Assessment of the extent of awareness

As nurses, the very first thing we regularly do when entering a patient’s room is assess their mental state and level of consciousness. We immediately observe whether the patient is conscious and alert. If they get up, we’ll ask them a couple of easy questions, akin to their name, date and reason for being within the hospital. This “small talk” will help us determine whether the patient is capable of respond appropriately, whether he is concentrated or confused. If the patient is unresponsive or unable to reply questions, proceed the neurological assessment with a more detailed assessment of the patient’s level of consciousness.

Level of awareness (Bickley et al., 2021; Hinkle, 2021)

Level of consciousness (LOC) is a sensitive indicator of neurological function and is often assessed using the Glascow Coma Scale, which incorporates eye opening, verbal response, and motor response. Document your patient’s LOC based on the next categories.

1. : the patient opens his eyes spontaneously, looks at you when spoken to in a standard voice, responds appropriately to stimuli, and movements are purposeful.
2. : the patient appears drowsy, but opens his eyes to loud verbal stimuli, looks at you, answers your questions, after which goes back to sleep.
3. : the patient opens his or her eyes to the touch and appears at you, but responds slowly and will be confused.
4. : the patient wakes up only when painful stimuli are applied (i.e. pressure on the nail bed). The patient’s verbal responses are slow or absent. When the stimuli stop, the patient will enter an unresponsive state.
5. : the patient isn’t aroused and his eyes remain closed. There are not any intentional responses to internal or external stimuli. However, unintentional responses to painful stimuli and brainstem reflexes should occur.

Revised LOC (Hinkle, 2021)

There are several underlying medical conditions that may cause an altered level of consciousness, including neurological disorders (head injury, stroke), toxicological disorders (drug overdose, alcohol poisoning), or metabolic disorders (liver or kidney damage, diabetic ketoacidosis). Early signs of altered LOC include changes in behavior akin to restlessness or anxiety. As the patient’s LOC decreases, changes occur in pupils, eye opening, verbal responses, and motor responses. In particular, pupillary light reflexes turn into sluggish. If the patient falls right into a coma, the pupils may solidify and stop responding to light, and the cause is a neurological disease. If the patient is in a coma however the pupillary light reflexes are intact, the cause could also be metabolic or toxicological.

Diagnostic tests are needed to find out the reason for significant LOC changes. Tests may include computed tomography (CT), perfusion tomography, magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), or electroencephalography (EEG). Some common laboratory tests must be performed: blood glucose, electrolytes, serum ammonia, liver function tests, blood urea nitrogen (BUN), serum osmolality, calcium, partial thromboplastin, and prothrombin time. Additional tests may include serum ketone bodies, alcohol and drug levels, and arterial blood gases.

Nursing management

When caring for a patient with altered or decreasing LOC, keep in mind that maintaining the patient’s airway stays the priority. Monitor the patient’s blood pressure and heart rate to make sure adequate perfusion to the brain. Insert an intravenous (IV) catheter to manage intravenous fluids and medications as needed and start dietary support. Determine and treat the cause.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s guide to physical examination and interviewing (thirteenth ed.). Wolters Kluwer Health: Philadelphia.

Hinkle, J. (2021). Brunner and Suddarth’s textbook of medical-surgical nursing (fifteenth edition)^vol ed.). Wolters Kluwer Health. https://wolterskluwer.vitalsource.com/books/9781975161057