Monitoring the unconscious patientLam Sai Chu SindyN.O. AHNH

Unconscious patientPatient makes no appropriate response to stimuli either external (pain) or internal (thirst)

Stage of unconsciousnessSomnolence - state of unconsciousness from which patient can be fully awakened

Stupor - state of unconsciousness from which patient can be awakened to produce inadequate responses to verbal & physical stimuli

Stage of unconsciousnessComa - state of unconsciousness from which patient who appears to be asleep, cannot be aroused by verbal and physical stimuli to produce any meaningful response

Cause of unconsciousnessPoisons & drugVascular causesInfectionSeizuresOthers

Objectives in monitoringAssess adequacy of vital organ functionFollow course of acute illnessAssess patient discomfort and effect of measuresTrack the effects of therapeutic interventionsDetect complications and other adverse event

Objectives in monitoringDetermine the need for interventionsAssess the performance of monitors and support devicesDetect readiness for and predict success of therapeutic interventionsEvaluate patients nutritional / metabolic state

Adverse effects of monitoring To patientpainuncomfortable positiondiscomfort restricting movementInconvenience and distress for family

Adverse effects of monitoringDiversion of caregivers attention away from patient

Noise pollution for both patient and staff

Physiological FunctionOxygenation CirculationNeurological functionNutritionFluids & electrolytes Elimination

Physiological FunctionPhysical activity & restSensesSkin IntegrityEndocrine functionPsychosocial state

Scenario 1A 45 year old woman was taken to hospital after falling 40 feet from the second floor. On arrival at hospital, RR 18 / minute, PR 100 / minutes, BP 145/90 mmHg, T 35.5 C, GCS - 6, pupils - equal and reacted sluggish to light, compound Rt. tibial fracture. After CT scan, she was admitted to ICU after wound debridement, insertion of subdural ICP monitor

Oxygenation - AirwayPatencyPosition of ETTMonitor taping of ETT - too tight or not+/- suction

BreathingBreath soundsCoping with ventilationPresence of spontaneous breathingAmount of sputumPresent of gap / cough reflex

Circulation and Cerebral PerfusionECG ( rate, rhythm and presence of ectopic beat)Blood pressurePulses (peripheral) & capillary refillPresence of bleedingLevel of consciousness, responsiveness

Neurological functionLevel of consciousnessPupil sizeICP monitorGlasgow Coma ScaleSedation level

Glasgow Coma ScaleBest Ocular Response

Open spontaneously 4Open to verbal command 3 Open to pain 2No response 1

Glasgow Coma ScaleBest motor responseObeys verbal command 6Localizes pain 5Flexion withdrawal 4Abnormal flexion 3 Abnormal extension 2No response 1

Glasgow Coma ScaleBest verbal responseOriented and converses 5Disoriented and converses 4Inappropriate words 3Incomprehensible sounds 2No response 1

Ramsay Sedation ScoreAwake levels1.anxious and agitated or restless2.co-operative, oriented and tranquil3.responds to command only

Ramsay Sedation ScoreAsleep level (response to glabellar tap or loud auditory)4.brisk response5.sluggish response6.no response

Fluids and Electrolytes IV fluids, IV line patency, Urine outputDrain - NG tubeSerum albumin level

Skin IntegritySign of edemaSign of dehydrationWound conditionSign of infectionPersonal hygieneSkin protection

Sensory-perceptual functionPain scoreHearing sensationDiscomfort Thirst

Psychosocial StateAnxiety / worryDepressionAgitation / restlessness

ICU Patients lamentDont monitor me - my wedge pressures fineMy QRS complex is not a straight lineI dont have a pneumo or sepsis or gout;At least if I do, I dont want to find out.Your fancy new gizmos and beepers and light.Are vaulting my bill up to unforeseen heights. Theypoke me and probe me and add to my stress.

ICU Patients lamentBut whether they help me is anyones guess.They havent been tested to see if they work,But using them youve gone completely berserkNo one asks me how it feels here in bed ----you spend all your time with my data instead.I want to be cared for, and comforted too.But that doesnt happen with all that you do

ICU Patients lamentSo go somewhere else with your new expertise ----Dont monitor me, just leave me in peace!

Hudson LD. Monitoring of critically ill patients : conference summary. 1985