When you admit a patient in your floor.You should assess the level of CONSCIOUSNESS( According to the hospital protocol).
The guidelines below will help.
For example:Hi Jack my name is Michelle and I will be your nurse from 07am to 3:30pm.
DIAGNOSIS:
DRUG and ALCOHOL Abuse
You are here because you have Drug and Alcohol problem. I will be one of the nurses to help you.
What is your name?.
What time is it?.
Where are you?.
Why are you here?.
FULL CONCIOUSNESS
That is the patient is alert and oriented x4. He or she response to verbal and nonverbal communication. Oriented to person (that is himself or herself)to the time, know the time,the date, (patient able to state the date)to know the place.Patient able to say where he or she is.Articulates clearly,verbalize spontaneously and coherently, clear and precise.Recent memory intact.
ALTERED LEVEL OF CONSCIOUSNESS.
Slow in thought process and the right response. Lethargy, recent memory loss, drowsiness.
Some confusion cannot remember the date or what he ate at lunch.
CONFUSION: Period of disorientation, unconsciousness, uncooperative, Easily agitated for nothing, irritability, restlessness, period of fear,loudness, response to light tactile stimuli ,misbehavior, and some delirium.
COMATOSE:No response to stimuli.Absent.
STUPOR: ( Latin word for insensibility or numbness)Decreased consciousness. Patient response only to painful tactile stimuli. It is used to describe people who are extremely intoxicated due to drug or alcohol. Lack of critical mental function.It is often caused by underlying mental illness that interfere with brain function such as brain tumors, brain infections,severe vitamin deficiencies can induce stupor.Some severe mental illness such clinical depression or Schizophrenia can cause Stupor.
MRI to check for brain tumors.
Intravenous antibiotics for treatment of brain infection.
Some psychotropic medications if indicated.
It is very important to know the level of CONSCIOUSNESS of your patient.The next Nurse will like to know at least the baseline.If your patient is confused frequent monitoring is very ,very important. To prevent falls .
Fall precautions signs placed and yellow gown worn by patient. (Fall Risk signs).
Fall risk sign.
Nurses You Move Me 