CARE OF PATIENTS WITH VARIOUS LEVELS OF UNCONSCIOUSNESS

DEPARTMENT OF NURSING

3RD COHORT

BY

GROUP 4

COURSE TITLE AND CODE: Objective structured clinical examination (OSCE)

MAY, 2023.
 GROUP MEMBERS

S/N GROUP MEMBERS MAT NUMBER

1 Ehioghae Praise Aisosa 00229

2 Masade Ebehireme Matilda 00234

3 Faith Jamani Omokhose 00233

4 Ahakon Ideiyemi 00236

5 Okoh Diana 00235

6 Idehen Jonathan 00227

7 Ogaluonye Precious 00288

8 Osaro Becky 00231

9 Akpovire-Akpobi QueenEsther 00228

10 Abdulrahman Fadhilatu 00232

11 John Osasenaga Judith 00301

12 Edenojie Omotese 00143

13 Obaidiku Daniel 00282

Definition
Consciousness describes our awareness of internal and external stimuli. Awareness of internal
stimuli includes feeling pain, hunger, thirst, sleepiness, and being aware of our thoughts and
emotions. Awareness of external stimuli includes experiences such as seeing the light from the
sun, feeling the warmth of a room, and hearing the voice of a friend.Consciousness refers to our
awareness and perception of ourselves and the world around us. It's like being awake and aware
of our thoughts, emotions, and experiences.

Definition Of unconsciousness
Unconsciousness refers to a state of being where a person is not awake or aware of their
surroundings. It can be caused by various factors such as trauma, illness, or anesthesia. When
someone is unconscious, they are not responsive to stimuli and are unable to consciously
perceive or interact with the world.
Unconsciousness is a physiological state in which the patient is not responsive to sensory stimuli
and lacks awareness of self and the environment.

CHANGES IN LEVEL OF CONSCIOUSNESS

An altered level of consciousness (LOC) is a state in which a person experiences a change in
their level of alertness and awareness. LOC can be caused by various factors such as illness,
injury, or medication. Some symptoms that may indicate that someone is experiencing an altered
level of consciousness include stupor, confusion, disorientation, delirium, lethargy, and coma.
STUPOR
Stupor can be a serious mental state where people don’t respond to normal conversation. Instead,
they respond only to physical stimulation, such as to pain or rubbing on their chest, which is
known as a sternal rub.
What Are the Symptoms of Stupor?
Someone experiencing stupor can be aroused or woken up with vigorous stimulation. Symptoms
include:
-minimal response to vigorous stimuli
-abnormal breathing, such as breathing too slow or fast
-muscles contracted in abnormal ways
-pupils that are wider or smaller than normal
DELIRIUM
Delirium is a sudden change in your alertness and thinking. People with delirium typically
become confused and have trouble paying attention.
Symptoms include:
-Having hard time concentrating or feel confused
-sudden changes in ability to carry out everyday activities, like eating or walking
-difficulty remembering recent events
-becoming agitated or paranoid, hallucinations, delusions
-unstable heart rate and blood pressure
COMA
Coma is the deepest level of impaired consciousness. It is a prolonged state of unconsciousness
which occurs when a temporary or permanent disruption of the brain’s function severely affects
consciousness. This damage results in:
unconsciousness, inability to awake, unresponsiveness to stimuli, such as pain, sound, and light.
Important functions like breathing and blood circulation are impaired in most cases, hence
patients are supported with medication or other interventions, such as airway pressure or
mechanical ventilation.
What are the symptoms of a coma?
A coma is diagnosed when a person has remained in a state of decreased consciousness and
meets certain criteria, such as:
-Unresponsiveness to all stimuli
-may lack gag reflex and pupil response
-irregular breathing
-no response of limbs, except for reflexes
-no response to pain, except for reflexes

Causes of Unconsciousness
Unconsciousness can result from the various underlying reasons
1. Shock
2. Asphyxia
3. Poisoning
4. Cerebro-Vascular Accident or Stroke
5. Haemorrhage
6. Low blood sugar
7. Traumatic brain injury
8. Ischemic stroke
7. Intracerebral hemorrhage
8. Subarachnoid hemorrhage
Stages of unconsciousness

There are five stages of unconsciousness.

• full consciousness with some impairment

• a minimally conscious state

• a confusional state

• a vegetative state

• a coma

People in vegetative states and comas are fully unconscious. People in minimally conscious
states may have some level of consciousness that comes and goes.

People usually enter into vegetative states and comas due to an illness or injury to the brain.
People may enter minimally conscious states by fainting or blacking out, and this is usually more
temporary.

Using Glasgow coma scale ( GSC)

GCS Scoring System
Eye responses
4 = Eyes open spontaneously
3 = Eyes open to verbal command
2 = Eyes open to pain
1 = No eye opening
Motor responses
6 = Obey commands
5 = Localize pain
4 = Withdrawal from pain
3 = Flexion response to pain
2 = Extension response to pain
1 = No motor response
Verbal responses
5 = Oriented to person place and time
4 = Confused
3 = Inappropriate words
2 = Incomprehensible sounds
1 = No verbal response

GCS 8 or less = Severe

GCS 9 to 12 = Moderate
GCS 13 to 15 = Mild

General examination of an unconscious patient

Coma is a state of unconsciousness caused by temporary or permanent impairment of the
ascending reticular system in the brainstem, or both cerebral hemispheres.
The key components of the neurological examination of the comatose patient are:
ABC'S
When assessing an unconscious patient, the initial step is to check for vital signs , this involves
examining for a pulse and ensuring the airway is clear and that there is a regular breathing
pattern. If the patient lacks a pulse or exhibits an irregular breathing pattern, it necessitates
initiating basic or advanced cardiovascular life support. Consequently, the evaluation shifts to a
general physical and neurological examination for patients with a pulse and breathing
effectively.
Responsiveness
One should assess an individual's reactivity using objective measures to measure responsiveness.
The person examining should start by addressing the patient verbally, then advance to gentle
shaking and more intense mechanical stimulation. Adequate discomfort can be induced by
applying sufficient stimulus to areas such as the supraorbital ridge or the nail beds without the
risk of causing tissue injury. In the case of a focal spinal cord lesion, it is important to grade the
response to these painful stimuli bilaterally. If these measures fail to elicit a response, the
examiner should firmly press their knuckles up and down the sternum, thereby awakening any
patient not in a profoundly comatose state.
The unconscious patient presents an challenging emergency in the intensive care unit. The
physical and neurological examination should be performed in a efficient way and must consider
the following eight points: best reaction to loud commands, best motor reaction to noxious
stimuli, respiratory pattern, size and reactions of pupils, eye movements, corneal and blink
reflex. muscle tone and deep tendon reflexes. With this approach it is possible to formulate a
working diagnosis, and the appropriate diagnostic steps can be performed.
Next is to evaluate using the GCS scoring system.

CHANGES THAT OCCURS IN AN UNCONSCIOUS PATIENT

During unconsciousness, several changes can occur in the body, such as altered breathing
patterns, decreased responsiveness to stimuli, changes in blood pressure and heart rate, and loss
of muscle tone. The specific changes depend on the cause and duration of unconsciousness.
Changes that occurs in posture: When someone is unconscious, their posture typically becomes
flaccid, meaning their muscles lose tone and tension. This can lead to a limp, relaxed posture,
often with arms and legs flopping down rather than being actively positioned. However, in some
cases, there may be involuntary muscle contractions or spasms, causing the body to twitch or
jerk. The exact posture changes can vary depending on the individual and the circumstances of
their unconsciousness.
Changes that occurs on the skin: For an unconscious patient, changes in skin appearance and
condition can occur due to decreased blood circulation and pressure on certain areas of the body.
These changes may include:
1. Pallor: The skin may become pale due to reduced blood flow.
2. Mottling: Irregular patches of skin discoloration may occur, often appearing as a marbled
pattern, due to poor circulation.
3. Pressure ulcers: Prolonged pressure on certain areas of the body, especially bony prominences
like the back, buttocks, heels, and elbows, can lead to the formation of pressure ulcers (also
known as bedsores).
4. Coolness: The skin may feel cool to the touch due to decreased circulation.
5. Sweating: In some cases, unconsciousness can trigger sweating, especially if the body is trying
to regulate its temperature or responding to stress.

When a person is unconscious, there are several changes that can occur in the pupils and motor
responses. These changes are as follows:
* Pupillary response: The pupils may become fixed and dilated, which means that they do not
respond to light. This is known as a "fixed and dilated" pupil response.
* Motor response: The muscles may become flaccid, meaning that they are unable to contract.
This can result in a loss of muscle tone and increased flexibility.
* Reflexes: The reflexes may become diminished or absent, which means that they do not
respond to external stimuli.

NURSING MANAGEMENT OF UNCONSCIOUSNESS

The care plan involves:
1. Maintaining patient’s airway: Maintain the patient in a position that keeps the airway open,
such as lateral recovery or head-tilt/chin-lift for those without a spinal injury. Use oropharyngeal
or nasopharyngeal airways to prevent airway obstruction. Regular suctioning to prevent
aspiration and Administer oxygen.
2. Protecting the patient from falling off the bed
3. Maintaining fluid balance and managing nutritional needs: Establish reliable intravenous
access to administer fluids, medications, and other treatments.
4. Maintaining skin integrity
5. Preventing urinary retention
6. Incontinence care
7. Providing sensory stimulation: Speak to the patient during care activities to provide familiar
auditory stimuli, even if they appear unresponsive. Introduce gentle sensory stimulation, like
soft music, tactile contact, or familiar voices, to maintain some level of environmental
engagement.
8. Identifying potential complications (Respiratory Distress, Pneumonia, Bed Sores):
continuously track heart rate, blood pressure, respiratory rate, and oxygen saturation. Reposition
the patient every 1-2 hours to prevent pressure injuries. Document the positions used and times
of repositioning.Use of Pressure-relieving devices and Inspect the skin regularly for signs of
pressure injuries. Apply barrier creams and ensure cleanliness.
9. Medication Management
10. Specialized diet management e.g Enteral and Parenteral Nutrition. In cases where enteral
feeding is not possible, consider total parenteral nutrition (TPN). Administer IV fluids to
maintain hydration, monitoring electrolyte balance.
11. Support To Family: Provide emotional support to family members, and guiding them through
the care process. Encourage family members to engage with the patient, maintaining a sense of
connection.
12. Physiotherapy
13. Assessing Progress
14. Effective documentation and communication
 SUMMARY/CONCLUSION

In summary, a patient can go through different levels and stages of both consciousness and
unconsciousness. It is therefore the nurses duty to cater for their needs throughout these stages
with help from the GCS scoring system and care for them till full health.
 REFERENCE

1. Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th

ed.). Wolters Kluwer Health.

2. Level of Consciousness: Bickley et al., 2021

3. Openstax.org. Oloriegbe, O. (2023). Explicit of medical surgical nursing (3rd ed.).

Nigeria. Ruyi print.
4. Sanctus Healthcare. (n.d.). Care of unconscious patient. [2023].
https://sanctushealthcare.com/services/care-of-unconscious-patient/

5. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical

scale. Lancet. 1974 Jul 13;2(7872):81-4. [PubMed]

6. Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a
new coma scale: The FOUR score. Ann Neurol. 2005 Oct;58(4):585-93. [PubMed]