its all about our mind how it work and what thing is need for it to function properly

1. Prsented by
Shantanu A
Msc N 1st year

2. Introduction
• The brain requires a constant supply of oxygenated blood and glucose
to function. Interruption of this supply will cause loss of consciousness
within a few seconds and permanent brain damage in minutes.

3. 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.

4. Reticular activating system

5. 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.

6. Level of unconsciousness
• Somnolent
• Excitatory unconsciousness
• Stuporous

7. Cont..
Excitatory 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.

8. Cont..
Somnolent
• a sate when patient feels drowsy or sleepy or we can say it is a state
between sleeping and awakning.
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.

9. Related terms
• Vegetative state
• Persistent vegetative states
• Locked in syndrome
• Akinetic mutism
• Brain death

10. Vegetative state
• Opens eyes spontaneously
• Does not follow commands
• No intentional movements
• Show spontaneous roving eyes
Sleep awake cycles
• can result from diffuse injury to
the cerebral hemispheres of the
brain without damage to the
cerebellum and brainstem

11. Persistent vegetative state
• Many patients emerge from a
vegetative state within a few
weeks, but those who do not
recover within 30 days are said
to be in a persistent vegetative
state (PVS).

12. Locked in syndrome
• Caused by damage to specific
portions of the lower brain and
brainstem with no damage to the
upper brain.
• Eye opening is well sustained
• Basic cognitive abilities are
evident on examination
• Mode of communication is eye
movements or clinking of the
upper eyelid

13. Akinetic mutism
• Patients are immobile and
usually lie with their eyes closed.
• Sleep wake cycles exists.
• There is little or no vocalization.
• Motor response to noxious
stimuli is absent or minimal
• Command following or
verbalization can be elicited but
occur infrequently

14. Brain death
• Irreversible damage of the brain,
including the brainstem and
cerebellum, and cessation of
functions. Pulmonary and
cardiac functions can be
maintained by artificial means.
• Untreated coma causes it.

16. Etiology
Structural lesions
1.Supratentorial lesions (causing brain stem dysfunction)
• E.g. EDH/SDH Brain abscess Cerebral infarction

17. Cont..
2.Subtentorial lesions : compressing/destroying the reticular formation
E.g.. Cerebellar abscess infarction, cerebellar haemorrhage/tumour

18. 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

19. Cont..
• Nutritional deficiency
• Anoxia or ischemia : Po2<25mmhg
• Disease of neuron e.g.. Lesions of motor neuron

20. Cont..
Psychogenic causes
• hysteria
• catatonia

21. Pathophysiology
Structural lesions cerebral hemorrhage
Danage to the brain and skull
Edema inflammation and hamorrhage
Increase icp

22. Cont..
Diffuse damage to the cerebrum car possum callousum and brainstem
Disruption of RAS
unconsciouness

23. Clinical manifestation
Respiratory system
• Stridor
• Rales
• Rhonchi
• Progressive cyanosis
• Decreased respiratory rate
• Asymmetrical chest wall

24. Cardiovascular symptoms
• Bradycardia
• Hypotension
• Ventricular tachycardia
• Arterial fibrillation
• Hyperaemic
• Decreased cardiac output

25. Neurological system
• Asterixis
• Myoclonus
• Seizures
• Cranial nerve palsies
• Lethargy
• Absent deep tendon reflexes

26. Gastrointestinal system
• Vagus dysfunction
• Abdominal distension
• Decreased bowel sounds
• Constipation
• Ascites
• hyperlipidaemia

27. Urinary system
• Urinary incontinence
• High creatinine index
• Oliguria
• Ketouria
• UTI
• pyuria

28. Nursing assessment (GCS)
EYE OPENING RESPONSE (E)
 Spontaneous eye opening - 4
 Opens to voice - 3
 Opens to painful stimuli - 2
 No response - 1

29. Cont..
BEST MOTOR RESPONSE (M)
 Obeys command -6
 Localizes pain -5
 Withdraws to pain -4
 Abnormal flexion -3
 Abnormal extension -2
 No response -1

30. Cont..
VERBAL RESPONSE (V)
Oriented, normal conversation -5
 Confused, disoriented -4
 Inappropriate words -3
 Incomprehensible sounds -2
 No response - 1

32. Physical assessment
• Voluntary movement- strength and asymmetry in the upper
extremities
• Deep tendon reflexes- biceps, triceps & patella.
• Posture:–
Decerebrate
Decorticate

34. Brain stem reflex
• Pupillary light reflex
• Corneal/lash reflex
• Ocular Reflex
1. Oculocephalic reflex(Doll’s Eye Reflex)
2. Oculovestibular Reflex/caloric testing
• Gag swallowing reflex

35. • Pupillary light reflex –Assess
pupil size, symmetry, and
reaction to light. –Reflex eye
movement elicited by head
turning
• Corneal reflex
• Absent eye close indicate
compression of CN
5th(trigeminal) nerve

36. Ocular Reflex

37. 2. Oculovestibular Reflex/caloric testing
• CN 8th (acoustic) sense of
equilibrium tests of vestibular
portion • Sense of hearing of
cochlear portion

38. Gag swallowing reflex
• Assess CN 9th (glossopharyngeal) ,11th. (spinal accessory) to
evaluate gag, swallowing reflex, tongue protrusion and ability to
handle secretions

39. DIAGNOSTIC TESTS
CT
• Cerebral edema
• Infarctions
• Hydrocephalous
• Shift of brain structure

40. MRI:
• Types of tissue
• Tumours
• Vascular abnormalities
• Intracranial bleeding

41. LUMBAR PUNCTURE
• Cerebral meningitis
• CSF evaluation
HAEMATOLOGICAL
• Complete blood count –BSL –Level of drugs in blood e.g.. Aspirin,
paracetamol
EEG
• Electrical activity of cerebral cortex layer

42. 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

43. 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.

44. • 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.

45. Surgical mangaement
• craniotomy • Shunting

46. • Decompressive surgery
• Removal of skull Part –Allow
a swelling brain To expand
without being squeezed

47. Nursing care of unconscious patient
Nursing management
• Ineffective airway clearance R/t inability to swallowing
Intervention:
• Airway management, an oral airway can be inserted
• Care of ETT/ tracheostomy
• Suctioning
• Positioning
• Chest physiotherapy
• Nebulization

48. • Impaired urinary elimination R/T impairment in neurologic
impairment in neurologic sensing and control sensing and control
Intervention—
• Catheterization
• Catheter care
• Maintain aseptic technique
• Monitor urine color
• Initiate bladder training as soon as consciousness regained.

49. Risk of skin integrity R/T immobility
Intervention:
• Personal hygiene
• Skin care, care of pressure points
• Keep nails trimmed
• Repositioned every 2 hours
• Put on special mattress or bed

51. Conclusion
Altered level of consciousness place a client at the risk of injury.
Nurse play a very important role in caring for an unconscious patient,
helping the
patient in carrying out ADL Proper assessment and prompt
intervention can improve the prognosis.

52. References
Luck Mann’ s “medical and surgical nursing” 4th edition, Saunders's
publications .page no.673-670.
Barker’s “neuro sciences nursing” 2nd edition, mosby publications.
Page no.698-712.
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