Altered Level of Consciousness

Altered Level of Consciousness (ALOC)

Clinical Findings

Neuro: Confused, lethargic, obtunded, stuporous, or comatose. Resp: Depressed (likely opioid OD), Cheyne-Stokes (likely CVA), Kussmaul’s respirations or fruity odor on breath (likely DKA), apneustic (likely brainstem injury), odor of alcohol (likely intoxicated), sweet almond odor (likely cyanide exposure). CV: Increased BP and decreased HR (likely ↑ ICP), hypotension (likely sepsis, MI, OD, internal bleeding), dysrhythmias. Skin: Cool and moist (likely hypoglycemia, vasovagal response, MI, shock), warm and flushed (likely spinal injury, hyperglycemia, sepsis). GI/GU: Nausea and vomiting, incontinence. MS:Weakness, fatigue, abnormal flexion or extension, trauma.

Nursing Interventions

■ Place Pt in position of comfort and offer reassurance. If Pt is unable to maintain airway or clear secretions, place Pt into lateral-lying position and suction airway as needed. Consider inserting oropharyngeal airway, or, if Pt has gag reflex and there is no evidence of facial trauma, use nasopharyngeal airway. ■ Administer supplemental oxygen titrated to SpO2 >90% and be prepared to ventilate Pt manually if RR <8 breaths/minute. ■ Assess pupils and establish baseline GCS score. ■ Assess for neuro deficits such as slurred speech, facial droop, or weakness or numbness on one side of the body. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Obtain STAT bedside blood glucose level. ■ Review medication administration record and recent labs for possible causes of ALOC (see AEIOU-TIPS, page 36). ■ Administer STAT medication if ordered: Glucose 25 g IV for hypoglycemia; naloxone 0.4–2 mg IV for narcotic OD; flumazenil 0.2 mg for benzodiazepine OD. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering STAT 12-lead ECG, labs (CBC, electrolytes, coagulation studies, medication levels) additional pharmacologic therapy (e.g., insulin drip, reversal agents, restoring electrolyte imbalances), and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.