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The Unconscious Patient and Nursing Management

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Janice Wong

on 16 April 2013

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Transcript of The Unconscious Patient and Nursing Management

(cc) photo by Metro Centric on Flickr (cc) photo by Franco Folini on Flickr (cc) photo by Metro Centric on Flickr The Human Brain
Objectives define consciousness and have an understanding of the related anatomy and physiology

discuss the various levels of consciousness

list the causes of unconsciousness

recognize the skills required for the assessment, planning and implementation of nursing care for an unconscious patient Unconsciousness Exercise Nursing Management of an Unconscious Patient 3. Examination Skin petechial rash - meningococcal meningitis, endocarditis, sepsis, thrombocytopenic purpura

Multiple injection marks - drug addiction, acute endocarditis, hepatitis B/C with encephalopathy, HIV Neurological Assessment GCS scores 1. Conscious

2. Confused

3. Delirius

4. Somnolent 5. Obtunded

6. Stuporous

7. Comatose Glasglow Coma Scale The Unconscious Patient and nursing management requires a constant supply of O2 and glucose for normal function

interruption of this supply will cause loss of consciousness within a few seconds and may also cause permanent brain damage Consciousness A state of wakefulness & awareness of self and the environment.

depends on the integrity of the cerebral hemi-spheres and the ascending reticular activating system (RAS) in the brain stem RAS A state of unarousable responsiveness, where the patient is unaware of the self or the surroundings and no purposeful response can be obtained to external stimuli. Unconciousness may be brief to or sustained

coma is a state of sustained unconsciousness in which the patient does not respond to verbal stimuli, does not move voluntarily, does not blink, may have altered respiratory patterns, altered pupillary response to light and varying responses to painful stimuli To produce unconsciousness, a disorder must: 1. disrupt the ascending reticular activating system, which extends the length of the brain stem and up into the thalamus;

2. significantly disrupt the function of both cerebral hemispheres; or

3. metabolically depress overall brain function Causes of Unconciousness Match the levels of consciousness with its clinical features... Normal, alert oriented to self, place, and time. Opens eyes spontaneously, responds to stimuli appropriately. Impaired or slowed thinking; disoriented. Disoriented, restless, attention deficit, possible incidence of hallucinations and delusions. Excessive drowsiness; responds to verbal stimuli although slow and inappropriate. Decreased alertness, slowed motor responses; sleepiness. Sleep-like state; can be aroused only by vigorous and repeated noxious stimuli; little or no activity; responsiveness only to pain Unarousable and unresponsive; no gag reflex or papillary response to light The patient is assessed against 3-criteria:

eye opening

best verbal response

best motor response 1. ABCs 2. Immediate Management
oxygen inhalation
maintain intravenous line
blood sample
control seizures
consider administration of medications if cause known (e.g. D5W, naloxone) Pulse
tachycardia - hypovolemia, hemorrhage
bradycardia - increased ICP
Increased temp. – sepsis, meningitis, brainstem hemorrhage
Decreased temp. – hypoglycemia, hypothermia (<31C), alcohol or drug intoxication
Blood Pressure
Increased BP – hypertensive encephalopathy, cerebral hemorrhage, raised ICP
Decreased BP – hypovolemia, myocardial infarction, intoxication, poisoning
Respiratory rate
Increased RR – pneumonia, acidosis (DKA, renal failure), pulmonary embolism, respiratory failure
Decreased RR – intoxication, poisoning to obtain baseline data

to monitor changes in LOC

to detect presence of increased ICP Skin Assessment Vitals Assessment Pupillary Response
- PEARL? unequal pupils may indicate pressure increase on one side of the brain, fixed and dilated pupils indicate brain herniation or drug overdose

General Posture
-lack of movements on one side, pronator drift, intermittent twitching, babinski reflexes A neurological scale that gives a reliable, objective record of the level of consciousness (LOC) of a person, for initial as well as continuing assessment. 15 = maximum score for an alert individual

3 = lowest possible score for the unconscious patient (severe injury)

GCS ≤ 8 = cause for concern

key point: look for patterns of change What are some limitations of the Glasgow Coma Scale? 4. History 5. Investigations -onset of the symptoms
-illnesses (e.g. seizures, diabetes), use of medications, allergies
-nutritional history
-socio-economic and environmental status -CBCs
-Blood and urine cultures
-Chest Xrays
-CT scan Nursing Diagnoses of an Unconcious Patient and Interventions... Summary management of an unconcious patient depends on the cause Assess ABCs Oxygen and I.V. access Brief Examination Obtain History Investigate Reassess the situation and plan further reflexes Consider Arthur's scenario... Day 1 0800hrs Drowsy but oriented ×3. He understands why he is in hospital but only remembers having breakfast yesterday morning. He is able to state name of
Prime Minister, etc. and can compute simple math. Becomes slightly irritated when questioned. No complaints of dizziness, diplopia, nuchal
rigidity, or nystagmus. States he has a dull
frontal headache. Reflexes and
motor strength are normal. PERLA. Negative Babinski. Appears neurologically stable but will remain on NSCU × 24hours for observation.
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