What are the levels of consciousness nursing

In this lesson we’re going to talk about the different levels of consciousness. This, plus your pupillary assessment are going to be the staples of your neuro exam. We’ll talk more about the pupillary assessment in the routine neuro assessments lesson.

In order to understand the varying levels of consciousness, we need to know what normal is. So let’s talk about what a normal neuro exam would look like. This is someone who is considered conscious. This would be like you and me. We’re awake, alert, aware of our surroundings. We’re able to respond to stimuli around us and follow commands. If they’re asleep, give them a chance to wake up. If they arouse easily and are able to remain alert, that is normal. Then we’ll ask the patient four questions. “What’s your name?” “Where are we right now?” “What month is it?” and “Why are you here?”. This tells us orientation to person, place, time, and situation. If they get all 4 correct, we say they’re Alert and Oriented times four. Now, not all facilities use situation, so you would just say they’re oriented times 3, and that would still be acceptable.

The next two levels of consciousness are patients who are alert but are NOT oriented. People who are confused can’t answer all of the orientation questions. They might be alert and oriented times 1 or 2, or even 0. They have difficulty following commands and their thought processes tend to be slow. They may even have memory loss. This can be caused by sleep deprivation, which happens a lot in the hospital, or even infection. In fact the number one sign of infection in the elderly is confusion. And remember hypoglycemia can also cause confusion.

The next level down would be delirious. Someone who is delirious is confused and disoriented AND also restless or agitated. They struggle to pay attention to their surroundings and may even experience hallucinations or delusions. I had a patient with ICU delirium once who SWORE there were spiders crawling on the walls. ICU delirium happens because of sleep deprivation and sometimes the number of meds we are giving, patients begin to lose touch with reality. We also see delirium in Alzheimer’s patients when they are sundowning.

The next level would be patients who are only minimally responsive. They are not alert. Patients who are somnolent are extremely sleepy. Somnolent, Sleepy (both start with S). But this is like next-level sleepy – this isn’t you after you pulled an all nighter studying. These patients are hard to keep awake, they just keep falling back asleep. You try to arouse them and they might just mumble at you. This is the point at which we begin to use painful stimuli to try to elicit a response. We want to give them credit for the best response they can give, so we’ll start with maybe nail bed pressure, then we could try a trapezius squeeze, and move on to a sternal rub to see what kind of response we get from the patient. Usually somnolent patients will open their eyes, mumble at you, and maybe swat at you, then they go right back to sleep.

Now, obtunded is a little different. This is someone who might actually be awake, but they’re not alert to their surroundings at all. It’s like the lights are on but no one’s home. Their responses are slowed or the may not respond at all. Sometimes it’s like they’re staring right through you. They may also have some delirium with it. This could be caused by a stroke or by high ammonia levels.

From there, we move down to patients who really aren’t responding at all. Stuporous patients are in a sleep-like state. They aren’t moving around on their own, but they do respond SOME to stimuli. You will see grimacing on their face, and sometimes they’ll pull away from you when you cause a painful stimulus like nailbed pressure or a trapezius squeeze. That’s called withdrawing. Again, we use increasing levels of painful stimuli so we can give them credit for their best response.

And finally we use the term comatose for people who are completely unarousable. They don’t respond to any painful stimuli, even super deep sternal rubs. The other thing we want to assess on these patients is whether they have a gag or cough reflex. We use our yankauer to stick in the back of their throat to try to elicit a gag response. The number one concern here is that this patient might have trouble protecting their own airway, so we need to get help as soon as possible.

Now any of these neuro changes could be attributed to a number of diseases, from cardiac to respiratory to metabolic to neurological. The most important thing is to recognize the change and notify the provider so that we can begin to identify the cause. And if you remember from the cerebral metabolism lecture, the brain is very sensitive to a low O2 and a low glucose level. So check your patient’s SpO2 and blood glucose levels while you wait for the doctor to arrive!

So remember when we assess level of consciousness, we are first assessing whether they’re alert and awake, then we assess their orientation to person, place, time, and situation. So we’d report they’re Alert and Oriented times 1, 2, 3, or 4 or 0 if they’re completely disoriented. Then if they aren’t alert and oriented, we need to assess their response to painful stimuli. So your basic levels are alert and oriented, alert but not oriented, minimally responsive, and unresponsive. Remember that if you note any changes, you need to notify the provider right away.

Make sure you check out the next few lessons to learn about routine and adjunct neuro assessments! Go out and be your best selves today, and, as always, happy nursing!!

Level of consciousness (LOC) is a medical term for identifying how awake, alert, and aware of their surroundings someone is. It also describes the degree to which a person can respond to standard attempts to get his or her attention.

Consistent medical terms describing a person's level of consciousness help in communication between care providers, particularly when the level of consciousness fluctuates over time.

There are a variety of medical conditions and drugs that contribute to the level of a person's consciousness. Sometimes impaired consciousness is reversible, while other times it is not.

According to medical definitions, a normal level of consciousness means that a person is either awake or can be readily awakened from normal sleep. Terms include:

• Consciousness identifies a state in which a patient is awake, aware, alert, and responsive to stimuli.
• Unconsciousness identifies a state in which a patient has a deficit in awareness and responsiveness to stimuli (touch, light, sound). A person who is sleeping would not be considered unconscious, however, if waking up would result in normal consciousness.

Between these two extremes, there are several altered levels of consciousness, ranging from confusion to coma, each with its own definition.

Altered or abnormal levels of consciousness describe states in which a person either has decreased cognitive function or cannot be easily aroused. Most medical conditions affect the brain and impair consciousness when they become serious or life-threatening, and an altered state of consciousness usually signals a serious medical problem.

Often, an altered level of consciousness can deteriorate rapidly from one stage to the next, so it requires timely diagnosis and prompt treatment.

Confusion describes disorientation that makes it difficult to reason, to provide a medical history, or to participate in the medical examination. Causes include sleep deprivation, fever, medications, alcohol intoxication, recreational drug use, and postictal state (recovering from a seizure).

Delirium is a term used to describe an acute confusional state. It is characterized by impaired cognition.

In particular, attention, alteration of the sleep-wake cycle, hyperactivity (agitation), or hypoactivity (apathy), perceptual disturbances such as hallucinations (seeing things that are not there) or delusions (false beliefs), as well as by instability of heart rate and blood pressure may be seen in delirium.

Causes can include alcohol withdrawal, recreational drugs, medications, illness, organ failure, and severe infections.

Lethargy and somnolence describe severe drowsiness, listlessness, and apathy accompanied by reduced alertness. A lethargic patient often needs a gentle touch or verbal stimulation to initiate a response. Causes can include severe illnesses or infections, recreational drugs, and organ failure.

Obtundation is a reduction in alertness with slow responses to stimuli, requiring repeated stimulation to maintain attention, as well as having prolonged periods of sleep, and drowsiness between these periods. Causes can include poisoning, stroke, brain edema (swelling), sepsis (a blood infection), and advanced organ failure.

Stupor is a level of impaired consciousness in which a person only minimally responds to vigorous stimulation, such as pinching the toe or shining a light in the eyes. Causes can include stroke, drug overdose, lack of oxygen, brain edema, and myocardial infarction (heart attack).

Coma is a state of unresponsiveness, even to stimuli. A person in a coma may lack a gag reflex (gagging in response to a tongue depressor placed at the back of the throat) or a pupillary response (pupils normally constrict in response to light).

It is caused by severely diminished brain function, usually due to extreme blood loss, organ failure, or brain damage.

The causes of these altered states of consciousness may overlap. For example, the early stages of brain edema or organ failure can cause confusion but can advance rapidly through the stages of lethargy, obtundation, stupor, and coma.

The states of coma and stupor may also be subdivided into levels or classifications that further clarify a person's degree of unresponsiveness. Several systems have been developed in order to standardize these classifications, which improves communication among healthcare providers and also aids in research.

The most commonly used classification systems are the Grady Coma Scale and the Glasgow Coma Scale:

• The Grady Coma Scale rates a coma in grades from I to V. The grades are determined based on a person's state of awareness and response to stimuli, such as response to the person's name being called, light pain, and deep pain. Grade I indicates confusion, while V indicates no response to stimuli (coma).
• The Glasgow Coma Scale uses a score to identify the level of consciousness, from 1 to 15, with 15 being a normal state of consciousness. This scale takes into account verbal, motor, and eye responses to stimuli in determining the overall score.

There are also psychological terms used to describe consciousness (fully aware of one's intentions), in contrast to the subconscious (often describes deeper intentions), and preconscious (related to memory).

There are also several other theories and definitions of consciousness describing stages of sleep, levels of self-awareness, and the relationship between humans and matter. While all of these definitions are certainly valid, they are not used to define medical states of consciousness.