UNCONSCIOUSNESS medical surgical nursing

1. Supervised by: Presenter:
Prof. GN Mandal Sushila Hamal
Medical Surgical Nursing M.Sc. Nursing 1st year
BPKIHS BPKIHS
1

2. 2

3. It is defined as a state of awareness of oneself and of
one’s environment
Ability to perceive sensory stimuli and respond
appropriately to them
3

4. It comprises of two components:
1. Arousal
2. Awareness
Awareness of self: It means that the client can identify
himself or herself.
Awareness of environment: It indicates that the client can
identify his/ her present location and reason for being there.
Awareness of time: It indicates that a client knows the date,
month and year
4

5. A state of complete or partial unawareness or lack of
response to sensory stimuli. Various degrees of
unconsciousness are there: e.g. confusion, stupor, somnolent,
excitary and deep coma etc.
Abnormal state - client is unarousable and unresponsive.
Degrees of unconsciousness that vary in length and severity.
Unconsciousness is a symptom rather than a disease.
5

6. State in which a patient is totally unaware of both self and
external surroundings
Coma is a state of sustained unconscious in which the patient:-
Totally unconscious, unresponsive, unaware and unarousable.
Do not respond to external stimuli, such as pain or light
Does not move voluntarily.
Altered respiratory patterns.
Does not blink
Coma is a deepest state of unconsciousness
6

7. Any abnormality of the following areas can cause
unconsciousness:
Bilateral hemispheric abnormality
Brainstem abnormality
Thalamic abnormality
7

8. Supratentorial lesion
Large cerebral infarct with edema
Brain tumor, brain abscess
 Intracerebral, subdural, extradural, Subarachnoid
hemorrhage
 Cerebral tumor, Cerebral abscess, Cerebral edema
8

9. Brainstem infarcts or hemorrhage
Brain stem tumor
Brainstem trauma
Cerebellar abscess
Cerebellar hemorrhage
9

10. Diseases of neurons
Metabolic encephalopathy
Diseases of other organs e.g.
liver, lungs and kidney etc.
Poisons, alcohol and drugs
Fluid and electrolyte
imbalance
Infections
Nutritional deficiency
Hypo/Hyperglycemia
Hypo/hypernatremia
Anoxia or ischemia
Temperature regulation
disorders
10

11. 11

12. Consciousness is a complex function controlled by RAS
RAS begin in the medulla as reticular formation
Reticular formation connect to RAS located in the midbrain, connects to the
hypothalamus and thalamus
Integrated pathway connects to the cortex via thalamus and to the limbic system
via hypothalamus
Reticular formation produces wakefulness whereas RAS are responsible for
awareness of self and environment
Both cerebral hemisphere and the brain stem are affected
12

13. Damage to the brain and skull
Inflammation, edema and hemorrhage
Increased ICP
Diffused damage to the cerebral tissues
Blocks the signal to the RAS (Reticular activating system)
UNCONSCIOUSNESS
13

14. Consciousness
Confusion
Delirium
Obtundation
Stupor
Coma 14

15. Disoriented
Shortened attention span
Memory deficits
Difficulty in following commands
Alteration in perception of stimuli.
15

16. Disoriented to time, place and person
Increased motor activities.
Illusion, hallucinations
16

17. Reduced ability to be aroused & limited response to
environment.
Reduce level of alertness or consciousness
Sleeps unless stimulated with speech or touch
Verbally a grunt or nod
17

18.  Deep sleep or unresponsiveness
 Responds by withdrawing or grabbing at the source of pain
 Can be aroused only with painful stimuli
18

19. Vegetative state
Persistent vegetative states
Locked in syndrome
Akinetic mutism
Brain death
19

20. Patient is awake but showing no sign of awareness
Opens eyes spontaneously
Does not follow commands
No purposeful movements
Show spontaneous roving eyes
Sleep awake cycles normal
Affect cognitive or affective function
20

21. 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).
 Irregular circadian sleep–wake cycles
21

22. Caused by damage to specific portions of the lower brain
and brainstem with no damage to the upper brain.
Patient is aware but cannot move or communicate verbally
due to complete paralysis of nearly all voluntary muscles in
the body except for vertical eye movements and blinking
Mode of communication is eye movements or clinking of the
upper eyelid
22

23. Patients are immobile and usually lie with their eyes closed.
It is a state of unresponsiveness to the environment
Absence of body movement and speech but sometimes open
the eyes
Motor response to noxious stimuli is absent or minimal
23

24.  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.
24

25. 1. Supratentorial lesion:
Early manifestation includes:
Headache
Localized sensorimotor deficit
Aphasia
Drowsiness
Seizures
25

26. As lesion expands, manifestation becomes more
pronounced
Unilateral sensory-motor deficit (e.g. Patient can’t raise
the right leg or arm)
Deficit in visual field (blind in one half of the visual field)
The person is unaware of his surroundings
Does not respond to sound or to touch
Inability to speak or move parts of his or her body
Loss of bowel or bladder control (incontinence)
If the lesion can’t be treated, coma develops.
26

27. Sudden loss of consciousness
Unusual respiratory pattern
Cranial nerve palsies, especially abnormal eye movements
and loss of pupillary reaction to light.
Specific pattern of pupil size(pinpoint) and reactivity to
light occurs
27

28. Disorders affects entire brain
Before any physical symptoms are noticed confusion and
stupor occurs
Pupillary response is normal unless the condition is
related to drug overdose
Tremor
Asterixis
Seizure
28

29. 29

30. X-ray : Skull
MRI (magnetic resonance imaging): tumors, vascular
abnormalities, IC bleeding
CT (computerized tomography): cerebral edema,
infarctions, herniation, hydrocephalus, toxic effect in CNS.
Lumbar puncture : cerebral meningitis, CSF evaluation
PET (positron emission tomography): Metabolic activity
EEG: electric activity of cerebral cortex
Blood test like CBC, LFT, RFT, ABG etc.
Glasgow coma scale test
30

31. 31

32. 32
Provide high quality CPR
1. Start compression within 10 second of
recognition of cardiac arrest
2. Push hard and fast, compress at a rate of
100
beats per minute with depth of at least 2
inches for adult and 1 inch for children
3. Allow complete chest recoil after each
compression
4. Minimize interruption in compression
5. Give effective breaths that makes the chest
rise
6. Avoid excess ventilation
7. Begin cycle of 30:2 compression

33. Danger - Looking for Dangers to yourself and Casualty
Response - Checking Response (AVPU). Use the Glasgow
Coma Scale to ascertain level of consciousness
Airway - Examining the Airway for obstruction
Breathing - Look, Listen and Feel for adequate respiratory
effort. Supplement with Oxygen to correct hypoxia if
saturation is below 95%
Circulation - Checking the Circulation. If a carotid pulse is
not palpable then resuscitation should be commenced.
33

34. Monitor vital signs, blood glucose levels.
Obtain history from relatives, family or witnesses.
Collect as much information as possible about the patient.
Allergies
Medication
Previous medical history (Epilepsy, Diabetes)
Last meal
Event - What has happened
34

35. Pharmacological treatment
Treating Increased ICP: mannitol, corticosteroids
 Mannitol 0.5 mg/kg over 15 min and repeat after 4 hrs.
 Steroids
 Dexamethasone
 Management of fever: ice packs, tepid sponging, Antipyretics, NSAIDS
 Management of elimination: laxatives and high fiber diet
 Loop diuretics: inj. Lasix 40 mg stat
 Surgical interventions: ventriculostomy
for draining CSF
35

36. Hypoglycemia: 50 ml of 50% D IV push
Wernicke's encephalopathy :thiamine
Drug overdose :naloxone
Seizures: antiepileptic, sedatives and paralytic
agents
Infection: antibiotics
Hyperglycemia: insulin
Poison ingestion: gastric lavage
Management of nutrition: TPN and Ryle’s Tube feeds
36

37. GOALS OF NURSING CARE
Maintain adequate cerebral perfusion
Remain normothermic
Be free from pain, discomfort, and infection
Attain maximal cognitive, motor and sensory function
37

38. LOC
RR, rhythm
Pupils
 Eye movements
Doll's eye reflex
Vital signs
Skin
 Bowel and Bladder function
Intake and output
Pulmonary functions
38

39. 39

40. Highest score is 15/15 - Good orientation
 Lowest score is 3/15 - Deep coma. Considered brain dead
if client dependent on a ventilator
GCS≤8- Severe brain injury
GCS 9-12- Moderate brain injury
GCS 13 Mild brain injury
40

41. Ineffective airway clearance related to altered level of
consciousness.
Fluid volume deficit related to inability to take in fluids by
mouth
Disturbed sensory perception related to neurological
impairment
Self-care deficit related to loss of consciousness.
Interrupted family process related to uncertain future and
impending death of a family member.
41

42.  Bowel incontinence related to impairment in neurological control.
 Impaired urinary elimination related to impairment in neurological
control.
 Risk for aspiration related to lack of effective airway clearance and loss
of gag reflex.
 Risk for impaired skin integrity related to immobility.
 Risk for increased ICP related to Brain Swelling, Blood accumulation
and Obstruction of Cerebrospinal Fluid Flow
 Risk for injury related to decreased level of consciousness.
42

43.  The breath sounds must be assessed every 2 hourly.
 ABG results must be interpreted to determine the degree of
oxygenation provided by the ventilators or oxygen.
 Assess for cough and swallow reflexes
 Use an oral artificial airway to maintain patency
 Tracheostomy or endotracheal intubation and mechanical
ventilation maybe necessary
PREVENTING AIRWAY OBSTRUCTION
 Position on alternate sides 2-4 hours to prevent secretions
accumulating in the airways on one side.
 Maintain the neck in a neutral position
43

44. Assess the hydration status by examining the tissue turgor,
mucous membrane, I/O chart monitoring, CVP
measurement.
Maintain I/O chart strictly.
Provide intravenous fluid as prescribed.
Daily weight should be taken.
Assess and document symptoms that may indicate fluid
volume overload or deficit.
Diuretics may be prescribed to correct fluid overload and
reduce edema.
44

45.  Assess the neurological status of the patient.
 Communicate with the patient as hearing often remains intact in
the unconscious patient.
 Avoid making any negative comments about the patient’s status or
explaining prognosis to the family members.
 Call the patient by preferred name, tell patient date, time.
 Touch the patient gently and describe the boundaries and
environment
 Tell family members to remain with the patient to communicate.
45

46.  Attending to the hygiene needs of the unconscious patient should
never become ritualistic, and despite the patient's perceived lack of
awareness, dignity should not be compromised.
 Involving the family in self care needs.
 Incontinence, perspiration, poor nutrition, obesity and old age also
contribute to the formation of pressure ulcers.
 Care should be taken to examine the skin properly, noting any areas
which are red, dry or broken.
46

47.  Observe the skin for evidence of skin breakdown.
 Change the patient's position at least every two hours and provide
back care.
 Provide complete bath every other day. Patient's perineal area
should be bathed daily.
 The skin should be lubricated with moisturizing lotion after bathing.
 The nails should be kept short, as many patients will scratch
themselves.
 Change the bed linen if damp or soiled.
47

48.  Unconscious patient is often a mouth breather. This causes
saliva to dry and adhere to the mouth and tooth surfaces.
 Provide oral hygiene at least twice per shift. Include the
tongue; all tooth surfaces, and all soft tissue areas.
 Apply lubricant to the lips to prevent drying.
 Keep the nostrils free of crusted secretions
 A chlorhexidine based solution is used.
48

49.  In assessing the eyes, observe for signs of irritation, corneal drying,
abrasions and edema.
 Gentle cleaning with gauze and 0.9% sodium chloride should be
sufficient to prevent infection.
 Artificial tears can also be applied as drops to help moisten the eyes.
 Corneal damage can result if the eyes remain open for a longer time.
49

50.  Diet prescribed nutrition based on individuals requirements
specifically to meet energy needs, tissue repair, replace fluid loss to
maintain basic life functions
 TPN is considered for prolonged unconsciousness.
 Intravenous fluids are administered for comatose patients. As fluid
intake is restricted and glucose is avoided to control cerebral edema
and intravenous infusion cannot be considered as a nutritional
support.
 Enteral feeding via Nasogastric, nasojejunal OR PEG tube. 50

51.  Side rails must be kept whenever the patient is not receiving direct
care.
 Seizure precautions must be taken.
 Adequate support to limbs and head must be given when moving or
turning an unconscious patient. Protect from external sources of heat.
 Over sedation should be avoided - as it impedes the assessment of the
level of consciousness and impairs respiration.
 Assess the Need for restrain
51

52.  Assess for constipation and bladder distention.
 Auscultate bowel sounds.
 Stool softeners or laxatives may be given. Bladder catheterization may
be done.
 Meticulous catheter care must be provided under aseptic techniques.
 Monitor the urine output and color.
 Initiate bladder training as soon as consciousness has regained.
52

53. Impaired Skin Integrity
The nurse should provide intervention for all self-care
needs including bathing, hair care, skin and nail care.
Frequent back care should be given.
Comfort devices should be used.
Positions should be changed.
Special mattresses or airbeds to be used.
Adequate nutritional and hydration status should be
maintained.
Patient's nails should be kept trimmed.
Cornea should be kept moist by instilling methyl cellulose
53

54.  Lateral position on a pillow to maintain head in a neutral position
 Upper arm positioned on a pillow to maintain shoulder alignment
 Upper leg supported on a pillow to maintain alignment of the hip
 Change position to lie on alternate sides every 2-4hrs
 For hemiplegia - position on the affected side for brief periods,
taking care to prevent injury to soft tissue and nerves, edema or
disruption of the blood supply
54

55.  Assess the GCS score, assess signs of increased ICP.
 Head elevation of 30 degrees, neutral position maintained to
facilitate venous drainage and prevent aspiration.
 Pre-oxygenation before suctioning should be mandatory, and each
pass of the catheter limited to 10 seconds, with appropriate sedation
to limit the rise in ICP.
 Insertion of an oral airway to suction the secretions.
 The breath sounds must be assessed every 2 hourly
55

56.  Restlessness
 Headache
 Pupillary changes: ASSESS every hourly
 Respiratory irregularity
 Widening pulse pressure, hypertension and bradycardia.
(CUSHING'S TRIAD)
 NORMAL ICP: 5 TO 15 mm of Hg
56

57. A retrospective analysis of the unaccompanied, unconscious patients attending the
emergency department of Bir hospital during 14 April 2009 to 13 April 2010 was
carried out. The aim of this study to analyze the morbidity & mortality as well as
the types of illness, causes of unconsciousness and the source of unconsciousness in
these patients without any identity.
 Results: Two-thirds of these patients were brought to hospital by the police. The
next category (20%) were brought by unknown person and left without any
information. In the span of one year, a total of 64,240 patients received care in the
emergency department of Bir Hospital and out of them, 248(0.4%) were
unaccompanied unconscious patients.
57

58.  Unaccompanied, unconscious patients are priority patients for
emergency medical service. Alcohol intoxication, infections in
beggars and ingestion of unknown substance are major causes
and quite a big amount of resources has been utilized for them.
58

59. 1. Mandal G.N. "Textbook of Medical Surgical Nursing". 6th ed. Baneshwor,
Kathmandu: Safal Publication House Pvt. Ltd; 2019.
2. Sharma M., Kalpana P., Gautam R. "Essential Textbook of Medical Surgical
Nursing". 2nd ed. Ghattekulo Rautahadevi Marga, Kathmandu: Samiksha
Publication Pvt. Ltd; 2017.
3. Chugh S N. "Textbook of Medical Surgical Nursing". 1st ed. New Delhi: Avichal
Publishing Company; 2013.
4. Singh D, Acharya R, Singh S. Profile of unaccompanied, unconscious patients in
the emergency department. J Inst Med. 2011;32(2):2009–11.
5. Bhatta S, Magnus D, Mytton J, Joshi E, Bhatta S, Adhikari D, Manandhar SR,
Joshi SK. The Epidemiology of Injuries in Adults in Nepal: Findings from a
Hospital-Based Injury Surveillance Study. Int J Environ Res Public Health.
2021 Dec 2;18(23):12701. doi: 10.3390/ijerph182312701. PMID: 34886427;
PMCID: PMC8656929.
59

60. 60

61. 61

62. 62