Unconsciousness Subject - Advance Nursing Practice Course - M.Sc Nursing

1. UNCONSCIOUSNESS
Jaice Mary Joy
M.Sc. Nursing Previous
GCON, Jodhpur

2. INTRODUCTION
Consciousness is defined as a state of awareness of one’s self, one’s environment,
and others, and assessed through a set of responses to that environment.
Consciousness includes arousal and awareness. Arousal is the state of awakeness that
is often called level of consciousness. Dysfunction in the arousal system manifests as
a decreased LOC or decreased awareness. Awareness includes cognitive functions
and affective states.
DEFINITION
Unconsciousness
 The unconscious client is in a state of depressed cerebral functioning with
unresponsiveness to stimulation of sensory and motor function.
 Unconsciousness can be brief, lasting for a few seconds to hours or few hours or
longer.
 Its onset is both gradual and sudden.
ETIOLOGY
RAS (Reticular Activating System) in the brainstem maintains normal consciousness.
Processes that disturb its function will lead to altered consciousness.
 Neurologic
• Head injury
• Stroke
 Toxicologic
• Drug overdose
• Alcohol intoxication
 Metabolic
• Hepatic or renal failure
• Diabetic ketoacidosis.
LEVELS OF UNCONSCIOUSNESS
 Excitatory: patient does not respond coherently but is disturbed by sensory
stimuli such as bright light, noise and sudden movement.

3.  Fainting: in this there is momentary loss of consciousness and the patient usually
recovers spontaneously.
 Somnolent: a state when patient feels drowsy or sleepy or we can say it is a state
between sleeping and awakening.
 Stupor: patient responds to external stimuli and shows the symptoms of
annoyance when stimulated by pinprick or loud noise such as clapping of hands.
 Coma: it is a clinical state of unconsciousness in which the patient may respond to
deep painful stimuli. In deep coma, there is no arousal.
 Vegetative stage: clinical condition of complete unawareness of self and
environment with damage to CNS. No chances to recover back.
PATHOPHYSIOLOGY
Consciousness depends on excitation of cortical neurons by impulses conducted to
them by a network of neurons known as the reticular activating system(RAS).
Drugs such as barbiturates are known to depress the RAS, decrease alertness and
induce sleep. Amphetamines, on the other hand, are that stimulate the cerebrum and
enhance alertness and wakefulness probably by stimulating RAS.
Disorders that affect any part of RAS can produce coma.
To produce coma a disorder must affect both cerebral hemisphere and brain stem.
CLINICAL MANIFESTATION
 Unarousable.
 Primitive or no response to painful stimuli.
 Altered respirations.
 Decreased cranial nerve and reflex activity.
DIAGNOSTIC STUDIES
 Electrolyte panel including chloride, potassium, sodium.
 CBC
 Drug screen for toxicology
 Blood urea nitrogen and creatinine
 Computed tomography or magnetic resonance imaging scan of the head may be
ordered to rule out cerebral hemorrhage, mass or structural causes.
 Lumbar puncture to rule out cerebral meningitis and CSF evaluation.
 EEG for electrical activity of cerebral cortex layer.

4. ASSESSMENT
 GLASS GOW COMA SCALE
It is gold standard tool but shortcoming of this scale is inability to assess the
verbal score after the patient has been intubated; lack of assessment of
respiration and brain stem reflexs; inability to assess a possible developing
vegetative state; and inability to recognize psuedocoma (locked-in-syndrome).
INTERPRETATION :- Severe _< 8, Moderate – 9 to 12, Minor >_ 13
 FOUR SCORE (Full Outline ofUnResponsiveness)
It has 4 components and for this we use the acronym EMBR. The examiner
rates each component on a 0 to 4 scale , with 0 signifying complete lack of
response and 4 indicating a normal or expected response. Each component is
scored individually eg.. E4, M3, B4 or R1 ; the four components are not
totaled but a score of 0 would likely indicate that the patient fulfill the criteria
of brain death. This scale is reliable can be used to predict outcomes, can be
performed within 1 to 2 minutes and requires very little training.

5. .
INTERPRETATION : -- Each component is scored individually eg.. E4, M3, B4 or
R1 ; the four components are not totaled but a score of 0 would likely indicate that the
patient fulfill the criteria of brain death.
MEDICAL MANAGEMENT
 The goal of the medical management is to preserve brain function and to prevent
additional brain injury.
 The primary focus is on maintaining the supply oxygen and glucose to the brain.
 The patient circulation, airway and breathing must be maintained.

6. NURSING MANAGEMENT
1. Nursing Diagnosis: Ineffective airway clearance related to altered level of
consciousness (LOC).
Nursing intervention
Maintaining the airway
 To establish an adequate airway and ensure ventilation.
 Elevate the head of the bed to 30 degrees helps prevent aspiration.
 Positioning the patient in lateral or semiprone position promotes drainage of
secretions.
 Suction and oral hygiene is required. ( before and after suction patient is
adequately ventilated to prevent hypoxia.)
 Chest physiotherapy and postural drainage initiated to promote pulmonary
hygiene.
 Chest should be auscultated every 8 hours to detect adventitious or absence of
breath sounds.
2. Nursing Diagnosis: Risk of injury related to decreased LOC.
Nursing intervention
Protecting the patient
 Raise the side rails and should be padded.
 Potential sources of injury should be identified such as restraints, tight
dressing, damp bedding or dressing ect.
 Protection also includes ensuring patient’s dignity during altered LOC.
Note : physical restraints should be avoided if possible; a written prescription
must be obtained if their use is essential.
3. Nursing Diagnosis: Deficient fluid volume related to inability to take fluids by
mouth.
Nursing intervention
Maintaining fluid balance and managing nutritional needs.
 Initially IV fluids are required.( IV solutions in patients with intracranial
conditions must be administered slowly.)
 Strict intake output charting should be maintained.
 If patient doesn’t recover quickly, a feeding or gastrostomy tube will be
inserted.

7. Impaired oral mucous membrane related to mouth breathing, absence of
pharyngeal reflex and altered fluid intake.
 Mouth is inspected for dryness, inflammation and crusting.
 Give careful oral care to prevent parotitis.
 A thin petrolatum coating avoid drying, cracking and encrustation.
 If ET tube present then the tube should be moved opposite side of mouth daily
to prevent ulceration.
4. Nursing Diagnosis: Risk of impaired skin integrity related to prolonged
immobility.
Nursing intervention
Maintaining skin and joint integrity.
 Regular schedule for changing position.
 Dragging and pulling patient must be avoided.
 Passive exercises for extremity to prevent contractures.
 Use of splints or foam boots aid to prevent foot drop.
 Air mattresses can be used.

8. BIBLIOGRAPHY
1. Smeltzer C. Suzanne, Bare G. Brenda, Hinkle L. Janice, Cheever H. Kerry. Text book
of medical-surgical nursing. 12th ed. New Delhi: Wolters Kluwer; 2011. Chapter 61.
Management of patient with neurological dysfunction; p.1858-1864.
2. Silvestri Anne Linda. Comprehensive Review for the NCLEX-RN Examination. 7th
ed, St. Louis, Missouri: Elsevier; 2009. Chapter 62. Neurological Disorders of Adult
Client; p.898-899.
3. Barker Ellen. Neuroscience Nursing A Spectrum of Care. 3rd ed, Green Ville
Delaware: Mosby Elsevier: 2008. Chapter 6. Altered States of Consciousness &
Sleep; p.181-200.
4. Joyce M. Black, Hawks Hokanson Jane. Medical- surgical nursing. 7th ed, St. Louis
Missouri: Elsevier; 2005. Chapter 9. Management of Comatosed or Confused Clients;
p.2065-2068.
5. Jafar Alasad, Ahmad Myuyyad. Communication with critically ill patients. Issues and
innovation in nursing practice; 2004.