When documenting your patient’s level of consciousness, you’ll notice you have a LOT of options to choose from. Your patient can be alert, confused, in a coma and anything in between. Knowing the difference between each level of consciousness will help you chart accurately and communicate your patient’s condition with precision. The different levels of consciousness are:
- Alert: awake and responsive
- Confused: note that confusion can occur anywhere along this spectrum and is not always present prior to the patient becoming somnolent, lethargic, etc… It is possible to have a patient who is somnolent or even lethargic and still oriented.
- Somnolent: sleepy
- Lethargic: very drowsy, falls asleep in between care
- Obtunded: difficult to arouse
- Stuporous: very difficult to arouse
- Unresponsive/Coma: unarousable
Describing your patient’s LOC correctly is especially important when there are acute changes in condition. For example, I had a patient recently who was stuporous upon arrival to the ICU, but quickly became unresponsive, requiring immediate intervention in order to keep the patient safe. Had I not known how to describe this patient’s level of consciousness using standardized language, there could have been a huge miscommunication between me and the MD. So, let’s go through a quick example using an entirely fictitious patient. Ready?
In report you learn the following about your patient: 56 year old female with CKD stage 4, CHF, DM2, and hyperlipidemia. BIBA yesterday for SOB, currently on 6L oxygen. BP 110/68, HR 77, O2 sat 94%, afebrile. Urine output minimal overnight at 20 ml/hr, dark and concentrated. Chemistry panel shows mild hyperkalemia, elevated BUN and Creatinine, mildly anemic with Hbg 9.2 and WBC WDL.
At the time of your initial assessment at 0800, you note that the patient opens her eyes spontaneously and responds to questions though not all her answers make sense. She will follow simple one-step commands, but when you ask her to do more than one thing at a time, she does not always follow through. You ask your patient where she is right now and she answers “in my living room.” At this time, your patient is ALERT and CONFUSED.
At 0900, you bring in your patient’s medications. She wakes easily to voice but yawns a few times and states she just wants to sleep. At this point your patient is SOMNOLENT.
At 1000, you go in to help your patient get repositioned when you notice she opens eyes only to voice or stimulation (not spontaneously) . She follows some basic commands, and is slow to respond. She drifts off again once no longer stimulated. Your patient is now LETHARGIC.
At 1200, your patient is more difficult to arouse. Her responses are delayed and minimal. She does not appear to fully wake when stimulated and she immediately goes back to sleep when not stimulated. When she does answer questions, she mumbles and is clearly confused. At this time she is OBTUNDED.
By 1300, your patient can only be aroused by vigorous and repeated stimulation. When the stimulation stops she immediately lapses back into her unresponsive state. The only vocalizations she makes are moans. She is now in a STUPOR.
At 1400, your patient is unarousable to any stimulation, even vigorous and painful stimuli. At this point she is UNRESPONSIVE or COMATOSE.
Of course, you’ve been updating the MD on your patient’s changes in LOC all morning, and you have both ensured that the appropriate interventions have been instituted. In a case with patient with renal disease, you will often see them have decreasing levels of consciousness as their pH drops secondary to their metabolic acidosis. With a patient like this, you might anticipate the MD ordering an ABG at some point…don’t be surprised if it comes back acidotic. Typically what happens is the patient will receive dialysis and as things start to come back into balance the patient becomes more alert (assuming they don’t have any other underlying physiologic derangements such as sepsis.)
The other common situation this occurs in is COPD exacerbation. The pH will decrease as the CO2 increases. As the CO2 rises, the patient becomes more and more comatose…usually we can pull the patient out of it with BIPAP, but in extreme cases they may be intubated. You’ll see this over and over and over again…especially if you work in a medical ICU or telemetry unit.
This whole topic of consciousness is so incredibly interesting, especially as it relates to anesthesia. If you’re interested in getting your CRNA someday, you might find this article fascinating…I know I certainly did! Enjoy!
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