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Soumya Ranjan Parida
• Loss or lack of consciousness.
• Alteration of mental state.
 Complete or near complete lack of
responsiveness to people and other
environmental stimuli.
 Comatose state is an illustration of
unconsciousness.
Unconsciousness is a state in which:-
• Unable to responds to people and
activities.
• Lacking awareness and the capacity for
sensory perception.
• Temporarily lacking consciousness.
• Without conscious control.
• Not awareness of one’s actions,behaviour
etc.
• Lacking normal sensory awareness of the
environment.
• Without conscious volition.
• Unconsciousness can be brief, lasting for
a few seconds to an hour or few hours or
longer.
To produce unconsciousness, a disorder
must-
o Disrupt ascending RAS extends length of
brain stem and up in to the thalamus .
o Disrupt the function of both cerebral
hemisphere.
o Metabolically depress over all brain
function, as in drug overdose.
Coma is a state of sustained unconscious
in which the patient:-
• Does not respond to verbal stimuli.
• May have varying painful stimuli.
• Does not move voluntarily.
• Altered respiratory patterns.
• Altered papillary response to light.
• Does not blink.
• In general the longer coma lasts, its
irreversible due to a permanent
disorder in the brain structure.
• The longer the coma, the higher the
mortality rates, and poorer the
neurologic outcome.
 Stupor: - State of semiconsciousness in which
person responds to external stimuli or loud
noise or painful stimuli i.e., pricking or
pinching.
 Somnolent :-State when person
feels drowsy or sleepy and will
responds only if spoken to directly.
 Excitatory :- Patient does not respond to
but disturb by sensory stimuli i.e., bright
light, noise and sudden movement.
 Deep coma :-Complete loss of
consciousness. Person is aware of himself
and the environment and cannot be aroused
if he is in deep coma.
• Light coma:-Spontaneous and evoked
movement.
• Deep coma :-Heart rate is slow and
respiratory rate is fast and the depth is
increased.
• Premoribund :-Rhythm is periodic, pulse
is irregular and BP rises.
• Moribund :-Apnoeic respiration, pupil
dilated and fixed; pulse rates beats faster
and BP falls.
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 where as RAS are
responsible for awareness of self and
environment .
Disorder that affect any part of RAS
can produce coma .
To produce coma a disorder must
affect both cerebral hemisphere and
the brain stem.
i. Laboratory test .
ii. CT or MRI Scan.
iii. Lumbar puncture.
iv. EEG.
a) OCULOCEPHALIC RESPONSE :-
 Also known as Doll’s eye reflex.
 Movement of eye in the opposite direction
that in which head is moved .
 Test can be performed only in unconscious
patient.
 Presence of Doll’s eye indicate brain stem
function is preserved .
 Brain stem in a comatose patient may be
functioning in the absence of Doll’s eye
reflex.
 Eg;If the eyes moves to the right when the
head is rotated to the left &vice versa-
Doll’s eye is present.
b) OCULOVESTIBULAR :-
 Performed to test cranial nerve
iii,iv,vi,viii.
 Nystagmus is the involuntary oscillation
of the eye ball.
 It may be horizontal, vertical and
oblique .
 Absence of an oculovestibular support
the diagnosis of brain death.
 Test performed only for comatose
patient .
 FIRST AID:-
 The most important function of the first
aid is to ensure that patient air passage
remains open and clear.
 Take note of any alteration in the state
of unconsciousness either improving or
deteriorating.
 Suppose if the patient is unresponsive no
breathing only gasping.
 Activate emergency response and get
defibrillator .
 Check pulse and high quality CPR
improves a victim’s chance of survival.
The critical characteristics of high
quality CPR include:
Start compression within 10 sec. of recognition of
cardiac arrest.
Push hard ,push fast: Compress at a rate of
100beats/min with a depth of at least 2 inches(5cm)
for adult and children, approximately 1 inch 1/2 (4 cm)
for infant.
Allow complete chest recoil after each compression.
Minimize interruption in compression.
Give effective breaths that make the chest rise.
Avoid excessive ventilation.
Begin cycles of 30:2
 AED/Defibrillator arrives.
 Check rhythm shock able give 1 shock and
resume CPR immediately for 2 min.
 If rhythm not shockable resume CPR
immediately for 2 min.
 Check rhythm every 2min, continue ALS
providers take over or victim start to move.
MEDICAL MANAGEMENT:-
 The goal of medical management are 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.
 The immediate intervention for the
patient in a coma include treatment of
common causes of coma .For comatose
patient who appear malnourished,
wernicke’s encephalopathy may occur
secondary to alcohol abuse.
 The patients are commonly given
thiamine for prevention especially if they
are given glucose.
 If the patient is having lorzepam
repetitive seizure, coma and brain
damage can follow. The patient iv
diazepam, or lorazepam to stop the
seizure.
 If the patient is not intubated ,closely
monitor the airway because of these
depressants effect of these medicine.
 If cerebral oedema is present ,osmotic
diuretic may used to promote shifting of
extracellular brain fluid back in to the
plasma.
 Steroid barbiturate (neuromuscular
blocking )decrease intracranial pressure.
 If the infection is suspected patient has
shivering then ICP increases.
 Use of vasoactive agents may be required
to keep systolic pressure at 100mmHg or
the mean systolic BP above 80 mmHg.
 Promote cerebral perfusion.
 Airway.
 Position.
 Pain and sedation .
 Temperature.
 Cornea.
 Food and fluid.
 Bladder.
 Anticonvulsant therapy.
 Environment and family.
 Physical care.
 Observation.
 Convalescence.
 End of life care.
 Environment and family :
 Physical care :
 Observation:
 Convalescence :
 End of life care :
 Communication :-
 Physical comfort :-
 Mental comfort :-
 Spiritual comfort :-
 Financial need :-
 Ineffective airway clearance related to
upper airway obstruction by tongue and soft
tissue, inability to clear respiratory secretion.
 Ineffective thermoregulation related to
damage to hypothalamic centre.
 Self care deficit related to impairment of
musculoskeletal impairment.
 Imbalanced nutrition related to poor appetite
and unconsciousness.
 Interrupted family process related to
uncertain future or impending death of a
family member.
 Risk for fluid volume deficit related to
inability to ingest fluid.
 Risk for aspiration related to lack of
effective airway clearance and loss of gag
reflex.
 Risk for skin integrity related immobility.
 Risk for infection related to external factor.
 Risk for injury related to lack of safety.
• Respiratory function:-
Inability to maintain patent airway means
that aspiration of fluid, oral secretion,
blood in presence of trauma all this lead to
chest infection.
• Supine position comprise the mechanics
of breathing ,flat position causes reduction
in residual and functional residual capacity
of lung leads to complete collapse of lung
(atlectasis)and poor ventilation.
• Venous stasis decrease vasomotor tone.
Pressure in blood vessel hypercoaguable state
leads to venous thromboembolism, pulmonary
embolism.
• Pressure ulcer.
• Altered metabolism: increased excretion of
calcium from bone has a reduced weight.
The comatose client may remain in
hospital for a few days, month or year.
Some comatose patient awaken may
make a complete recovery while in the
hospital. Therefore some expected
outcomes have a brief time frame (e.g.;
airway obstruction) whereas other are
prolonged, requiring frequent re-
evaluation.
Unconsciousness presentation 1
Unconsciousness presentation 1
Unconsciousness presentation 1
Unconsciousness presentation 1

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Unconsciousness presentation 1

  • 2.
  • 3.
  • 4. • Loss or lack of consciousness. • Alteration of mental state.  Complete or near complete lack of responsiveness to people and other environmental stimuli.  Comatose state is an illustration of unconsciousness.
  • 5. Unconsciousness is a state in which:- • Unable to responds to people and activities. • Lacking awareness and the capacity for sensory perception. • Temporarily lacking consciousness.
  • 6. • Without conscious control. • Not awareness of one’s actions,behaviour etc. • Lacking normal sensory awareness of the environment. • Without conscious volition. • Unconsciousness can be brief, lasting for a few seconds to an hour or few hours or longer.
  • 7. To produce unconsciousness, a disorder must- o Disrupt ascending RAS extends length of brain stem and up in to the thalamus . o Disrupt the function of both cerebral hemisphere. o Metabolically depress over all brain function, as in drug overdose.
  • 8. Coma is a state of sustained unconscious in which the patient:- • Does not respond to verbal stimuli. • May have varying painful stimuli. • Does not move voluntarily. • Altered respiratory patterns. • Altered papillary response to light. • Does not blink.
  • 9. • In general the longer coma lasts, its irreversible due to a permanent disorder in the brain structure. • The longer the coma, the higher the mortality rates, and poorer the neurologic outcome.
  • 10.  Stupor: - State of semiconsciousness in which person responds to external stimuli or loud noise or painful stimuli i.e., pricking or pinching.
  • 11.  Somnolent :-State when person feels drowsy or sleepy and will responds only if spoken to directly.
  • 12.  Excitatory :- Patient does not respond to but disturb by sensory stimuli i.e., bright light, noise and sudden movement.
  • 13.  Deep coma :-Complete loss of consciousness. Person is aware of himself and the environment and cannot be aroused if he is in deep coma.
  • 14. • Light coma:-Spontaneous and evoked movement.
  • 15. • Deep coma :-Heart rate is slow and respiratory rate is fast and the depth is increased.
  • 16. • Premoribund :-Rhythm is periodic, pulse is irregular and BP rises.
  • 17. • Moribund :-Apnoeic respiration, pupil dilated and fixed; pulse rates beats faster and BP falls.
  • 18.
  • 19.
  • 20. 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.
  • 21.
  • 22. Reticular formation produces wakefulness where as RAS are responsible for awareness of self and environment . Disorder that affect any part of RAS can produce coma . To produce coma a disorder must affect both cerebral hemisphere and the brain stem.
  • 23. i. Laboratory test . ii. CT or MRI Scan. iii. Lumbar puncture. iv. EEG.
  • 24. a) OCULOCEPHALIC RESPONSE :-  Also known as Doll’s eye reflex.  Movement of eye in the opposite direction that in which head is moved .  Test can be performed only in unconscious patient.  Presence of Doll’s eye indicate brain stem function is preserved .  Brain stem in a comatose patient may be functioning in the absence of Doll’s eye reflex.  Eg;If the eyes moves to the right when the head is rotated to the left &vice versa- Doll’s eye is present.
  • 25.
  • 26. b) OCULOVESTIBULAR :-  Performed to test cranial nerve iii,iv,vi,viii.  Nystagmus is the involuntary oscillation of the eye ball.  It may be horizontal, vertical and oblique .  Absence of an oculovestibular support the diagnosis of brain death.  Test performed only for comatose patient .
  • 27.  FIRST AID:-  The most important function of the first aid is to ensure that patient air passage remains open and clear.  Take note of any alteration in the state of unconsciousness either improving or deteriorating.  Suppose if the patient is unresponsive no breathing only gasping.  Activate emergency response and get defibrillator .  Check pulse and high quality CPR improves a victim’s chance of survival.
  • 28.
  • 29.
  • 30.
  • 31. The critical characteristics of high quality CPR include: Start compression within 10 sec. of recognition of cardiac arrest. Push hard ,push fast: Compress at a rate of 100beats/min with a depth of at least 2 inches(5cm) for adult and children, approximately 1 inch 1/2 (4 cm) for infant. Allow complete chest recoil after each compression. Minimize interruption in compression. Give effective breaths that make the chest rise. Avoid excessive ventilation. Begin cycles of 30:2
  • 32.  AED/Defibrillator arrives.  Check rhythm shock able give 1 shock and resume CPR immediately for 2 min.  If rhythm not shockable resume CPR immediately for 2 min.  Check rhythm every 2min, continue ALS providers take over or victim start to move.
  • 33.
  • 34. MEDICAL MANAGEMENT:-  The goal of medical management are 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.
  • 35.  The immediate intervention for the patient in a coma include treatment of common causes of coma .For comatose patient who appear malnourished, wernicke’s encephalopathy may occur secondary to alcohol abuse.  The patients are commonly given thiamine for prevention especially if they are given glucose.  If the patient is having lorzepam repetitive seizure, coma and brain damage can follow. The patient iv diazepam, or lorazepam to stop the seizure.
  • 36.  If the patient is not intubated ,closely monitor the airway because of these depressants effect of these medicine.  If cerebral oedema is present ,osmotic diuretic may used to promote shifting of extracellular brain fluid back in to the plasma.  Steroid barbiturate (neuromuscular blocking )decrease intracranial pressure.  If the infection is suspected patient has shivering then ICP increases.
  • 37.  Use of vasoactive agents may be required to keep systolic pressure at 100mmHg or the mean systolic BP above 80 mmHg.  Promote cerebral perfusion.
  • 38.  Airway.  Position.  Pain and sedation .  Temperature.  Cornea.  Food and fluid.  Bladder.  Anticonvulsant therapy.
  • 39.  Environment and family.  Physical care.  Observation.  Convalescence.  End of life care.
  • 44.  End of life care :
  • 50.  Ineffective airway clearance related to upper airway obstruction by tongue and soft tissue, inability to clear respiratory secretion.  Ineffective thermoregulation related to damage to hypothalamic centre.  Self care deficit related to impairment of musculoskeletal impairment.  Imbalanced nutrition related to poor appetite and unconsciousness.  Interrupted family process related to uncertain future or impending death of a family member.
  • 51.  Risk for fluid volume deficit related to inability to ingest fluid.  Risk for aspiration related to lack of effective airway clearance and loss of gag reflex.  Risk for skin integrity related immobility.  Risk for infection related to external factor.  Risk for injury related to lack of safety.
  • 52. • Respiratory function:- Inability to maintain patent airway means that aspiration of fluid, oral secretion, blood in presence of trauma all this lead to chest infection. • Supine position comprise the mechanics of breathing ,flat position causes reduction in residual and functional residual capacity of lung leads to complete collapse of lung (atlectasis)and poor ventilation.
  • 53. • Venous stasis decrease vasomotor tone. Pressure in blood vessel hypercoaguable state leads to venous thromboembolism, pulmonary embolism. • Pressure ulcer. • Altered metabolism: increased excretion of calcium from bone has a reduced weight.
  • 54. The comatose client may remain in hospital for a few days, month or year. Some comatose patient awaken may make a complete recovery while in the hospital. Therefore some expected outcomes have a brief time frame (e.g.; airway obstruction) whereas other are prolonged, requiring frequent re- evaluation.