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UNCONSCIOUSNESS

UNCONSCIOUSNESS. Meaning. Unconsciousness is a state in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli. Coma : is a state of sustained unconsciousness.

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UNCONSCIOUSNESS

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  1. UNCONSCIOUSNESS

  2. Meaning • Unconsciousness is a state in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli. • Coma: is a state of sustained unconsciousness.

  3. A wide range of awareness and responsiveness exist between consciousness and unconsciousness • Level of consciousness is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end.

  4. Diagnostic tests • This include • Detailed history • Physical assessment including neurologic examination • Radiologic examinations • Laboratory testing

  5. 1.History collection… • Date and type of onset(sudden or slowly progressive) • Recent history of falls, infection, convulsion or other trauma • Medication use –prescription and OTC drugs, alcohol, opioids, barbiturates, nutritional supplements and herbal preparations.

  6. Other co- morbid health problems (DM, hypertension, epilepsy, COPD or bronchial asthma, IHD, renal disease, liver disease etc) & treatment regimen. • Related symptoms- headache, fever, vomiting,chestpain etc

  7. 2.Physical examination….. • Head to foot assessment • Neurological examination • level of consciousness • mini mental status examination • cranial nerves • motor and cerebellar system • sensory system • reflexes

  8. Assess the LOC using Glasgow coma scale • EYE OPENING • spont.opening4 • to verbal commands 3 • to pain 2 • no response 1 • VERBAL RESPONES • oriented 5 • Confused 4 • Inappropriate words 3 • Incoherent 2 • No response 1 • MOTOR RESPONSE • obeys verbal commands 6 • localize pain 5 • withdraws from pain 4 • flexion 3 • extension 2 • no response 1

  9. 3.Laboratory Tests • CBC • Blood sugar • Electrolytes • LFT,BUN • Cardiac enzymes • Serum osmolarity • ABG • Toxicology( screening for opiates, alcohol, and barbiturates)

  10. 4.Radiological Examination • Skull x ray films • CT brain • MRI brain • EEG • Cerebral angiogram

  11. Medical management 1.Establish ABCs 2.Determine the cause and level of involvement of unconsciousness. 3.Reverse the common causes of unconsciousness. 4. Management of complications of unconsciousness.

  12. 1.Establish ABC’s i. Airway and breathing • Position the patient in a lateral or semi prone position • Insert an oral airway if the tongue is paralyzed or obstructing the airway • Suctioning

  13. Assess the breathing of the patient frequently • Start oxygen OR do ET if needed

  14. ii. Circulation • Monitor the circulatory status to ensure adequate perfusion to the body and brain. • Establish an IV line • Give fluids and ionotropes according to the hydration/ circulatory status of the patient. • Ensure continuous cardiac monitoring

  15. 2.Determine the cause and level of involvement of unconsciousness. • A complete physical assessment including neurological assessment and other investigations.

  16. 3.Reverse the common causes. • Treat the underlying causes identified • Hypoglycemia :Glucose(5%DEXTROSE) • Seizure :diazepam or lorazepam • Infection :antibiotics • Drug overdose :specific antidotes (eg; Opioids- naloxane) • Structural causes : surgery.

  17. 4. Management of complications of unconsciousness. Potential complications include • Aspiration of gastric content or pharyngeal secretions. • Pneumonia. • Pressure ulcer • Deep vein thrombosis, parotitis, keratitis • Musculoskeletal detoriation • Malnutrition • Fluid and electrolyte imbalance

  18. Nursing management 1.Assessment • Airway, breathing, and circulation. • neurologic status • vital signs including breathing pattern and oxygenation • nutritional status and hydration • urinary and bowel pattern • Potential problems like impaired oral mucosa, skin integrity &corneal integrity

  19. 2.Nursing diagnosis • Ineffective airway clearance related to upper airway obstruction by tongue and inability to clear secretions. • Hyperthermia related to infectious process / damage to hypothalamic center. • Impaired urinary elimination related to unconscious status.

  20. Impaired bowel pattern related to unconscious status. • Risk for imbalanced fluid volume related to inability to ingest fluids, dehydration form osmotic therapy. • Risk for imbalanced nutrition related to inability to ingest food.

  21. Risk for impaired oral mucus membranes related to mouth breathing, and absences of pharyngeal reflex. • Risk for impaired skin integrity related to immobility or restlessness. • Risk for tissue integrity of cornea related to diminish/ absent corneal reflex.

  22. Care of unconscious patients

  23. 1.Maintaining airway • Position the patient in a lateral or semi prone position. • Do regular oral and nasal suctioning • Insert oral airway

  24. Administer oxygen as prescribed to deliver oxygenated blood to the brain. • Initiate chest physiotherapy and drainage. • Auscultate the chest 8 hourly to detect adventitious sounds.

  25. 2.Protecting the patient • Provide padded side rails and raised at all the time. • Prevent injury from invasive lines and equipments and potential source of injury (eg;restraints,tight dressing,enviorment irritants etc)

  26. 3.Maintaining fluid –electrolyte balance and managing nutritional needs • Assess the hydration status • Maintain hydration and enhance nutritional status with use of parenteral fluids. • Monitor circulatory status to measure circulatory adequacy or inadequacy

  27. Measure the I/O. • Intravenous solutions and blood products should be administered slowly in patient with intracranial conditions to prevent cerebral edema. • NG feeding for enteral nutrition

  28. 4.Maintaining healthy oral mucus membranes • Inspect the mouth for dryness, inflammation and presences of crusting. • Provide mouth care with appropriate solution every 2 to 4 hours

  29. If the client is intubated ET tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips.

  30. 5.Maintaining skin and joint integrity • Keep the skin clean, dry, well lubricated and free from pressure • Turn the patient from side to side on a regular schedule to relieve pressure areas and help clear lungs by mobilizing secretion

  31. Perform ROM exercise of extremities at least four times to prevent contracture. • Use special bed such as water or air beds.

  32. 6.Preserve corneal integrity • Some unconscious patients have their eyes open and have inadequate or absent corneal reflex. • If the eye remains open for long periods, cornea is likely to get irritated leads to ulceration and keratitis. • Irrigate the eyes with sterile saline or prescribed solutions to remove discharge and debrides.

  33. Instill prescribed ophthalmic ointments. • Apply eye patches; ensuring that eyes remain closed under the patch.

  34. 7.Achieving thermoregulation • Monitor for possible cause for infections. • Monitor core temperature continuously and treat hyperthermia promptly. • Maintain a cool ambient environment. • Administer prescribed antipyretics.

  35. Use cool-water sponging and an electrical fan blow over the patient to increase surface cooling. • Use hypothermic blanket • Frequent temperature monitoring

  36. 8. Promoting urinary elimination • Insert an indwelling urethral catheter • Monitor for fever or cloudy urine to identify any UTI.

  37. Initiate bladder training as soon as the consciousness is regained.

  38. 9.Promoting bowel function • Auscultate for bowel sounds and palpate lower abdomen for distention. • Observe for constipation due to immobility and lack of dietary fibre.Stool softner or laxative, scheduled or as needed.

  39. Monitor diarrhea resulting from infection,antibiotics,enteric feedings etc • Use fecal collection bag and provide meticulous skin care if patient has fecal incontinence.

  40. 10.Providing sensory stimulation • Sensory stimulation is provided at the appropriate time to help overcome the sensory deprivation of the unconscious patient. • Use physical touch and reassuring voice. • Talk to patient in a meaningful way even when the patient doesn’t not seem to respond. Assume the patient is able to hear even if unresponsive.

  41. Orient the patient periodically to person, time and place. • When arousing from unconscious state patient may experience a period of agitation. At this time it is necessary to minimize the stimulation to the patient .It can be done by • Limiting environmental stimuli(background noises) • Having only one person speak to the patient at time

  42. 11. Ongoing assessment of the patient status • neurologic status to evaluate the effectiveness of management.

  43. 12.Family education and support • Provide information and frequent update on the patient’s condition and progress. • Involve them in routine care, and teach procedures that they can perform at home. • Demonstrate and teach methods of sensory stimulation to be used frequently.

  44. Reference • Black M J, Hawks HJ.Medical Surgical Nursing.7th Edition. Missouri: Saunders Elsevier;2005 • Levis, Heitkemper, Dirksen, O’brien, Bucher.Medical Surgical Nursing.7th Edition.Missouri:Mosby;2007 • Brunner &Suddarth.Medical Surgical Nursing.10thedition. Philadelphia:Mosby;2004

  45. THANK YOU

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