Difference Between Lethargic And Obtunded

[wonderbee]

I'm a new RN, and new on a neuro trauma ICU. It is very important that I understand assessment descriptions. My last pt. was an SAH/SDH whose only response was localization to deep (and I mean deep) painful stimuli. No spontaneous movement and follows commands x0. 8 on the GCS. I described her in my assessment as "obtunded".

My preceptor corrected me and pointed out that she was "lethargic".

Lethargic in my mind describes someone who is drowsy but arousable. I think I can describe myself as lethargic at times.

Would love some insight.

Understanding Lethargic vs Obtunded

suzanne4 said:

I do not agree with your preceptor. Any time that you really need to physically stimulate a patient to get any type of response from them, that is obtunded. If you did nothing, they would be doing nothing.

Lethargic is someone who is very sleepy, but arouses easily by name calling or just a slight tap, but true physical stimulation needed and that is obtunded.

alisaf23 said:

OK technically your patient would be classified as semi comatose or possibly in a stupor.

As an ICU nurse myself if that was my patient I would chart him as being semicomatose.

Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.

Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.

Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.

Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state. (caused by narcotics, intoxicants, etc.: )

Semi comatose An imprecise term for a state of drowsiness and inaction, in which more than ordinary stimulation may be required to evoke a response, and the response may be delayed or incomplete.

Coma is a state of unarousable unresponsiveness.

[nurseap]

I'm a student practicing for the nclex and came across this description of the difference between certain terms:

The patient is obtunded if he can be aroused with stimulation. If the patient shows no verbal or motor response to noxious stimuli, he’s comatose. If the patient remains in a deep sleep and only responds to vigorous and repeated stimulation, he is stuporous. If the patient has limited spontaneous movement and sluggish speech, he’s lethargic.

[Esme12, ASN, BSN, RN]

speechpathologist said:

So where does "somnolent" fit in this hierarchy of rousability?

Somnolence (or "drowsiness") is a state of near-sleep, a strong desire for sleep, or sleeping for unusually long periods (cf. hypersomnia). it has two distinct meanings, referring both to the usual state preceding falling asleep, and the chronic condition referring to being in that state independent of a circadian rhythm. the disorder characterized by the inability to stay awake.

[Biffbradford]

nurseap said:

I'm a student practicing for the nclex and came across this description of the difference between certain terms:

The patient is obtunded if he can be aroused with stimulation. If the patient shows no verbal or motor response to noxious stimuli, he's comatose. If the patient remains in a deep sleep and only responds to vigorous and repeated stimulation, he is stuporous. If the patient has limited spontaneous movement and sluggish speech, he's lethargic.

Perfect. Then you have those who will go 'lights out' mid-sentence while talking right to you.

[alisaf23]

Ok technically your patient would be classified as semi comatose or possibly in a stupor

As an ICU nurse myself if that was my patient I would chart him as being semicomatose.

Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.

Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.

Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.

Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state. (caused by narcotics, intoxicants, etc.: )

Semi comatose An imprecise term for a state of drowsiness and inaction, in which more than ordinary stimulation may be required to evoke a response, and the response may be delayed or incomplete.

Coma is a state of unarousable unresponsiveness.

[bluescrubs07]

Working in neuro ICU for 3 years, we will describe this LOC as stupor. Describing a patient as obtunded, the pt will be able to sustain a little bit longer awakening compared to stuporous pt. For stupor, however, patient can only be stimulated by deep pain stimuli and responds usually with brief grimace/moan or brief opening of eyes.

[elfself25]

I agree with wonderpoints. Additionally I would like to discern the differences between 3,4, and 5 on motor assessment of Glascow Coma Scale. 5 is purposeful movement, i.e., patient grabs ETT or pushes you away. 4 is semi-purposeful movement. It is though the patient is too sleepy to complete the action, i.e., hand gets part way to ETT, then pt falls back to sleep. 3 is abnormal flexion; used to be called decorticate posturing. Hands go to the chest with centrally provided noxious stimuli like a trapezius squeeze; hips, knees and feet may all flex (triple flex). The Glascow Coma Scale defines coma as a score of 8 or less. Intubation is required with a score of 8 or less as patient has lost ability to protect airway from aspiration. The motor part of the Glascow Coma Scale is considered a most excellent prognostic indicator. I think describing the patient's behavior is more important than the distinctions between lethargy, obtunded, and stuporous as I have witnessed multiple misinterpretations of these terms. There is an interesting component of arousal when the patient's reticular activating system is working but the patient is unable to interact in any meaningful way with the environment--"The lights are on, but nobody is home."--often seen in patients with persistent vegetative states.