Unconsciousness

Consciousness

A state of awareness of yourself and your surroundings
Ability to perceive sensory stimuli and respond appropriately to them.

Unconsciousness-A state of complete or partial unawareness or lack of response to sensory stimuli. Various degrees of unconsciousness are there: e.g. confusion, stupor, somnolent, excitary and deep coma etc

Abnormal state - client is unarousable and unresponsive.

Coma is a deepest state of unconsciousness.
Unconsciousness is a symptom rather than a disease.

Degrees of unconsciousness that vary in length and severity:

Brief -Fainting
Prolonged - Deep coma

Causes of unconsciousness

Trauma
Epidural / Subdural hematoma
Brain contusion
Hydrocephalus
Stroke
Tumor
Infection
Meningitis
Encephalitis
Hypo/hyperglycemia
Hepatic encephalopathy
Hyponatremia
Drug /alcohol overdose
Poisoning /intoxication

Pathophysiology

Consciousness is a complex function controlled by reticular activating system (RAS) and its integrated components.
The RAS begins in the medulla as the reticular formation that connects to the RAS (located in the mid-brain which then connects hypothalamus and thalamus).
Integrated pathways connect to the cortex via the thalamus and to the limbic system via the hypothalamus. Feedback systems also connect at the brainstem level.
The reticular formation produces wakefulness, whereas the RAS and higher connections are responsible for awareness of self and the environment.
To produce a coma, a disorder must affect both cerebral hemisphere and the brain stem itself (in one of the three ways)

Stages of Unconsciousness

Confusional state
Delirium
Obtundation
Stupor
Coma

1. Confusional State-Confusion is a state in which the patient cannot take into account all elements of his/her immediate environment, implying an element of sensorial clouding.

Disoriented.
Shortened attention span.
Memory deficits.
Difficulty in following commands.
Alteration in perception of stimuli.

2. Delirium-It is characterized by a fluctuating disturbance in consciousness and change in cognition that usually develops over a short period of time.

Disoriented to place and person.
Increased motor activities.
Illusion, Hallucinations

3.Obtundation-Decreased alertness and hypersomnia.

Obtundation is characterized by reduced alertness and hypersomnia.
Hypersomnia is technically defined as a state of sleep in excess i.e, 25% more of the expected normal sleep.
Obtundation is often seen with substance abuse in the form of narcotic or alcohol over dosage.

4. Stupor-Stupor is unresponsiveness from which the patient can only be aroused by vigorous repeated painful stimuli.

Deep sleep or unresponsiveness
Can be aroused only with painful stimuli.
Responds by withdrawing or Grabbing at the source of pain.

5.Coma- State in which a patient is totally unaware of both self and external surrounding, and unable to respond meaningfully to external stimuli.

Characteristics of coma

No eye-opening
Inability to follow instructions
No speech or other forms of communication
No purposeful movement

Sign and Symptom

The person will be unresponsive (does not respond to activity, touch, sound, or other stimulation
Is unaware of his surroundings and does not respond to sound
Makes no purposeful movements
Does not respond to questions or to touch
Drowsiness
Inability to speak or move parts of his or her body
Loss of bowel or bladder control (incontinence)
Stupor
Respiratory changes (cheyne stroke respiration, cluster breathing, ataxic breathing, hyperventilation)
Abnormal pupil reactions

Diagnostic test

X-ray
MRI (magnetic resonance imaging) -Tumors, vascular abnormalities, IC bleed
CT (computerized tomography) - Cerebral edema, infarctions, hydrocephalus
Lumbar puncture -Cerebral meningitis, CSF evaluation
PET (positron emission tomography)
EEG- electric activity of cerebral cortex
Blood test like CBC, LFT, RFT, ABG etc.

Complications of immobility

Skin - Pressure sore, laceration.
Respiratory- Hypostatic pneumonia, pulmonary. Embolism.
C.V. complications - DVT, postural hypotension, thrombo embolism.
G.I. system - Paralytic ilius, constipation, distention.
Urological - UTI, stone.
Muskulo skeleton- Contracture, osteoporosis, dystrophy, weakness.
Neurological - Foot drop.
Psychological - Anxiety, depression

Medical Management

The goal of medical management are to preserve brain function and prevent further damage.

Ventilatory support
Oxygen therapy
Management of blood pressure
Management of fluid balance
Management of seizures -anti epileptic sedatives, paralytic agents
Treating Increased ICP -Mannitol, corticosteroids
Management of temperature regulation (fever)- ice packs, tepid sponging, Antipyretics, NSAIDS
Management of elimination - laxatives
Management of nutrition- TPN and RT feeds
DVT prophylaxis

Nursing Diagnosis

Ineffective airway clearance related to altered level of consciousness.
Risk for injury related to decreased level of consciousness.
Risk for impaired skin integrity related to immobility.
Impaired urinary elimination related to impairment in sensing and control.
Disturbed sensory perception related to neurologic impairment.
Interrupted family process related to health crisis.
Risk for impaired nutritional status

Nursing management of unconscious patient (emergency care)

A. Maintaining a patent airway

ABC Management
ABG results must be interpreted to determine the degree of oxygenation provided by the ventilators or oxygen.
Assess for cough and swallow reflexes
Use an oral artificial airway to maintain patency
Tracheotomy or endo-tracheal intubation and mechanical ventilation maybe necessary Preventing airway obstruction
Oronasopharyngeal suction equipment may be necessary to aspirate secretions.
If facial palsy or hemi paralysis is present the affected side must be kept the uppermost.
Dentures are removed
Nasal and oral care is provided to keep the upper airway free of accumulated secretions debris
Monitoring neurological signs at intervals determined by their condition and document results.

B. Ineffective Cerebral tissue Perfusion

Assess the Glasgow Coma Scale(GCS) SPO2 level and Arterial blood gas (ABG) of the patient.
Monitor the vital signs of the patients (increased temperature)
Head elevation of 30 degrees, neutral position maintained to facilitate venous drainage. Reduce agitation .(Sedation.)
Reduce cerebral edema (Corticosteroids, osmotic or loop diuretics.) Generally peaks within 72 hrs after trauma and subsides gradually.
Talk softly and limit touch and stimulation.
Administer laxatives, and antiemetic as ordered
Manage temperature with antipyretics and cooling measures.
Prevent seizure with ordered dilantin.
Administer mannitol 25-50 g IV bolus if ICP >20, as prescribed.

C. Risk for increased ICP

Head elevation of 30 degrees, neutral position maintained to facilitate venous drainage and prevent aspiration.
Pre-oxygenation before suctioning should be mandatory , and each pass of the catheter limited to 10 seconds, with appropriate sedation to limit the rise in ICP.
Insertion of an oral airway to suction the secretions.
As fluid intake is restricted and glucose is avoided to control cerebral edema and intravenous infusion cannot be considered as a nutritional support.

Nursing management of unconscious patient (routine care)

A. Fluid and electrolyte balance

Intake-Output chart should be meticulously maintained.
Assess and document symptoms that may indicate fluid volume overload or deficit. Diuretics may be prescribed to correct fluid overload and reduce edema.
Over hydration and intravenous fluids with glucose are always avoided in comatose patients as cerebral edema may follow.

B. Skin integrity

The nurse should provide intervention for all self-care needs including bathing, hair care, skin and nail care.
Frequent back care should be given.
Comfort devices should be used.
Positions should be changed.
Special mattresses or airbeds to be used.
Adequate nutritional and hydration status should be maintained.
Patient’s nails should be kept trimmed.
Cornea should be kept moist by instilling methyl cellulose 0.5% to 1%.
Protective eye shields can be applied or the eyelids closed with adhesive strips if the corneal reflex is absent. These measures prevent corneal abrasions and irritation.
Inspect the oral cavity.
Keep the lips coated with a water-soluble lubricant to prevent encrustation, drying, cracking. Inspect the paralyzed cheek.
Frequent oral hygiene every 4 hourly.
Nasal passages may get occluded so they may be cleaned with a cotton tipped applicator.

C. Proper positioning

Lateral position on a pillow to maintain head in a neutral position
Upper arm positioned on a pillow to maintain shoulder lignment
Upper leg supported on a pillow to maintain alignment of the hip
Change position to lie on alternate sides every 2-4hrs
Taking care to prevent injury to soft tissue and nerves, edema or disruption of the blood supply
Maintaining correct positioning enables secretions to drain from the client’s mouth, the tongue does not obstruct the airway and postural deformities are prevented.

D. Self care deficit

Attending to the hygiene needs of the unconscious patient should 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 illnesses, such as diabetes needs more attention
Minimum two nurses should bathe an unconscious patient as turning the patient may block the airway.
Proper assessment of the condition of the skin must be done when giving a bed bath. Hair care should not be neglected.

E. Oral Hygiene

A chlorhexidine based solution is used.
Airway should be removed when providing oral care. It should be cleaned and then re-inserted.
If the patient has an endotracheal tube the tube should be fixed alternately on each side.
Minimum of four-hourly oral care to reduce the potential of infection from micro-organisms.
Also not to damage the gingiva by using excessive force.

F. Eye Care

In assessing the eyes, observe for signs of irritation, corneal drying, abrasions and oedema.
Gentle cleaning with gauze and 0.9% sodium chloride should be sufficient to prevent infection.
Artificial tears can also be applied as drops to help moisten the eyes.
Corneal damage can result if the eyes remain open for a longer time.
Tape can be used to close the eyes

G. Nutrition need

TPN (Total parenteral nutrition)
Enteral feeding via Nasogastric, nasojejunal or PEG tube.
Intravenous fluids are administered for comatose patients.

H. Risk for injury

Side rails must be kept whenever the patient is not receiving direct care.
Seizure precautions must be taken.
Adequate support to limbs and head must be given when moving or turning an unconscious patient.
Protect from external sources of heat.
Oversedation should be avoided – as it impedes the assessment of the level of consciousness and impairs respiration.
Assess the Need for restrain.

I. Impaired bowel/ bladder functions

Assess for constipation and bladder distention.
Auscultate bowel sounds.
Stool softeners or laxatives may be given.
Bladder 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

Maintain the extremities in functional positions by providing proper support.
Remove the support devices every four hours for passive ROM exercises and skin care.
Foot support should be provided.

K. Sensory stimulation

Brain needs sensory input.
Widely believed that hearing is the last sense to go.
Talk, explain to the patient what is going on.
Upon waking many clients remember….. and will accurately recall events and processes that happened while they were “sleeping”(unconscious)

L. Nurses must

Show respect.
Encourage family to contribute to the care of their loved ones.
Afford the privacy both the client and family deserve.

M. Encourage stimulation by

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

N. Impaired family process

Include the family members in patient’s care.
Communicate frequently with the family members.
The family members should be allowed to stay with the patient when and where it is possible.
Use external support systems like professional
Counsellors, religious clergy etc.
Clarifications and questions should be encouraged