LEVEL OF CONSCIOUSNESS  Assess ability to obey or respond to

Altered Level of Consciousness command

Consciousness-a state when these 2  Record GCS frequently (refer
factors are present: accordingly)
 Assess motor nerve reflexes
1. Awareness - Mediated by the cortical  Assess Vital signs
activity in the cerebral hemispheres  Assess cranial nerves
(cerebrum)  Perform head-to-toe assessment
2. Arousal - Mediated by the reticular
activating system in the brain stem Management
 Prevent secondary brain injury
Unconsciousness  Monitor for signs of complications,
 A condition when there is depression progress or deterioration
in cerebral function that may range  Minimize risk for increased
from stupor to coma intracranial pressure, etc.
 COMA results
 when there is impairment in both Management
awareness and arousal  Maintain patent airway
 Attain and maintain fluid and
The GLASGOW Coma Scale electrolyte balance • Maintain good
•A tool that is used to assess the level of oral mucous membrane
consciousness  Maintain skin integrity
 Maintain corneal integrity
Altered LOC may be due to:
 Maintain body functioning - urination,
 Hypoxemia
defecation, circulation
 Trauma
 Prevent infection
 Vascular disorders
 Neoplasm Increased Intracranial Pressure
 Degenerative and infectious disorders  Intracranial Pressure is the pressure
 Metabolic and neurologic conditions, exerted by the contents in the cranial
etc. vault.
Note:  ICP is measured in millimeters of
• Perfect score=15 mercury (mmHg) and is normally 7-
• A score of 7 and below = COMA 15 mmHg for a supine adult at rest
• Change of 2 in the previous assessment =
significant 3 Components in the Cranial Vault:
• GCS - used to assess LOC: this is not used to
measure the IQ of a person • Exist in the following ratio:
1. Brain tissue = 80%
Consciousness 2. CSF = 10%
s a state that involves 2 important 3. Blood volume/ pressure: = 10%
components: TOTAL: 100%
1. Awareness Concepts:
2. Arousal
Altered Level of Consciousness  The pressure relationship of the 3
Assessment: elements constantly adjust to achieve
 Assess level of responsiveness an acceptable steady equilibrium.
  An increase in the volume of one A. Changes in behavior restless in able,
component results in the decrease in drowsy
the volume of the other components B. Changes in level of orientation O
(COMPLIANCE) C. Inability to follow commands
 When compliance is poor, increased D. Difficulty with verbalization E. Changed
ICP occurs. response to painful stimuli
F. Abnormal posture.
Increased-ICH
 When the intracranial pressure Manifestations
becomes greater than 15 mmHg = 2. Deterioration in Vital signs
Increased ICP A. Widening pulse pressure
B. Rising blood pressure
This may result from: C. Pulse changes - bradycardia to tachycardia
 head injury D. Respiratory changes tachypnea. Cheyne-
 cerebral edema Stokes respi Kussmaul's respiration
 abscess and infection E. Temperature may be moderately elevated
 Lesions
 Intracranial surgery Manifestations
 radiation therapy. 3. Pupillary/Visual Changes

Pathophysiology A. Unequal pupil sizes B. Semi-dilated pupils

Brain, CSF, Blood pressure fAll cranial vault to or non-reactive pupils
capacity C. Presence of retinal hemorrhage or
/ papilledema
Increase in the volume of one or more of the D. Blurred to no vision
components (NORMALLY: must result in E. Glare, unconjugated eye movement
decrease in volume of the other components) F. Absent doll's eyes sign
/
Failure of the oth component to compensate Manifestations
(Poor compliance) 4- Other Changes
/ A. Headache that is increasing in intensity,
Increased Intracranial Pressure bulging fontanel in infants and young
/ children
When ICP Increases, the brain compensation B. (Projectile) Vomiting without antecedent
/ nausea
Displacement/ shunting = of the CSF from the C. Motor and sensory dysfunctions
intracranial compartment to the lumbar D. Contra lateral hemiparesis (progressing to
subarachnoid space hemiplegia)
/ E. Speech impairment
Increasing the absorption of CSF F. Cranial nerve deficits
/ G. Pathologic reflexes: Babinski reflex,
Decreasing cerebral volume by displacement changes in grasp, chewing, sucking reflexes
of cerebral venous blood into venous sinuses
/ Management
Increasing the compliance • Establish and maintain airway
• Mechanical ventilation
Manifestations • Maintain indwelling catheter
1. Deterioration in LOC (use GCS)
• Fluids - electroly balance • Monitor ICP and
vital signs
• Prevention of hypoxia, fever and other
complications

Administer drugs:

 Osmotic - diuretics (Mannitol)

 Corticosteroids
 High dose barbiturates Beizures)
 Mannitol
 Is an osmotic - diuretic

It increases osmotic pressure of glomerular

filtrate, inhibiting tubular reabsorption of
water and electrolytes: It elevates plasma
osmolality, increasing water flow into
extracellular fluid.

• Give as infusion, DO NOT As direr injection

• WATCH OUT: Oliguria, Fluid imbalance,

Electrolyte imbalance, heart failure.