ADVANCED NURSING PRACTICE

SEMINAR ON UNCONSCIOUSNESS

Introduction:

The word unconsciousness means loss of conscious state or active state of a person.

In our body the brain is responsible for conducting all activities and for consciousness reticular
activating system is responsible.

The reticular formation is composed of a complex network of grey matter ascending reticular pathways
and descending reticular pathways.

Its nuclei extends from the superior part of the spinal cord to the Diane cephalon and communicate with
basal ganglia cerebrum and cerebellum.

The reticular formation assists in the regulation of skeletal motor movements and spinal reflexes.

It also filters incoming sensory information to cerebral cortex about 99% sensory information is
regarded as essential. Only one component of reticular formation controls the sleep away cycle and
consciousness.

The brain system serves many functions in the body and like other body systems that monitor and
regulate a group of functions such as gastrointestinal tract regulates digestion The nervous system
monitors and regulates all other body systems.

Some of these functions are self protective and include the ability to think be awake response
appropriately to the environment and more about.

Other functions are automatic and include the regulation of body temperature and protective are are at
automatic and include the regulation of body temperature and protective reflex responses.

When these protective functions are lost the symptoms reflect the complexity of The nervous system
clients with the loss of protective functions may have mild symptoms such as the inability to move or
life-threatening since symptoms such as irreversible coma.

The brain requires a constant supply of oxygenated blood and glucose to function the interruption of the
supply will cause a loss of consciousness within a few seconds and permanent brain damage in minutes.

Ongoing assessment of patients neurologic function and health needs identification of problems mutual
goal setting development and implementation of care plans and evaluation of outcomes of care are
nursing actions integral to the recovery of the patient.

The nurse also collaborates with other members of the healthcare team to provide essential care of a
variety of solutions to problems help the patient and family in control of their lives and explore the
educational and supportive resources available in community.
The goals are to achieve as higher level of function as possible and to enhance the quality of life for the
patient with neurological impairment and his and her family.

DEFINITIONS OF CONSCIOUSNESS:

Consciousness is the state of being that has two components and important aspects wakefulness and
awareness to self others and time awareness of time include the past present and future.

Navdeep kaur brar

Consciousness is the state of being that has two important aspects wakefulness and awareness to self
others and time.

Shebeer p bhasheer

Consciousness is the patient's wakefulness and ability to respond to the environment level of
consciousness is the most sensitive indicator of the neurological function.

Brunner and suddarth

Consciousness is a state of being that has three important aspects wakefulness awareness of self
awareness of environment and time.

Wikipedia

Consciousness is the awareness of surroundings and respond to the questions and commands.

DEFINITION OF UNCONSCIOUSNESS:

Unconsciousness are alerted level of consciousness is a condition of living less responsive to and aware
less of environmental stimuli are needs persistent stimuli to achieve a state of alertness.

Navdeep kaur

Unconsciousness is a state of depressed cerebral function that results in abnormal loss of awareness of
self our surroundings.

Unconsciousness is a state in which there is a disrupt ascending reticular activating system which
extends from length of brainstem to the thalamus.

Significantly disrupt the function of both cerebral hemisphere.

Metabolically depressed overall brain function as in drug overdose.

KC rawath
Unconsciousness is an abnormal state resulting from the disturbance of sensory perception to the
extent that the patient is not aware of what is happening around him or her periods of unconsciousness
maybe momentary or may last for months.

Shebeer p basheer

Unconsciousness is an abnormal loss of awareness of self and surroundings its one set of both sudden
and gradual.

Wikipedia

ALTERED LEVEL OF CONSCIOUSNESS:

Altered level of consciousness is present when the patient is not oriented does not follow commands or
needs persistent stimuli to achieve a state of alertness and gauged on a continuum Vidya normal state
of alertness and ful cognition on one end and on the other end.

Altered level of consciousness is a condition of living less responsive to an awareness of environmental

stimuli on AIDS persistent stimuli to achieve a state of alertness or unconsciousness is a state of
depressed cerebral function that results in a abnormal loss of awareness of self our surroundings are
unconsciousness is a state in which there is

1. Disrupt ascending reticular system which extends from length of brainstem to the thalamus
2. Significantly disrupt the function of both cerebral hemisphere
3. Metabolically depressed oral brain functions as in drug overdose.

COMPONENTS OF ALTERED LEVELS OF CONSCIOUSNESS:

 Confusion
 Disorientation
 Lethargy
 Obtundation
 Excitatory
 Stupurous
 Fainting
 Somndents
 Drowsiness
 Coma
 Vegetative stage
 Brain death

A client who is awake alert and fully oriented to self others place and time is considered to be e fully
conscious from the normal alert state consciousness deteriorates in the stages.
 1. CONFUSION: loss of ability to think rapidly and clearly an important in judgement and decision
making
2. DISORIENTATION: beginning loss of consciousness disorientation of time followed by
disorientation to place and inability to recognise others the last step of disorientation is the
inability to know self.
3. LETHARGY: a lack of spontaneous movement are speech the client is easily aroused with speech
or touch but is not oriented to place person at a time.
4. OBTUNDATION: reduced ability to around unlimited response to the environment the client's
leaps and less stimulated with speech heart touch verbal response to question is minimal
perhaps anod
5. EXCITORY UNCONSCIOUSNESS: the patient does not respond coherently but is disturbed by
sensory stimuli such as bright light noise are sudden movements he may become excited are
agitated at the slightest disturbance.
6. STUPOR: in stupor patient response to external stimuli and shows the symptoms of annoyance
when stimulated by pinprick are loud noise such as clapping of hands.
7. DROWSINESS: which is familiar to all persons stimulates light sleep and is characterized by easy
arousal and the persistent of alertness for brief periods drowsiness and stupid are usually
accompanied by some degree of confusion.
8. FAINTING: in fainting there is a momentary loss of consciousness and the patient usually
recovers spontaneously
9. SOMNOLENT: a state when patient feels drowsy or sleepy or we can say it is a state between
sleeping and awakening
10. COMA: comma is a clinical state of unconsciousness in which the patient is unaware of himself
and his environment the patient may respond to deep painful stimuli in Deep coms, there is no
arousal no matter or verbal response to the environment or or any stimuli event deep pain or
suctioning.
11. VEGETATIVE STATE: vegetative state signifies and awake but non-responsive state in a patient
who has emerged from coma.
In the vegetative state the eyelids open giving the appearance of of wakefulness respiratory and
autonomic functions are retained. The prognosis for regaining mental abilities once the
vegetative state is declared is very poor and after a year almost nil hence the term as persistent
vegetative state.
It is a clinical condition of complete awareness of self and environment with damage to central
nervous system.
No chance to recover back

12. BRAIN DEATH: it is the last and CVS test characterized by a complete irreversible damage to the
cerebrum cerebellum and midbrain. The damage is so severe that there is no hope for recovery and the
client's life must be maintained with a respiratory vasoactive drugs

Brain death occur when there is no discernible evidence of cerebral activity are brain stem activity.

PREDISPOSING FACTORS
 These factors include

1. Stress-vasodepressor syncope
2. Impaired physical status
3. Restriction or injection of drugs-LA drugs
Analgesics antianxiety agents CNS the present leading to alterations in consciousness
When a patient with impaired physical status is exposed to physiological psychological
stress that answer even greater than the patient may react adversely to the situation.
PATHOPHYSIOLOGY

Structural lessons

Due to any logical factors example semi durall hemorrhage cerebellar hemorrhage

There will be damage to the brain and skull which is the primary injury to the brain which
leads to the edema inflammation and hemorrhage that is secondary injury to the brain which
further leads to the increase in intracranial pressure hours to days which diffuse and damage to
the cerebrum Corpus callosum and brain stem which then leads to disruption of the reticular
activating system finally ends up in the the state of unconsciousness.

METABOLIC DISORDER AND DIFFUSE LESSON

Due to any tailors kal factors and diffuse lesson respiratory disorders there will be decrease
in oxygen concentration leads to cerebral hypoxia po2+25 mm HG which then leads to
impairment in CNS cell function for the lead to disruption in cerebral function which gives rise
to disruption in reticular activating system finally leads to unconsciousness in liver disease there
will be decrease in blood sugar sodium osmolar imbalance and cerebral hypoglycemia
impairment in CNS then disruption in in cerebral function and finally on consciousness

In case of neurological disorders there will be decrease in blood supply to the brain tissue leads
to cerebral ischemia and impairment and disruption of cerebral function finally disruption in
reticular activating system then unconsciousness.

CLINICAL MANIFESTATIONS

Respiratory system:

Stridor: yah harsh vibrating noise when breathing wheeze like sounds caused by obstruction of
the windpipe or larynx.

Rales: small clicking bubbling sounds in the lungs they are heard when a person inhales
Ronchi: sounds that resembles knowing that occur when area is blocked are a floor becomes
rough through the large airways

Progressive cyanosis: cyanosis is a bluish are purplish discoloration of the skin or mucous
membrane.

Patients with a large ducts develops progressive pulmonary vascular disease and pressure
overload

Chinese stroke respiration: Chinese stroke respiration is also known as periodic respiration is
an abnormal pattern of breathing.

Cardiovascular system:

Bradycardia: Brandus- slow; kardia ; heart normally slow heart action

Hypertension: it is a medical term for low blood pressure less than 90/60 mmHg

Ventricular tachycardia: a condition in which the lower chambers half heart beat very quickly

Atrial fibrillation: atrial fibrillation is an irregular and often rapid heart rate that occurs when
two upper chambers of heart experience chai otic electrical signals HR is 100 to 175b/min

Hypokalemia: increase of potassium levels in blood high potassium in blood

Neurological system:

Asterexis: asterexis is a clinical sign that described in ability to maintain and sustain posture
with subsequent brief shop like involuntary movements.

Myoclonus: it refers to a quick involuntary muscle jerk hiccups are the form of myoclonus as
our sudden jerks or sleep starts.

Seizures: seizure is a burst of uncontrolled l electrical activity between brain cells and neurones

It can cause changes in your behaviour movements are feelings and in loss of consciousness

Cranial nerve palsy: epilepsy is a lack of functioning of a nerve a cranial nerve palsy may cause a
complete or partial weakness or parallel paralysis of the areas served by the affected nerve.

Lethargy: a condition marked by drowsiness and unusual lack of energy and mental alertness
caused by illness injury or drugs

Gastrointestinal system:
Abdominal: it is usually used to refer distension or swelling of abdomen and not of stomach
itself related to digestion and absorption etc.

Decreased bowel sounds: decreased are absent of bowels sounds of an indicate constipation.

Urinary system:

Urinary incontinence: loss of bladder control

High creatinine index: elevated creatinine impaired kidney function

Oliguria: decrease in urine production

Ketonuria: excretion of ketone bodies in urine that is diabetes mellitus

UTI: urinary tract infection.

DIAGNOSTIC FINDINGS

CT scan (computed tomographic scan): a computerized tomographic scan combined series of

X-Ray images taken from different angles and uses computer processing to create cross-
sectional images slices of the bones blood vessels and soft tissues inside your body.

CT scan image provide more detailed information than plain X Ray

MRI-magnetic resonance imaging: it usually provides data that indicate whether the cause of
the coma is structural

Tumors are areas of bleeding will be evident on the scan

Sometimes the patient will require emergency surgery to remove the mass or drain the
fluid and thereby released pressure

Lumbar puncture: it can be done in patients when it is known from data provided by the CT
are MRI scan that there is no expanding intracranial man.

Lumbar puncture can assist with the diagnosis of infection or bleeding as cause of coma.

CISF may be cloudy are bloody when the client has an infection or bleeding into the
ventricular or the sab arachnoid space l4 and l5 region.

EEG electroencephalogram: it can be used to determine whether the patient is comatose

because of continuous seizure
 Results are abnormal in many patients in metabolic coma and do not serve as a clear
diagnostic tool.

Hematological:

Complete blood count

BSL

Level of drugs in blood example aspirin

Intracranial pressure: combined volume of three cranial components

Blood

CSF

Brain tissue

Normal ICP is 5 to 15 mmHg

MANAGEMENT

First aid: call are tell someone to call

1. Check the person's airway breathing and pulse frequently if necessary begin rescue
breathing and CPR
2. If the person is breathing and lying on the back and you don't think there is a spinal
injury carefully roll the patient towards one side. Banda top legs so both hip and knee
are at right angles gently tilt the head back to keep the airway open. Is breathing or
pulse stops at the anytime roll the person onto his back and begin CPR
3. If you think ok there is a spinal injury leave the person found as long breathing
continuous. If the person vomits roll the entire body at one time to the side. Support the
neck and back to the keep head and body in the same position while you roll.
4. Keep the person warm until medical help arrives
5. If you see a person fainting try to prevent hair fall lay the person flat on the floor and
raise the feet about 12 inches
6. If fainting is likely due to low blood pressure give the person something sweet to eat and
drink when consciousness returns.

DO NOT:

Do not give any food or drink

 Do not leave the person alone

.. do not place a pillow under the head of the person

Do not slap and consciousness person face or splash water on face to try to receive him.

Call immediately for emergency medical assistance:

If if the person is unconscious

 Is not breathing
 Does not return to consciousness quickly within a couple of minutes
 Fell down or has been injured especially if bleeding
 As diabetes
 Is pregnant
 Over 50 years of age
 Feels chest pain in chest pressure chest discomfort or has a founding or irregular heartbeat
 Can't speak has vision problems
 Can't move the arms or legs
 Has seizes
 Loss of bhawal control

EMERGENCY NURSING CARE: clues and cause of unconsciousness

NBM

Loosen clothes

Ease breathing by turning head to side

. Keeping next right chin forward

Drain and clean mouth secretions

Remove artificial teeth if any

Keep warm and comfortable

Observe loss of consciousness

Keep his extremities and joints in a functional position

It is important to remember that hearing sense is the last one to go and first one to come back so
avoid necessary talk.

MEDICAL MANAGEMENT:
  Obtain and maintain airway
 Insert oral airway
 Monitor circulatory status to ensure adequate perfusion to the body and brain
 Central line catheterization
 Foley's catheterization
 Ryles tube insertion
 Prevention of complication

SURGICAL MANAGEMENT:

 Craniotomy
 Shunting ; CSF drainage
 Decompressive surgery; removal of skull part, allow a swelling brain to expand without
being squeezed.
 Most cases of coma cannot be cured by surgery alone but if the cause of the comma is
bleeding or tumor within the brain the patient will require emergency ICP monitors may
also be placed.
 A ventricular catheter aur Shunt may be placed to relieve hydrocephalus.

PREVENT COMPLICATIONS:

Is coma is prolonged initiate enteral feeding to promote nutrition and prevent muscle
wasting.

Parenteral nutrition may be used if paralytic ileus is present.

 Take care to avoid hyperglycemia

 Immobility
 Suctioning may be needed to keep the airway clear and prevent pneumonia
 Passive range of motion exercises keeps the joints mobile and minimises the muscle
wasting.

NURSING MANAGEMENT OF UNCONSCIOUS PATIENT:

A. FLUID AND ELECTROLYTE BALANCE

 Intech and output charge should be ee meticulously maintained

 Assess and document symptoms that may indicate a fluid volume overload a deficit
 Diuretics maybe prescribed to correct fluid overload and reduce edema
 Hydration and IV fluids with glucose are always avoided in comatose patients as cerebral
edema may follows.
B. SkIN INTEGRITY:

 The nurse should provide intervention for all self care needs including bathing hair
care skin care and nail care
 Frequent back care should be given
 Comfort devices should be used
 Position should be changed
 Special mattresses or air beds to be used
 Adequate nutrition and hydration status should be maintained
 Patients nails should be kept trimme protective ICS can be applied to prevent corneal
abrasions and irritation
 Inspect the oral cavity
 Keep the lips coated with a water-soluble lubricant to prevent encrustation drying
cracking
 Frequent oral hygiene every fourth hourly
 Nasal passage maggot occluded so they may be cleaned with a cotton tipped applicator.

C. PROPER POSITIONING:

 Lateral position on a pillow to maintain head in neutral position

 Upper arm position 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 to 4 hours taking care and to prevent
injury to soft tissues and nerves edema are disruption of the blood supply.
 Maintaining correct positioning enables secretions to drain from the clients mouth the
tongue does not obstruct the airway and postural deformities are prevented

D. SELF CARE DEFICIT:

 Attending to the hygiene needs of unconscious patient should be never become

ritualistic and despite the patient's perceived lack of awareness dignity should not be
compromised.
 Involving the family in self care needs
 Fingernails and toenails also need to be assessed
 Chronic illness such as diabetes needs more attention
 Minimum to nurses should bathe and unconscious patient as turning the patient may
block the airway
 Hair care should not be neglected

E. ORAL HYGIENE:
  A chlorhexidine /potassium permanganate solution is used
 Railway should be removed when providing oral care it should be cleaned and then re
inserted
 If the patient has an endotracheal tube then the tube should be fixed alternately on
each side.
 Minimum of four hourly care to be reduce the potential of infection from
microorganisms
 Also not to damage the the gingiva by using excessive force

F. EYE CARE:

 In assessing the eyes observe science of irritation corneal driving aberrations and
oedema
 Dental cleaning with gauze and 0.9% sodium chloride should be sufficient to prevent
infection
 Artificial tears can also be applied as drops to help moistens the eyes
 Corneal damage can result if the eyes remain open for a longer time

G. NUTRITION NEEDS:

 TPN-total parenteral nutrition

 Enteral feeding via NG, Naso jejunal or PEG tube
 IV fluids are administered for comatose patients

H. RISK FOR INJURY:

 Side rails must be kept whenever the patient is not receiving direct care
 Seizuress precautions must be taken
 Adequate support to limbs and head must be given when moving are turning and
unconscious patient.
 Protect from external source of heat
 Over sedations should be avoided
 Assess the need for restrain

I. IMPAIRED BUBBLE ARE BLADDER FUNCTIONS:

 Assess for constipation and bladder distention

 Auscultate bowel sounds
 Stool softener or laxatives may be given
 Catheterization may be done
 Catheter care must be provided under aseptic techniques
  Monitor the urine output and colour
 Initiate bladder training as soon as consciousness has regained

J. RISK FOR CONTRACTURES:

 Maintained the extremities in functional positions by providing proper support

 Remove the support devices every four hours for passive and ROM exercise and skin
care
 Foot support should be provided

K. SENSORY STIMULATION:

 Brain need sensory input

 Widely believed that hearing is the last sense to go
 Talk explain to the patient what is going on
 Upon walking make lions remember and will accurately recall events and process that
happen while they were sleeping unconscious

L. NURSES MUST:

 Show respect
 Encouragee family to contribute to the care at their loved ones
 Effort the privacy both the clients and family deserve

M. ENCOURAGE STIMULATION BY:

 Massage
 Combing/washing hair
 Playing music or radio or CD aur TV
 Reading a book
 Bring in perfumed flowers
 Update them with family news

N. IMPAIRED FAMILY PROCESS:

 Include the family members in a patient care

 Communicate frequently with the family members
 The family members should be allowed to stay with the patients when and where it is
possible
 Use external support systems like professional counselors religious etc...
 Clarifications and questions should be encouraged.