Shalini Joshi

8/13/2019 Shalini Joshi

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Subject :- advanced nursing practice

Assignment

on

unconciousness

Submitted to submitted by

Mrs.Aparna Shalini Joshi

(Lecturer) M.Sc.nursing 1styear

Submitted on

19/11/201


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index

s.No. Content Page no.

1 Introduction 1

2 Definition 1

3 Meaning of unconsciousness 1

4 Levels of unconsciousness 1-2

5 Causes 2-3

6 Pathophysiology 4

7 Sign and symptoms 5-6

8 Complications of unconsciousness 6

9 Assessment 7-9

10 Management

-medical

-surgical

-nursing

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INTRODUCTION

Unconsciousness: Loss of consciousness that may result from a wide variety of

causes. An unconscious person is usually completely unresponsive to their environment or

people around them. Unconsciousness can occur as a result of brain injury, lack of oxygen or

poisoning as well as numerous other conditions.

Nursing the unconscious patient can be a challenging experience. unconscious

patient have no control over themselves or their environment and thus are highly dependent

on the nurses. The skill required to care for unconscious patient are not specific to critical

care. With good knowledge base nurse initiate the assessment, planning and implementation

of quality care.

DEFINITION

A state of impaired consciousness in which one shows no responsiveness to environmental

stimuli but may respond to deep pain with involuntary movements.

Medical dictionary

Or

A state in which the cerebral functions are decreased, the individual are unresponsive to

sensory stimuli.

Or

an abnormal state of lack of response to sensory stimuli, resulting from injury, illness, shock

or some other bodily disorder.

Or

By dictionary meaningUnconsciousnessis the condition of being notconsciousin

a mental state that involves complete or near-complete lack of responsiveness to people and

other environmental stimuli. Being in a comatose state orcomais a type of unconsciousness.

Fainting due to a drop in blood pressure and a decrease of the oxygen supply to the brain is a

temporary loss of consciousness.

-From Wikipedia

Or

Unconsciousness is a state of complete or partial unawareness or lack of response to

sensory stimuli as a result of hypoxia caused by respiratory insufficiency or shock; from
http://en.wikipedia.org/wiki/Consciousnesshttp://en.wikipedia.org/wiki/Consciousnesshttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Consciousness


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metabolic or chemical brain depressants such as drugs, poisons, ketones, or electrolyte

imbalance; or from a form of brain pathologic condition such as trauma, seizures,

cerebrovascular insult, brain tumor, or infection. Various degrees of unconsciousness can

occur during stupor, fugue, catalepsy, and dream states.

MEANING OF UNCONSCIOUSNESS

The word unconscious means a person is lacking awareness and the capacity for

sensory perception as if asleep or dead. This word describes a person who has passed out due

to sickness. It can also be defined as a dramatic alteration of mental state that involves

complete lack of responsiveness.

LEVELS OF UNCONSCIOUSNESS

Excitatory unconsciousness Stuporous Fainting Somnolent Coma Vegetative stage

Exicitatory unconsciousness

Does not respond coherently but is disturbed by sensory stimuli such as bright light, noise.

Stupor

In stupor, patient responds to external stimuli and shows the symptoms of annoyance when

stimulated by pinprick or loud noise such as clapping of hands.

Fainting

In fainting, there is a momentary loss of consciousness and the patient usually recoversspontaneously Somnolent a sate when patient feels drowsy or sleepy or we can say it is a

state between sleeping and awakening.

Coma

Coma 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 coma, there is no

arousal.

Vegetative state


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Clinical condition of complete unawareness of self & environment with damage to CNS, No

chance to recover back.

CAUSES

Unconsciousness is when a person suddenly become unresponsive. he or she will not be ableto communicate and will not respond to stimulation. unconsciousness can be brought on by a

major illness or injury, or complication from drug use or alcohol abuse.

A person may become temporarily unconscious when sudden changes occur within

the body. common causes of temporary unconsciousness include:

-low blood sugar

-low blood pressure

-syncope

C-erebral:

-haemorrhage

-infarction

-tumour

-infection

-trauma

O-verdose

-alcohol

-alcohol withdrawal

-drugs

.sedatives

.narcotics.

.psychotropic

-poisons

.CN

.CO

-venom-snakes

M-etabolic

-endocrine

.hypoglycaemia

.hyperglycaemia

-environmental

.hypothermia

.hyperthermia

-organ failure

-electrolytes

-acid-base disorders

-vitamine deficiencies

-sepsis

A-

-arrhythmia

-asphyxia

-anaemia

-any cause of shock


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-dehydration

-problems with heart rhythm neurologic syncope(caused by a seizure)

-straining

-hyperventilating

PATHOPHYSIOLOGY

Due to any cause

Changes in cardiovascular system,

Decrease venous return and delayed loading

Decrease cardiac out put and

Increased cardiac workload

Insufficient oxygen and nutrition supply

(Deprivation)

Insufficient tissue perfusion

Alteration in cell/tissue functioning

Multi organ dysfunction


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Sign and symptoms of unconsciousness

Signs (that a person may become unconscious)-sudden inability to respond

-slurred speech

-a rapid heart beat

-confusion

-dizziness or light headness

Symptoms1-unresponsiveness

2-lack of awareness of self

3-lack of awareness of surrounding

Systematically clinical manifestation

RESPIRATORY SYSTEM

Stridor rales rhonchi progressive cyanosis cheyne stokes respiration Assymetrical chest wall movements decreased respiratory rate, decreased depth

CARDIOVASCULARSYMPTOMS

Bradycardia Hypotension Ventricular tachycardia Atrial fibrillation Hyperkalemic Arrythmias Decreased cardiac output


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NEUROLOGICAL SYSTEM

Asterexis

myoclonus

seizures

cranial nerve palsies

lethargy

unequal pupillar dialation

absent deep tendon reflexes

absent dolls eye reflex

GASTROINTESTINAL SYSTEM

Due to the disruption of CN -10th (vagus) function Abdominal distension Decreased bowel sounds Constipation Ascites Hyperlipedemia

Urinary system

Urinary incontinence High creatinine index Oliguria ketonuria UTI& Pyuria

Complications of unconsciousnessPotential complications of being unconscious for a long period of time include:

1-coma

2-brain damage

3-chocking

4-injuries

5-respiratory compromises


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Assessment

First of all make sure quickly that they are unconscious and not just asleep. Primary care is

exactly the same as basic life support airway breathing circulation.

1-history collection:

Historyshould be obtained from whatever sources are available, including friends,bystanders, police, and EMS personnel.Accurate and early identification of poison(s),

time of ingestion, vomiting history etc can critically assist in management.Crucial points

include the following:

recent head trauma, even seemingly trivial drug use (including alcohol), recent or past past medical history, including a history of seizures, diabetes, cirrhosis, or other

neurologic disease precomatose activity and behaviour (headache, confusion, vomiting) sudden versus gradual onset of coma other individuals with similar symptoms (indicates food poisoning, carbon monoxide

poisoning, bioterrorism etc..)

scenario- location/environment, suicide note, pills/bottles etc. Present family history social history and personal history

2-Physical examination


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Neurologic assessment in unconscious patients is of paramount importance, and a

structured evaluation should be conducted as soon as possible once immediate threats

to life have been addressed. Although originally developed for traumatic brain injury,

the Glasgow Coma Scalehas been shown to have predictive value in many different

types of coma. Both total and component (eye, verbal, motor) scores should be

documented:

.

Cranial nerve examination (especially papillary response) is an essential part of the

neurologic examination and may assist in determining the level of brainstem dysfunction.

Symmetrically reactive pupils that are unusually large or small are commonly secondary to

drug ingestions.

Diagnostic evaluation

1-Laboratory Evaluation


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o Electrolytes, LFTs, CBC, UA, urine/serum toxicology screens, thyroid functionstudies, BUN/Cr, and ABG should be obtained early in the evaluation of coma.

o Lumbar puncture and CSF analysis should be performed if not contraindicated (e.g.,mass lesions or other evidence of increased ICP) in patients for whom the cause of

coma is unclear or in whom an infectious cause is suspected.

o ECG should be obtained and cardiac monitoring instituted to eliminate cardiacarrhythmias as a contributing factor.o An EEG should be obtained when possible, especially in intubated patients receiving

paralytics and in those for whom nonconvulsive status epilepticus is a consideration.

2-Imaging

Not indicated when unconsciousness is obviously relate to hypoglycaemia, overdose or other

metabolic causes, but a noncontrast head CT is an integral part of the workup for coma and

should be strongly considered in any patient who remains comatose after dextrose and

naloxone.

3-MRI

Types of tissue, Tumors, Vascular abnormalities, Intracranial bleeding can be easily assessed.

4- LUMBAR PUNCTURE

Cerebral meningitis, CSF evaluation

5-EEG :- Electrical activity of cerebral cortex layer

Management

Medical management

Obtain And Maintain Airway. Insert oral airway Monitor Circulatory Status To Ensure Adequate Perfusion To The Body And

Brain.

Central Line Catheterization Foleys Catheterization Ryles Tube Insertion Prevention Of Complication

Empiric therapy,

Often referred to as the "coma cocktail, " consists of IV dextrose, thiamine, naloxone.


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Naloxone (0.42.0 mg IV) rapidly reverses coma and respiratory depression secondary to

narcotic overdose but has a short half-life and multiple doses may be required.

Dextrose (50 mL of 50% solution in adults) reverses coma secondary to hypoglycemia and is

indicated if rapid testing of blood glucose is unavailable.

Thiamine (100 mg IV) is commonly given along with dextrose to avoid precipitating

Wernicke encephalopathy in predisposed patients.

Flumazenil (0.2 mg/min IV) specifically antagonizes benzodiazepines but is not routinely

given empirically as it may precipitate seizures that are then refractory to benzodiazepines.

SURGICAL MANAGEMENT

CRANIOTOMY

SHUNTING CSF DRAINAGE

DECOMPRESSIVE SURGERY Removal of skull PartAllow a swelling brain To

expand without being squeezed

EMERGENCY NURSING CARE

- Check clues and causes of unconsciousness

- NBM

-Loosen clothes

-Ease breathing by turning head to side

-- keeping neck straight, chin forward

-drain and clean mouth secretion

- remove artificial teeth if any.

- Keep warm and comfortable

- Observe LOC-Keep his extremities and joints in functional position

It is important to remember that hearing sense is the last one to go and first one to come

back, so avoid unnecessary talk

NURSING MANAGEMENT

the unconscious patient is assessed immediately upon arrival in order to initiate emergency

intervention as needed.

1-Asses adequacy of airway and ventila tory status.


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A) .keep the neck in a neutral position, when indicated, based on mechanism of injury,

maintain cervical spine immobilization until cervical spine injury has been ruled out.

B). if the patient is brething spontaneously and does not require further airway management,

position patient ,when staff is not in attendance, in a lateral recumbent position with the head

is slightly elevated to prevent obstruction and aspiration.

C).assess need for oral suctioning to clear secretions.

2-Assess vital signs and neurologic vital signs utilizing GCS every 15 min unless otherwise

indicated until the patient condition stabilizes.

3-Monitor EKG and pulse oximetry .

4-Administer oxygen per provider order.

5-Lab work, ABG, EKG, X-Ray per provider order.

6-Stablish IV access and draw routine blood including toxicology screen as ordered. Initiate

IV fluids as ordered.

7-administer medication as provider order and assess response.

8-reorient patient to his/her environment as he/she awakens.

Nursing diagnosis-

1-Ineffective airway clearance R/t inability to swallowing

-Intervention

Airway management, an oral airway can be inserted

Care of ETT/ tracheostomy

Suctioning

Positioning

Chest physiotherapy Nebulization

2-Risk for aspiration R/T altered LOC

Intervention

Monitor ABG

Keep suctioning equipment available

Observe cardiac monitoring for dysrhythmias

Positioning


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3- Impaired oral mucus membrane, R/T mouth breathing absence of pharyngeal reflex,

& altered fluid intakeIntervention----

Inspect pts mouth every 8 hours

Apply water-soluble lubricant to prevent cracking, drying.

Oral hygiene( to avoid parotities, aspiration and RTI)

4- Deficient fluid volume r/t inability to take fluids by mouth

intervention-

Accurate documentation of intake and output

Assessment and documentation of conditions that might increase fluid volume

deficit (diaphoresis, polyuria, diarrheal, vomiting)

Avoid over hydration in a patient receiving IV fluids because of risk of cerebral

edema

5-Imbalanced nutrition less than body requirements R/T inability to feed

Intervention

IV fluids NG Tube feeding

Maintain intake output chart

6-Risk for injury R/T decreased LOC

Intervention-

Side rails

Seizure precautions ( use padded side rails, keep the patients nail short)

Protect patients head

Usecaution when moving

Always turn an unconscious patient toward you or someone else to prevent fall.

Do not restrain the patient unless absolutely necessary, if restraints are used, they

must be released at least every 2hours for skin check. Avoid over sedation (which increases ICP)

Do not leave unattended.

7-Impaired urinary elimination R/T impairment in neurologic sensing and controlIntervention

Catheterization

Catheter care

Maintain aseptic technique

Monitor urine colour Initiate bladder training as soon as consciousness regained.


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8- Bowel incontinence R/T changes in nutritional delivery methods

Intervention

Auscultate for bowel sounds; palpate lower abdomen for distension

Maintain food hygiene.

9-Risk of skin integrity R/T immobility

Intervention

Personal hygiene

Skin care, care of pressure points

Keep nails trimmed

Repositioned every 2 hours Put on special mattress or bed

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