f.y.b.sc nsg

1. MRS. SAPANA THAKOR
LECTURER
NSIN,JETALPUR

2. INTRODUCTION
 The totality of those parts of the brain that receive,
process and interpret sensory stimuli.
The sensorium is the supposed seat of sensation, the
place to which impressions from the external world are
conveyed and perceived.
 The sensorium also refers to the entire sensory
apparatus of the body.

3. DEFINITION
 The totality of those parts of the brain that receive,
process and interpret sensory stimuli. The sensorium
is the supposed seat of sensation, the place to which
impressions from the external world are conveyed and
perceived.

4. ALTERED SENSORIUM
 The term altered sensorium describes limitation on or
problems with the brain’s ability to receive, process or
interpret sensory information,
 Ex- altered sensorium include hallucinatory and
confusional states , delirium , coma and sleep.

5. Care of unconscious patient
 It is a lack of awareness of one’s environment and the
inability to respond to external stimuli.
 Unconsciousness is a condition where cerebral
functions are depressed and patient has inability to
respond to sensory stimuli.
 A coma is a state of unconsciousness.

6. causes
 Head injury
 Cerebral catastrophes.
 Infection
 Asphyxia
 Poisons.

7. Types
 1. brief , lasting for a few seconds or an hour.
 2. sustained , lasting for a few hours.

8. Investigation
 Blood test for glucose, urea nitrogen, electrolytes and
ph value
 Complete blood count
 Lumbar puncture for cerebrospinal fluid examination.
 Liver function tests.
 X-ray of skull
 Electroencephalography.

9. Assessment
 Physical assessment.
 Glasgow coma scale.
 Eye opening-spontaneous 4
 to speech 3
 to pain 2
 no response 1
 Verbal response-oriented 5
 confused 4
 inappropriate words 3
 Incomprehensible sound 2
 no response 1

10. Motor response
 Obeys commands 6
 Localize 5
 Withdraws 4
 Flexes 3
 Extends 2
 No response 1
 Total score - 3-15

11. Treatment
 Respiration should be maintained by patient
airway. The passage should cleared of secretion. If
necessary oxygen should be administered. Blood
gas studies should be monitored.

12.  If the patient in the shock, it should be treated.
 Reduce the intracranial pressure –
A) ventricular tapping to remove the csf.
B)burr hole to monitor intracranial pressure.
C)use of osmotic diuretics to relieve tension caused due
to cerebral oedema. Ex. Mannitol.

13.  Antibiotics are necessary , to treat
infections.
 Sedatives are prescribed for the restless
patients
 Stool softer may be required to prevent
constipation.
 Specific treatment should be started early.

14. Nursing management.
 constant observation
 Vital signs
 Complications.
 Respiration by airway
 Semi prone position on one side
 Suction
 Cleared secretions
 Facilitated ventilation
 According to level consciousness observed sign –
reflexes , responses.

15.  Cerebral edema should be prevent by diuretics
 Eye care
 protect from injury
 Prevent pressure sores
 Prevent constipation
 Deformities should be prevent

16. Nursing process

17. Assessment
 Evaluation of mental status
 Cranial nerve functioning
 Reflexes
 Motor and sensory functioning
 Scanning , imaging , tomography
electroencephalogram
 Glasgow coma scale.

18. Nursing diagnosis