UNCONSCIOUSNESS

Introduction Unconsciousness is apparent in the patient who is not oriented does not follow commands or need persistent stimuli to achieve a state of alertness. Unconsciousness is gauged on a continuous with a normal state of alertness and full cognition on one end and coma on other end. Coma is a clinical state of unconsciousness is which the patient is unaware of staff or the environment for prolonged periods. Definition Unconsciousness a state of loss of awareness from which a person cant be aroused. Or Unconsciousness is an inability to respond to any sensory stimuli or being unaware of the surrounding Causes of unconsciousness Brain tumor Head trauma Cerebral hemorrhage Cerebral hemorrhage can occur as a consequent of hypertension or from rupture of a vascular anomaly Hemorrhage cause coma by placing pressure on brain tissue Hypoxia is a common cause of metabolic coma Blood loss, high attitudes or carbon monoxide poisoning may deprive the brain of oxygen Cardiac arrest Disorders of the liver, kidney and lungs produce coma through the accumulation of metabolic waste products Toxins Hypoglycemia Fever Infections such as Encephalitis
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 Fluid, electrolyte or acid base imbalance Pathophysiology Unconsciousness is not a disorder itself rather it is a function and symptoms of multiple pathophysiological phenomena. The underlying cause of the neurological dysfunction is description in the cells of the nervous system, neurotransmitters or brain anatomy. A disruption in the basis functional unit or neurotransmitters result in faulty impulse transmission impeding communication within the brain or from the brain to other parts of the body. These disruptions are caused by cellular edema and other mechanism such as antibodies disrupting chemical transmission at receptor sites. Intact anatomic structures of the brain are needed for proper function. The two hemisphere of the cerebrum must communicate via an intact corpus collosum and the lobes of the brain (frontal, parietal, temporal and occipital) must communicate and coordinate their specific function. Additional anatomic structure of importance is the cerebellum and the brain stem. The cerebellum has both exhibitory and inhibitory action and is largely responsible for coordination of movement the brain stem. Certain area that are control the heart, respiration and blood pressure. Disruption in the anatomical structure are caused by trauma, edema, pressure from tumor as well as other mechanism such as increase or decrease in blood a cerebrospinal fluid circulation. Clinical manifestations Clinical manifestation depends on where the patient is along this continuum. In the patient state of alertness and consciousness decreases there will be changes in the Papillary response Eye opening response Verbal response Motor response

Initial changes may be reflected by behavioral changes such Restlessness Increase anxiety

Changes present in pupils are If the patient in comatose pupil becomes fixed Before going to coma stage, the pupils become sluggish Diagnostic finding For the unconsciousness patient a complete assessment is performed with particular attention to the neurological system. Assessment of neurologic system The neurologic evaluation is the corner stone of care for a patient with neurologic disorder. Assessment is the first phase of the nursing process and all subsequent plans and interventions are based on assessment. There are main components of neurological assessment are A comprehensive history A neurologic physical examination General and specific neuro diagnostic studies History History consists of biographical data, chief complaints and symptoms analysis, past health history, family health history and psychosocial history Biographical data a) Demographic data age, sex, race, home address, religion b) Source of history patient relatives c) Client mental status reliability of data Current health a) Chief complaints b) Symptoms analysis Onset, duration, site, precipitating factor, relieving factor, interventions done, related response, related symptoms

Past health history Childhood and infectious disease and immunization Collect data regarding common childhood diseases and immunizations Rubella Rubeola Cytomegalovirus Herpes simplex Influenza Meningitis a) Major illness and hospitalization Head injury Seizure Stroke Diabetes mellitus Hypertension Renal diseases Liver diseases Meningitis Encephalitis Psychiatric disorders Neurologic disorders Cardiologic problems Congenital anomalies b) Medications Prescribed medicines and OTC drugs Aspirin Anticoagulant Anticonvulsant Antidepressant Antihypertensive CNS depressant opiods, tranquilizers, sedatives CNS stimulants diet, pills Anti histamines Antibiotics Bronchodilators
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 c)

Muscle relaxant Psychiatric agent Herbal preparations Growth and Development Prenatal history Mothers infections - Alcohol, smoking, tobacco - Radiation Birth premature - Prolonged labor Family history To identify general risk factors Epilepsy CVA MR Headache Tumor Psychiatric disorder Muscular dystrophy Neurofibromatosis Other neurological disorders Psychosocial history To identify personal psychosocial factor Educational background Level of performance Personality hobbies and recreation - sleep pattern - Perceived stressors - Sexual activity - Occupation - Social relation - Exposure to neuro toxins

Physical examination It is intended to detect abnormalities in neurologic functioning. It includes a) Vital signs b) Mental status c) Head, neck & back d) Cranial nerves e) Motor systems f) Sensory function g) Reflexes a) Vital signs Neurologic disorder can cause life threatening changes in vital signs e.g., 1. Cervical cord injury hypotension - Bradycardia - Hypothermia 2. Increased ICP Gushings triad - Increased systolic B.P - Widened pulse pressure - Bradycardia b) Mental status It includes Level of consciousness (LOC) Consciousness is maintained by the cerebral hemisphere and reticular activity system. Test LOC using stimuli to determine arousal stimuli. *Visual, * Verbal, *Tactile, * Noxious agents Noxious central stimulus sterna pressure - Supra orbital ledge pressure - sternocleidomastoid muscle pinch - Peripheral stimulus nail bed pressure Glasgow coma scale Tool used to determine LOC. Cant be used when the patient is intubated , immobilized or paralyzed or the eyes are swollen shut. Total score 15, minimum is less than 7 is coma.

Eye opening

Spontaneous opening To verbal command To pain No response

4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Verbal response

Oriented Confused Inappropriate words Incoherent No response

Motor response

Obey verbal command Localizes pain Withdraw from pain Flexible Extension No response

7 or below 7 Orientation

coma

Orientation to time, place & person 3) Memory: immediate, recent, remote i) Long term memory ii) Short term memory - State 3 words for client to remember -ask to say words immediately
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- ask to repeat it after few minutes 4) Mood and affection Ask the client to describe how he or she feels facial expression may reveal anxiety, distrust, depression etc., 5) Intellectual performance - ask the client to identify commonly know people, places, recent event & the likes - To count by 7s - Simple addition & subtraction 6) Judgments and insight - reasoning - Abstract thinking explain a proverb - Problem solving describes a situation and asks to find situation 7) Language and communication It tests the ability to express and comprehend ones ones environment. Speech quality, content, articulation Able to comprehend spoken language Able to written language Hygiene grooming

Head, neck and back Inspection Reopen eyes anterior, basilar for skull fracture periorbits ecchymosis Battls sign echymosis once mastoid process, middle for a basilar skull fracture Palpation Palpate the skull for nodule & mass Palpate the neck muscle
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 Check nuchal rigidity Palpate spinal alignment Palpate parietal muscles Percussion Auscultation Assess the cranial nerve Motor system 1. 2. 3. 4. 5. 6. Muscle size, symmetry, hypertrophy & atrophy Muscle strength 5/5 Muscle tone hypo or hypertonicity Muscle coordination Gait and station Movement

Sensory system Peripheral nerve sensory function Superficial touch Superficial pain Temperature & deep pressure Vibration Joint position

Cortical sensory function (Discrimination) Stereo gnosis place a coin in patient hand patient should identify the object by touch and manipulation Two point discrimination simultaneously prick the skin two point at varying distance apart to identify the smallest distance at which the client can perceives two pinch Extinction phenomena prick the clients skin at the same point on the two sides of the body at the same time. ask the patient to state whether one or two pricks felt

 Glaphesthenia - use the stick to draw a member or lefler on the pallor of the hand. Ask him to identify the figure Point location Reflexes Two types 1. Superficial or cutaneous reflexes 2. Deep tendon reflexes or muscle stretch muscle If the patient is comatose with localized signs such as abnormal papillary and motor responses, it is assured that neurologic disease present until proven otherwise if the patient is comatose and papillary light reflexes are present a toxic a metabolic disorder is suspected. Procedure used to identify the causes if unconscious include Scanning Imaging Tomography (e.g., computer tomography) Electro encephalography Laboratory test include analysis of Blood glucose Electrolytes Serum ammonia Blood urea nitrogen level Partial thermoplastic & prothrombin time Other studies are used to evaluate serum ketosis and alcohol, drug level and arterial blood gas level Complication Potential complication for the patient altered level of consciousness include Respiratory failure Pneumonia Pressure ulcer Aspiration

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Respiratory failure may develop shortly after the patient becomes unconsciousness. If the patient cannot maintain effective respiratory supportive care in initial to promote adequate ventilation. Pneumonia is common in patient receiving mechanical ventilation or those who cannot maintain and clear the airway. The patient with altered level of consciousness is subjected to all the complication associated with immobility such as Pressure ulcer Sepsis Medical management The first priority of treatment with unconscious patient is obtained and maintains a patient airway. The patient may be orally or nasally in tubated or a tracheotomy may be performed. Control the patients ability to breathe on his or her own is determined a mechanical ventilator is used to maintain adequate oxygenation. The circulatory status is monitored to ensure the adequate perfusion to the body and brain. An intravenous catheter is inserted to promote access for fluid and intravenous medication. Neurological care focus on the specific neurologic pathology, if any nutritional support using either a feeding tube or a gastrostomy tube is to determine and treat the underlying causes of altered level of conscious, other medical interventions are aimed at pharmacological management of complications and strategies to prevent complications Nursing process The patient with an altered level of consciousness Assessment Where to begin assessing the patient an unconscious depends somewhat on each patient circumstance but clinicians often start by assessing the verbal response, the patient is asked to identify the day, date or reasons of the year and to identify where he or she identifies the clinicians family members and visitors present. Other questions such as who is the president? & what is the recent holiday also helpful is determining the patients process of information in the environment. Alertness is measured by the patient ability to open the eyes spontaneously or to stimulus as per the neurologic assessment. If certain severe neurologic dysfunction
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cannot do this. The nurse should assess the periorbital edema or trauma which may present the patient from opening the eyes provide excessive for the patient for e.g. back care and improve the circulation to present pressure so on. Nursing diagnosis Ineffective airway clearance related to altered level of consciousness Risk for injury related to decrease level of consciousness Deficient fluid volume related to inability to take in fluids by mouth Impaired oral mucus membranes related to mouth breathing assess of pharyngeal reflexes and altered fluid intake Risk for impaired skin integrity related to immobility Impaired tissue integrity to cornea related to diminished or absent corneal reflexes Ineffective thermo regulation related to damage of hypothalamic centers Bowel incontinence related to impairment in neurologic sensory and control and also related to transition in nutritional delivery method Disturbed sensory perception related to neurologic impairment Interrupted family process related to health team

Nursing management The most important consideration in managing the patient with adequate airway and ensure ventilation Elevate the head at 30 angle it help to prevent aspiration The patient may require suction and oral hygiene Protecting the patient condition paddles, side rails at all time Maintaining fluid balance and manage nutritional needs Provide mouth care Maintain skin and joint integrity Preventing corneal injury eye patches should be needed Achieving thermo regulation Prevention urinary retention Promoting bowel function Providing sensory stimulation Meeting the family needs

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Conclusion Care of an unconscious patient is very important than other. This provides totally defined to assessing the care. Bibiliography Campell.G.Victor et.al. Neurologic disorders. 1st edition, Mosby, 18-34 Joyce.M.Black, (2005), Medical surgical nursing, 7th edition, Saunders Publications, 686-687 Suzanne .C. Smeltzer Brenda Bare, Text book of medical surgical nursing, 10 th Edition, Lippincott Williamss publication, 1850-1856

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