter is usually removed when the patient has a stable cardiovascular system and if no di-uresis, sepsis, or voiding dysfunction existed before the onset of coma. Although many unconscious patients urinate sponta-neously after catheter removal, the bladder should be palpated or scanned with a portable ultrasound device periodically for urinary retention (O’Farrell et al., 2001). An intermittent catheterization program may be initiated to ensure complete emptying of the bladder at intervals, if indicated.

An external catheter (condom catheter) for the male patient and absorbent pads for the female patient can be used for the un-conscious patient who can urinate spontaneously although invol-untarily. As soon as consciousness is regained, a bladder-training program is initiated. The incontinent patient is monitored fre-quently for skin irritation and skin breakdown. Appropriate skin care is implemented to prevent these complications.

PROMOTING BOWEL FUNCTION

The abdomen is assessed for distention by listening for bowel sounds and measuring the girth of the abdomen with a tape mea-sure. There is a risk of diarrhea from infection, antibiotics, and hyperosmolar fluids. Frequent loose stools may also occur with fecal impaction. Commercial fecal collection bags are available for patients with fecal incontinence.

Immobility and lack of dietary fiber may cause constipation. The nurse monitors the number and consistency of bowel move-ments and performs a rectal examination for signs of fecal im-paction. Stool softeners may be prescribed and can be administered with tube feedings. To facilitate bowel emptying, a glycerine sup-pository may be indicated. The patient may require an enema every other day to empty the lower colon.

PROVIDING SENSORY STIMULATION

Sensory stimulation is provided at the appropriate time to help overcome the profound sensory deprivation of the unconscious patient. Efforts are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep. The nurse touches and talks to the patient and encourages fam-ily members and friends to do so. Communication is extremely important and includes touching the patient and spending enough time with him or her to become sensitive to his or her needs. It is also important to avoid making any negative comments about the patient’s status or prognosis in the patient’s presence.

The nurse orients the patient to time and place at least once every 8 hours. Sounds from the patient’s home and workplace may be introduced using a tape recorder. Family members can read to the patient from a favorite book and may suggest radio and television programs that the patient previously enjoyed as a means of enriching the environment and providing familiar input (Hickey, 2003).

When arousing from coma, many patients experience a period of agitation, indicating that they are becoming more aware of their surroundings but still cannot react or communicate in an ap-propriate fashion. Although disturbing for many family members, this is actually a good clinical sign. At this time, it is necessary to minimize the stimulation to the patient by limiting background noises, having only one person speak to the patient at a time, giving the patient a longer period of time to respond, and allow-ing for frequent rest or quiet times.

When the patient has regained consciousness, videotaped fam-ily or social events may assist the patient in recognizing family and friends and allow him or her to experience missed events.

MEETING FAMILIES’ NEEDS

The family of the patient with altered LOC may be thrown into a sudden state of crisis and go through the process of severe anx-iety, denial, anger, remorse, grief, and reconciliation. Depending on the disorder that caused the altered LOC and the extent of the patient’s recovery, the family may be unprepared for the changes in the cognitive and physical status of their loved one. If the patient has significant residual deficits, the family may require considerable time, assistance, and support to come to terms with these changes. To help family members mobilize their adaptive capacities, the nurse can reinforce and clarify information about the patient’s condition, permit the family to be involved in care, and listen to and encourage ventilation of feelings and concerns while supporting them in their decision-making process about posthospitalization management and placement (Hauber & Testani-Dufour, 2000). Families may benefit from participation in support groups offered through the hospital, rehabilitation fa-cility, or community organizations.

In some circumstances, the family may need to face the death of their loved one. The neurologic patient is often pronounced brain dead before physiologic death occurs. The term brain death describes irreversible loss of all functions of the entire brain, in-cluding the brain stem. The term may be misleading to the family because although brain function has ceased, the patient appears to be alive, with the heart rate and blood pressure sustained by vaso-active medications, and breathing continues by mechanical ven-tilation. When discussing a patient who is brain dead with family members, it is important to use the term “dead”; the term “brain dead” may confuse them (Shewmon, 1998). Chart 61-1 discusses ethical issues related to patients with severe neurologic damage.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Pneumonia, aspiration, and respiratory failure are potential com-plications in any patient who has a depressed LOC and who can-not protect the airway or turn, cough, and take deep breaths. The longer the period of unconsciousness, the greater the risk for pul-monary complications.

Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. Total blood count and arterial blood gas measurements are assessed to deter-mine whether there are adequate red blood cells to carry oxygen and whether ventilation is effective. Chest physiotherapy and suctioning are initiated to prevent respiratory complications such as pneumonia. If pneumonia develops, cultures are obtained to identify the organism so that appropriate antibiotics can be administered.

The patient with altered LOC is monitored closely for evi-dence of impaired skin integrity, and strategies to prevent skin breakdown and pressure ulcers are continued through all phases of care, including hospital, rehabilitation, and home care. Factors that contribute to impaired skin integrity (eg, incontinence, in-adequate dietary intake, pressure on bony prominences, edema) are addressed. If pressure ulcers develop, strategies to promote healing are undertaken. Care is taken to prevent bacterial conta-mination of pressure ulcers, which may lead to sepsis and septic shock.

The patient should also be monitored for signs and symptoms of deep vein thrombosis. Patients who develop deep vein throm-bosis are at risk for pulmonary embolism. Prophylaxis such as sub-cutaneous heparin or low-molecular-weight heparin (Fragmin, Orgaran) should be prescribed (Karch, 2002). Thigh-high elas-tic compression stockings or pneumatic compression stockings should also be prescribed to reduce the risk for clot formation. Measures to assess for deep vein thrombosis, such as Homans’ sign, may be clinically unreliable in this population, and the nurse should observe for redness and swelling in the lower extremities.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Maintains clear airway and demonstrates appropriate breath sounds

2)    Experiences no injuries

3)    Attains/maintains adequate fluid status

a)     Has no clinical signs or symptoms of dehydration

b)    Demonstrates normal range of serum electrolytes

c)     Has no clinical signs or symptoms of overhydration

4)    Attains/maintains healthy oral mucous membranes

5)    Maintains normal skin integrity

6)    Has no corneal irritation

7)    Attains or maintains thermoregulation

8)    Has no urinary retention

9)    Has no diarrhea or fecal impaction

10)       Receives appropriate sensory stimulation

11)       Family members cope with crisis

a)     Verbalize fears and concerns

b)    Participate in patient’s care and provide sensory stim-ulation by talking and touching

12)       Is free of complications

a)     Has arterial blood gas values within normal range

b)    Displays no signs or symptoms of pneumonia

c)     Exhibits intact skin over pressure areas

d)    Does not develop deep vein thrombosis