STUDY - Technical - New Dacian's Medicine
Level of consciousness decrease (Classical / Allopathic Medicine)
A decrease in
level of consciousness (LOC), from lethargy to stupor to
coma, usually results from a neurologic disorder and
commonly signals life-threatening complications of
hemorrhage, trauma, or cerebral edema. However, this sign
can also result from a metabolic, GI, musculoskeletal,
urologic, or cardiopulmonary disorder; severe nutritional
deficiency; exposure to a toxin; or drug use. LOC can
deteriorate suddenly or gradually and can remain altered
temporarily or permanently.
Consciousness is
affected by the reticular activating system (RAS), an
intricate network of neurons whose axons extend from the
brain stem, thalamus, and hypothalamus to the cerebral
cortex. A disturbance in any part of this integrated system
prevents the intercommunication that makes consciousness
possible. Loss of consciousness can result from a bilateral
cerebral disturbance, an RAS disturbance, or both. Cerebral
dysfunction characteristically produces the least dramatic
decrease in a patient's LOC. In contrast, dysfunction of the
RAS produces the most dramatic decrease in LOC - coma.
The most
sensitive indicator of a decreased LOC is a change in the
patient's mental status. The Glasgow Coma Scale, which
measures the ability to respond to verbal, sensory, and
motor stimulation, can be used to quickly evaluate a
patient's LOC. (See Glasgow Coma Scale.)
Glasgow Coma
Scale
You've probably heard such terms as lethargic, obtunded, and stuporous used to describe a progressive decrease in a patient's level of consciousness (LOC). However, the Glasgow Coma Scale provides a more accurate, less subjective method of recording such changes, grading consciousness in relation to eye opening and motor and verbal responses.
To use the Glasgow Coma Scale, test the patient's ability to respond to verbal, motor, and sensory stimulation. The scoring system doesn't determine an exact LOC, but it does provide an easy way to describe the patient's basic status and helps to detect and interpret changes from baseline findings. A decreased reaction score in one or more categories may signal an impending neurologic crisis. A score of 7 or less indicates severe neurologic damage.
You've probably heard such terms as lethargic, obtunded, and stuporous used to describe a progressive decrease in a patient's level of consciousness (LOC). However, the Glasgow Coma Scale provides a more accurate, less subjective method of recording such changes, grading consciousness in relation to eye opening and motor and verbal responses.
To use the Glasgow Coma Scale, test the patient's ability to respond to verbal, motor, and sensory stimulation. The scoring system doesn't determine an exact LOC, but it does provide an easy way to describe the patient's basic status and helps to detect and interpret changes from baseline findings. A decreased reaction score in one or more categories may signal an impending neurologic crisis. A score of 7 or less indicates severe neurologic damage.
Test reaction
score
Eyes Open spontaneously 4
Open to verbal command 3
Open to pain 2
No response 1
Eyes Open spontaneously 4
Open to verbal command 3
Open to pain 2
No response 1
Best motor
response
Obeys verbal
command 6
Localizes painful stimulus 5
Flexion - withdrawal 4
Flexion - abnormal (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1
Localizes painful stimulus 5
Flexion - withdrawal 4
Flexion - abnormal (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1
Best verbal
response
Oriented and
converses 5
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Total 3 to 15
ALERT:
If the patient has a decreased LOC:
- evaluate his airway, breathing, and circulation
- use the Glasgow Coma Scale to quickly determine LOC and obtain baseline data. If the patient's score is 13 or less, he should be immediately evaluated for a life-threatening occurrence.
If the patient's condition permits, perform a focused assessment.
ALERT:
If the patient has a decreased LOC:
- evaluate his airway, breathing, and circulation
- use the Glasgow Coma Scale to quickly determine LOC and obtain baseline data. If the patient's score is 13 or less, he should be immediately evaluated for a life-threatening occurrence.
If the patient's condition permits, perform a focused assessment.
HISTORY:
Obtain history information from the patient (if he's lucid) or his family. Ask if the patient complained of headache, dizziness, nausea, visual or hearing disturbances, weakness, fatigue, or other problems before his LOC decreased.
Ask the patient's family if they noticed changes in the patient's behavior, personality, memory, or temperament.
Review the patient's medical history for neurologic disease, cancer, and recent trauma.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Obtain history information from the patient (if he's lucid) or his family. Ask if the patient complained of headache, dizziness, nausea, visual or hearing disturbances, weakness, fatigue, or other problems before his LOC decreased.
Ask the patient's family if they noticed changes in the patient's behavior, personality, memory, or temperament.
Review the patient's medical history for neurologic disease, cancer, and recent trauma.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
PHYSICAL
ASSESSMENT:
Perform a complete neurologic assessment. Because a decreased LOC can result from any one of several disorders that can affect any body system, tailor the physical assessment according to the patient's associated symptoms.
Perform a complete neurologic assessment. Because a decreased LOC can result from any one of several disorders that can affect any body system, tailor the physical assessment according to the patient's associated symptoms.
SPECIAL
CONSIDERATIONS:
Reassess the patient's LOC and neurologic status at least hourly. Ensure airway patency. Take precautions to help ensure the patient's safety.
Reassess the patient's LOC and neurologic status at least hourly. Ensure airway patency. Take precautions to help ensure the patient's safety.
PEDIATRIC
POINTERS:
The primary cause of decreased LOC in children is head trauma, which commonly results from physical abuse or a motor vehicle accident. Other causes include accidental poisoning, hydrocephalus, and meningitis or brain abscess following an ear or respiratory tract infection.
The primary cause of decreased LOC in children is head trauma, which commonly results from physical abuse or a motor vehicle accident. Other causes include accidental poisoning, hydrocephalus, and meningitis or brain abscess following an ear or respiratory tract infection.
PATIENT
COUNSELING:
Advise the family to talk to the patient even if he appears comatose; their voices may help reorient the patient to reality.
Advise the family to talk to the patient even if he appears comatose; their voices may help reorient the patient to reality.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)