This document discusses unconsciousness and coma. It defines unconsciousness as a temporary state of lacking awareness and responsiveness. Coma is described as a state of sustained unconsciousness where the patient does not respond to stimuli. The causes, assessment tools, medical management, nursing care needs, and outcomes of unconsciousness and coma are covered. Reticular activating system is identified as controlling consciousness and disorders of this system can cause coma.

1. Soumya Ranjan Parida

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.

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.

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.

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.

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.

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.

40.  Environment and family :

41.  Physical care :

42.  Observation:

43.  Convalescence :

44.  End of life care :

45.  Communication :-

46.  Physical comfort :-

47.  Mental comfort :-

48.  Spiritual comfort :-

49.  Financial need :-

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.