3.  Unconsciousness can be brief, lasting for
a few seconds to hours or
so, sustained, lasting for a few hours or
longer.
 Coma is state of sustained
unconsciousness in which the patient:
-Does not respond to verbal stimuli.
-Does not move voluntarily.
-May have altered respiratory patterns.
-Does not blink.
-Joyce M Black

4.  An altered level of consciousness is
apparent in the patient who is not
oriented, does not follow commands or
needs persistent stimuli to achieve a
state of alertness.
 Coma a clinical state of unconsciousness
in which the patient is unaware of self or
the environment for prolonged
periods[days to months of even years]
-Smeltzer Suzanne. C.

5.  Akinetic mutism
 Altered level of consciousness
 Brain death
 Coma
 Decerebration
 Décortication
 Epilepsy
 Peristent vegetative state

6.  Altertness
 Drowsiness
 Stupor
 Somnolence
 Sopor
 Coma
 Semicoma

7. Hypoxia
a)Respiratory insufficiency
b)Shock
 Metabolic [chemical brain depressants]:
a) Extrinsic:
b) Intrinsic
c) Hypoxic encephalopathy’s
d) Extremes of body temperature
e) Deficiency states

8.  Brain pathologic conditions:
a) Trauma
b) Seizures
c) Tumors
d) Infections

11.  EYE MANIFESTATION AND RESPIRATORY PATTERNS:

13.  Physical examination:
-Vital signs:
Temperature, pulse, respiration.
-Height and weight[approximate].
-Integumentary system.
(1)Observe for skin.
(2)Observe for nails.
(3)Head.
(4)Eyes and vision.
(5)Ears and hearing.
(6)Nose and sinuses.
(7)Mouth.

14. (8)Neck.
(9)Breast.
(10)Thorax and lungs.
(11)Cardio vascular.
(12)G. I. system.
(13)Genitor urinary system.
(14)Genitor reproductive.
(15)Musculo skeletal system.
(16)Nervous system.
(17)Hematologic.

16.  Examinaton of neck and cervical spine
 Examination of cranial nerves
 Reflexes-superficial reflex,deep reflex
 Discrimination-
stercognosis,graphesthesia
 Motor function test - muscle
tone,muscle strengh grading,rapid
alternating movement, PIN POINT
TEST, ROMBERG TEST

17.  CT ,MRI
 Lumbar puncture
 Electroencephalography
 Laboratory test
 Tests for abnormal ocular reflexes:
-Oculocephalic response
-Oculovestibular response

18.  Skull x-ray film
 Cerebral angiogram
 Evoked potentials

19. -Metabolic test:
-Complete blood count
-Urinalysis
-Electrolytes[includes glucose, blood
urea nitrogen, creatinine]
-Liver function studies
-Cardiac enzymes
-Serum osmolarity
-Arterial blood gas
-Toxicology screens for drugs of abuse

20. › Goals: to preserve brain function and to
prevent additional brain injury.
› Determine level of involvement: once
airway, breathing, and circulation are
established, initial assessment of the
comatose patient includes evaluation of the
following factors:
-Level of consciousness, though
observation of response to stimuli.
-Presence or absence of localizing
neurologic manifestation.
-Pupils size and reactivity to light.

21. › Reverse common causes of coma:
-After a blood specimen is drawn for
testing, intravenous glucose is given
to reverse potential insulin reaction.
-Who appear malnourished,
wernicke’s[alcohol abuse], can be
given thiamine For prevention.
-Repetitive seizures: iv diazepam or
lorazepam to stop the seizures.
-Coma from drug overdose: opioid
overdose may be reversed with
naloxone.

22. -The patient’s altered level of
conscious is a space-occupying
lesion, surgical removal of the mass may
improve the patient’s condition.
-Burr holes may be created to drain
a subdural hematoma.
-A craniotomy may be performed to
remove a tumor, abscess, or
intracerebral hematoma.
-A ventricular catheter or shunt may
be place to relive hydrocephalus.

23. -Assessment:
 -History collection,
-Physical examination
-Neurological examination
-Alertness is measured by the patient’s
ability to open the eye spontaneously
or to a stimuli
-Motor response includes
spontaneous,
purposeful movement

24. -Determining the patient’s orientation to
time, person, and place assess verbal
response.
-Verbal response cannot be evaluated
when the patient is intubated or has a
tracheotomy, and this should be clearly
documented.
-Alertness is measured by the patient’s
ability to open the eyes spontaneously or to
a stimulus.
-Patients with severe neurologic dysfunction
cannot do this.
-Posturing may be decorticate or decelerate
-The most severe neurologic impairment
results in flaccidity.

26.  RESPIRATORY FAILURE
 PNEUMONIA
 PRESSURE ULCER. ASPIRATION
-

28. 1,Black Joyce. M., Hawks Jane
Hokanson, Medical surgical
Nursing, Clinical Management for
positive outcomes, 2007, 7th
ed, Saunders, St. Louis, Pp: 2051-2071
2,Kinney Marguerite Roders, et.
Al., AACN, Clinical Reference for Critical
Care Nursing, 1998, 4th ed, mosby, St.
Louis, Pp: 672-675.
3,Bradley Walter. G., et. Al., Neurology in

30. 4,Kandel ekric. R, et. al., Principles of Neural
Science, 2000, 4th ed, Mc Graw-Hill, New
York, Pp: 901-908
5,Lewis Sharon. I., et.al., Medical Surgical
Nursing, Assessment and Management
of clinical Problems, 2007, 7th
ed,Elsevier, ST. Louis, Pp:1470-1471, 1478-
1480.
6, Lippincott, Manual of Nursing
practice, 2006, 8th
ed, Lippincott, Philadelphia, Pp: 475-478
7,Smeltzer Suzanne. C., Bare
Brenda, Burnner and Suddarth’s , Text
book of Medical Surgical
Nursing, 2004, 10th
ed, Lippincott, Philadelphia, Pp: 1850-

31.  Based on the assessment data, the major
nursing diagnoses may include the
following:
(1)Ineffective airway clearance related to
altered level of consciousness
-Outcome identification: patient
maintains
the clear airway
 Assess the general condition of the patient.
 Assess for the airway clearance for the
patient.

32. (2)Risk of injury related to decreased level
of consciousness
-Outcome identification: patient will be
prevented from injuries
 Assess the general condition of the patient
 Assess the patient for the risk for the injury
(3)Deficient fluid volume related to
inability to take in fluids by mouth
-Outcome identification: Patient
maintains adequate fluid status
 Assess for the general condition of patient
 Check for the hydration status

33. (4)Self care deficit [complete]related to
decreased level of conscious.
(5)Impaired oral mucous membranes
related to mouth breathing, absence of
pharyngeal reflex, and altered fluid
intake.
(6)Risk for impaired skin integrity related to
immobilization
(7)Impaired tissue integrity of cornea
related to diminished absent corneal
reflex.
(8)Ineffective thermoregulation related to
damage to hypothalamic center.

34. (9)Impaired verbal communication
related to altered level of conscious.
(10)Impaired urinary elimination related to
impaired in neurologic sensing and
control.
(11)Bowel incontinence related to
impairment in neurological sensing and
control also related to transitions in
nutritional delivery methods.
(12)Disturbed sensory perception related
to neurological impairment.

35. (13)Interrupted family process related to
health crisis.
-Outcome identification: Patient
relatives is able cope up with the
patient long term duration in the
hospitals
-Collaborative problems:
-Respiratory distress or failure
-Pneumonia
-Aspiration
-Pressure ulcer
-Deep vein thrombosis

37.  Most of the time, a “wait-and-see”
approach was taken.
 Today the family and the health care
team should have some idea of the
probable eventual outcome for the
patient.
 Coma after injury has a statistically better
outcome than coma associated with
medical illness.
 About 50% of patients in coma from
head injury die, many instantly.

38.  The central nervous system contains a vast
network of neuron controlling the body’s
vital functions. Yet this system is
vulnerable, and its optimal function
depends on several key factors. The
neurologic system relies on its own structural
integrity for support and homeostasis. As the
brain tissue expands in the inflexible
cranium, ICP rises and cerebral perfusion is
impaired. Further expansion places pressure
on viral centers, which can cause
permanent neurologic deficits or lead to
brain death.

40. 8,William Linda. S, Hopper Paula.
D., Understanding Medical Surgical
Nursing, 2008, 3rd, Jaypee Brothers, New
Delhi, Pp: 282-284
9,Long Barbara. C., et. al., Medical Surgical
Nursing, A Nursing Process
Approach, 1993, 3rd ed, Mosby St. Louis, Pp:
1220-1227, 1541.
10,Phipps Wilma. P., et, al., Medical Surgical
Nursing, Health and Illness
Perspective, 2003, 7th ed, Mosby, St.
Louis, Pp: 1317-1325
11,Morhr. J. P., and Gautier. J.C., Guide to
Clinical Neurology, 1995, 1st ed, Churchill
Living stone, New York, Pp: 221-235

41.  Kristen Mc Donald, AJN, “ The singing the
Broke the Coma’, 2007, April, 107, 4,
Pg: 72

42. • http://www.redorbit.com
• http://www.lifeissues.net
• http://dhealth solution.blogspot.com
• http://www.ncl.ac.uk/nsa/coma.html
• http://faculty.ksu.edu

43. THE END…