INTRODUCTIONThe brain requires a constant supplyof oxygenated blood and glucose to function. Interruption of this supply will cause loss of consciousnesswithin a few seconds and permanent brain damage in minutes.
MEANING OF CONSCIOUSNESS It is a state of that has three important aspects-1)wakefulness;2) Awareness of self,3)Awareness of Environment and time.
REVIEW OF ANATOMYBRAIN :-1.Cerebrum – Cerebral cortex – Corpus callosum2.Diencephalon – Thalamus – Pineal body – Hypothalamus3.Brain stem – Midbrain – Pons – Medulla oblongata 4.cerebellum
MEANING OF UNCONSCIOUSNESS • Unconsciousness implies that is a stage of depressed cerebral function that result impairment in response to sensory stimuli; abnormal loss of awareness of self & surroundings • Its onset is both sudden and gradual.
Contd…• Exicitatory unconsciousness Does not respond coherently but is disturbed by sensory stimuli such as bright light, noise.• Stupor In stupor, patient responds to external stimuli and shows the symptoms of annoyance when stimulated by pinprick or loud noise such as clapping of hands.
Cont…..• Fainting In fainting, there is a momentary loss of consciousness and the patient usually recovers spontaneously• Somnolent a sate when patient feels drowsy or sleepy or we can say it is a state between sleeping and awakning.
Cont….. Coma• Coma is a clinical state of unconsciousness in which the patient is unaware of himself and his environment. The patient may respond to deep painful stimuli. In deep coma, there is no arousal.
Cont…..Vegetative state• Clinical condition of complete unawareness of self & environment with damage to CNS.• No chance to recover back.
Etiology Cont…..Metabolic disorder & diffuse lesions• Diabetic coma :- • cellular starvation, ketone bodies• Hepatic coma :- – accumulation of waste product in systemic circulation.• Fluid and electrolyte imbalance – Na+ and osmolar imbalance in CNS• Nutritional deficiency• Anoxia or ischemia :- Po2<25mmhg • Disease of neuron e.g.. Lesions of motor neuron
Etiology cont…• Concussion and postictal states• Drug overdose e.g. Sedatives, analgesic, alcohol – Decrease HR, BP, RR, Tempt.• Anesthetic agent• RTI• UTI• Psychogenic causes • hysteria or catatonia
Glasgow Coma Scale (GCS)• Assess neurological function by using Glasgow Coma Scale (GCS)• Score range - 3 to 15• Abnormal - <10 Parameter Eye opening• Normal - >10 Best verbal response Best motor response
GCS contd…1. PARAMETER FINDINGS SCORE Eye opening spontaneous 4 to speech 3 To pain 2 do not open 12. Best verbal response Oriented 5 confused 4 inappropriate speech 3 incomprehensible sound 2 no verbalization 1
contd…Best motor response obeys command 6 localizes pain 5 withdraws from pain 4 Abnormal flexion 3 (decorticate posture) abnormal extension 2 (decerebrate posture) No motor response 1
PHYSICAL ASSESSMENT• Voluntary movement- strength and asymmetry in the upper extremities• Deep tendon reflexes- biceps, triceps & patella.• Posture:- – Decerebrate – Decorticate
2. Oculovestibular Reflex/calorictesting• CN 8th (acoustic) sense of equilibrium tests of vestibular portion• Sense of hearing of cochlear portion
Gag swallowing reflex• Assess CN 9th (glossopharyngeal) ,11th. (spinal accessory) to evaluate gag, swallowing reflex, tongue protrusion and ability to handle secretions.
DIAGNOSTIC TESTSCT:- Cerebral edema Infarctions Hydrocephalous Shift of brain structure
DIAGNOSTIC TESTSMRI:- Types of tissue Tumors Vascular abnormalities Intracranial bleeding
cont…LUMBAR PUNCTURE Cerebral meningitis CSF evaluationHAEMATOLOGICAL – Complete blood count – BSL – Level of drugs in blood e.g.. Aspirin, paracetamol• EEG:- electrical activity of cerebral cortex layer
Intra cranial pressure(ICP)• Combined volume of 3 intracranial compartment:- – Blood – CSF – Brain tissue• Normal - 5-15mmhg
Medical management• Obtain And Maintain Airway.• Insert oral airway• Monitor Circulatory Status To Ensure Adequate Perfusion To The Body And Brain.• Central Line Catheterization• Foley’s Catheterization• Ryle’s Tube Insertion• Prevention Of Complication
EMERGENCY NURSING CARE• Check clues and causes of unconsciousness• NBM• Loosen clothes• Ease breathing by turning head to side• keeping neck straight, chin forward• drain and clean mouth secretion• remove artificial teeth if any.
cont…• Keep warm and comfortable• Observe LOC• Keep his extremities and joints in functional position• It is important to remember that hearing sense is the last one to go and first one to come back, so avoid unnecessary talk.
SURGICAL MANAGEMENT• DECOMPRESSIVE SURGERY – Removal of skull Part – Allow a swelling brain To expand without being squeezed
NURSING CARE OF UNCONSCIOUS PATIENT
NURSING MANAGEMENT• Nsg diagnosis-Ineffective airway clearance R/t inability to swallowingIntervention• Airway management, an oral airway can be inserted• Care of ETT/ tracheostomy• Suctioning• Positioning• Chest physiotherapy• Nebulization
Risk for aspiration R/T alteredLOCIntervention—• Monitor ABG• Keep suctioning equipment available• Observe cardiac monitoring for dysrhythmias• Positioning
Impaired oral mucus membrane, R/T mouth breathing absenceof pharyngeal reflex, & altered fluidintakeIntervention----• Inspect pt’s mouth every 8 hours• Apply water-soluble lubricant to prevent cracking, drying.• Oral hygiene( to avoid parotities, aspiration and RTI)
Deficient fluid volume r/t inabilityto take fluids by mouthINTERVENTION-• Accurate documentation of intake and output• Assessment and documentation of conditions that might increase fluid volume deficit (diaphoresis, polyuria, diarrhea, vomiting)• Avoid overhydration in a patient receiving IV fluids because of risk of cerebral edema
Imbalanced nutrition less than body requirements R/T inability to feed Intervention— • IV fluids • NG Tube feeding • Maintain intake output chart
Risk for injury R/T decreasedLOCIntervention-• Side rails• Seizure precautions ( use padded side rails, keep the patient’s nail short)• Protect patient’s head• Use caution when moving• Always turn an unconscious patient toward you or someone else to prevent fall.
• Do not restrain the patient unless absolutely necessary, if restraints are used, they must be released at least every 2hours for skin check.• Avoid oversedation (which increases ICP)• Do not leave unattended.
Impaired urinary elimination R/Timpairment in neurologic sensing and controlIntervention—• Catheterization• Catheter care• Maintain aseptic technique• Monitor urine color• Initiate bladder training as soon as consciousness regained.
Bowel incontinence R/Tchanges in nutritional deliverymethods.Intervention—• Monitor• Auscultate for bowel sounds;• palpate lower abdomen for distention• Maintain food hygiene.
Risk of skin integrity R/TimmobilityIntervention—• Personal hygiene• Skin care, care of pressure points• Keep nails trimmed• Repositioned every 2 hours• Put on special mattress or bed
RESEARCH STUDIES• Topic:- Communicating with unconscious patients RESEARCHER :- KAREN LEIGH BSC,DIPHE,RN Staff nurse, royal surrey county hospital, Guildford PUBLISHED- NURSINGTIMES.NET• “ hearing is the last sense to go and first one to come” SISSON(1990)• There for health professionals evaluate the way in which they communicate with unconscious patients
Contd…• METHODOLOGY:- Assessment is depend on different theme- – Verbal communication – Patients memories – Psychological distress – Technology barrier e.g.. Cardiac monitor – touch
Contd…• The nurse’s role – One way communication from the nurse – Individualized care to the patient by preferred name, create family voice. – Aware about the nagative relationship effect of visitors• Conclusion – It indicate that this process help to patient meet their psychological need & prevent unnecessory stress
RESEARCH STUDIES• Topic:- use of behavioural pain scale (BPS) to assess pain in ventilated, unconscious and/or sedated patients.• RESEARCHER:- YOUNG J., SIFFLEET J. Intensive critical care nurse, 22 Feb. 2006 Sir Charles gairder hospital, Centre for nursing, Australia PUBLISHED:- PUBMED.GOV
RESEARCH STUDIES contd……..• Abstract- – Validate the BPS for assessment of pain in critically ill patient.• Parameter:- – Facial expressions – Upper limb movement – Compliance with mechanical ventilation
Contd….• Methods:- – Prospective, descriptive study design was use to check validity & reliability of assessment. – Routine painful stimuli = repositioning – Non painful = eye care• Results:- – 73% BPS score increased = indicating pain after repositioning – 14% BPS score shows = no pain after eye care – Pre & post procedure assessment 25 times higher for repositioning than eye care, after controlling for analgesic & sedative.
Contd….• Conclusion:- – BPS was found to be valid & reliable tool in the assessment of pain in unconscious patient. – Result also highlights that traditional pain indicators such as fluctuation in hemodynamic parameter are always not accurate measure for assessment of pain.
REFERENCE• Donina D. Ignatavicius, medical surgical nursing, a nursing process approach, W. B. Saunders company• Brunner & suddarth “ a textbook medical surgical nursing, vol. 2, 10th edition, lippincott williams & willinknson.• Phipps cassmeyar, sande lehman, medical surgical nursing concept and clinical practice, 5th edition, mosby• The lippincott manual of nursing practice, 7th edition, vol 2• Gary a. Thibodue, kevin t. Patton, anatomy and physiology, 5th edition mosby.• Sharon mantic, idolia cox, assessment and management of clinical problems, 3rd edition, mosby.