This occurs when there is damage to the pons in the brain stem, resulting from cerebral vascular disease or trauma, paralysing voluntary muscles without interfering with consciousness and cognitive functions. Confused = scores 4. The nurse needs to be aware if the patient has any hearing deficits because if their eyes are closed, this will affect the initial response. Initiate appropriate initial management. hourly position changing to relieve pressure on pressure areas. Some neuro-rehabilitation units use a structured technique for assessing various sensory aspects of communication, movement awareness and wakefulness, known as SMART (sensory modality assessment and rehabilitation technique –, There is ongoing debate, both in the UK and other countries, about the moral, ethical and legal issues surrounding the care and treatment of these individuals and the dilemma posed by some patients to ‘the right to die’ and withdrawal of treatment has received considerable professional, public and political attention over recent years (Porter 2005) (see. over the bladder region. The RF is involved in the coordination of skeletal muscle activity, including voluntary movement, posture and balance, as well as automatic and reflex activities that link with the limbic system. It is the field that maintains quality of life in a community. This initiates a cycle that causes continued intense excitation of both regions. There is no international definition of levels of consciousness but, for assessment purposes, differing states of consciousness can be considered on a continuum between full consciousness and deep coma (Hickey 2003) (see Box 28.1). Posner JB, Saper CB, Schiff N, Plum F. Plum and Posner’s Diagnosis of Stupor and Coma 4e Oxford university Press, 2009. This is indicated on the patient’s chart as ‘T’. Nurses are advocates of a patient. Repeat the patient’s blood glucose level after 1 hour. Review the contributory causes of altered consciousness shown in Figure 28.3 and consider the underlying mechanism for each of them. The mesencephalic area is composed of grey matter and lies in the upper pons and midbrain of the brain stem. nurse play and important role in the care of unconscious (comtosed) patient to prevent p otential complications respiratory eg;distress, pneumonia,a spiration,p ressure ulcer.this achived by: 1. This assesses the area of the brain associated with receptive and expressive speech. Flexion to pain. Assessment of Unconscious Clients For the care to be effective, a nurse should perform frequent, systematic and objective assessment on the comatose client. During the first few hours of coma, neurologic assessment is to be done as often as every 15 minutes. It provides a standardised approach to observing and recording adverse changes in the patient’s level of consciousness, so that appropriate action can be taken (, National Institute for Health and Clinical Excellence [NICE] 2003, Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults, CT scanning based on presenting signs and symptoms, frequent and consistent neurological assessment to identify early signs of neurological deterioration, prompt referral and transfer to a specialist tertiary neurosurgical centre, early identification and clearance of cervical spine fractures, identification of non-accidental injuries. Despite our strong ethical and moral commitment to others, our biases have a significant impact on nursing practice and the nation's health. In order to function, the RAS must be stimulated by input signals from a wide range of sources. It is this nucleus that sends inhibiting messages back to the thalamic nuclei using the neurotransmitter γ-aminobutyric acid (GABA). A person may become unconscious due to oxygen deprivation, shock, central nervous system depressants such as alcohol and drugs, or injury. The patient will moan or groan in response to painful stimulation. Deep coma, the opposite of consciousness, is diagnosed when the patient is unrousable and unresponsive to external stimuli; there are varied states of altered consciousness in between the two extremes (, Anatomical and physiological basis for consciousness. Nursing the recumbent patient can be both challenging and rewarding. Only the best response from the arms is recorded as leg responses to pain are less consistent and may be confused with a simple spinal reflex. These disorders interfere with the integrity of the RAS, affecting the patient’s arousal response. LISTEN and FEEL for … Although the patient has sleep/waking cycles, the higher centres of the brain are destroyed. The approach is based on the belief that after a history and a general physical and neurologic examination, the informed physician can, with reasonable confidence, place the patient into one of four major groups of illnesses that cause coma. Figure 28.1 Mid-sagittal section of the brain, showing the reticular activating system and related structures. What is visual communication and why it matters; Nov. 20, 2020. In 1974, Teasdale and Jennett developed the Glasgow Coma Scale (GCS), a process used throughout the UK and worldwide as part of the neurological assessment and ongoing observation of the patient (see Figure 28.4). Involving the family in self care needs. This occurs when there is damage to the pons in the brain stem, resulting from cerebral vascular disease or trauma, paralysing voluntary muscles without interfering with consciousness and cognitive functions. (BS) Developed by Therithal info, Chennai. Your body language, focused attention, or level of care can be directly impacted by your feelings toward the patient. C. Flexing to pain. absence of comprehensible speech, a failure to obey commands. Whenever any of these areas becomes excited, impulses are transmitted into the RAS, thus increasing its activity. Loosen the garments to allow free movements of the chest and abdomen. The reticular nucleus, which receives impulses from the RF, surrounds the front and sides of the thalamus. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Anatomical and physiological basis for consciousness 737, The reticular activating system (RAS) 738, Chronic states of impaired consciousness 741, Emergency care of the unconscious patient 745, Nursing management of the unconscious patient 748, Hickey (2003) defines consciousness simply as ‘a state of general awareness of oneself and the environment’ and includes the ability to orientate towards new stimuli. Injury to, or disease of, the cerebral hemispheres may cause diffuse damage that can inhibit or block the signals from the RAS, depressing the level of consciousness. Activation of the muscle stimulates proprioceptors to transmit sensory impulses upward to re-excite the RAS. These are transmitted via the spinal reticular tracts and various collateral tracts from all the modalities of sensation, e.g. Reassess after intervention. A neurological assessment includes the recording of additional measurements as follows: A rising blood pressure (elevated systolic pressure), widening of the pulse pressures and a slowing pulse (see Ch. Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail, Care of unconscious patient: Causes, Diagnosis, Management. accurate output. Gratitude in the workplace: How gratitude can improve your well-being and relationships Pressure is applied to the lateral inner aspect of the second or third finger using a pen or pencil, for a maximum of 15 seconds (Figure 28.5). Nursing the unconscious patient. It is important to remember that the patient is cognitively aware, even if they appear to be mentally and physically inert. Score = 4. This response is only recorded when sufficient painful stimulus has been applied to provoke a response and no detectable movement has been observed. Deep coma, the opposite of consciousness, is diagnosed when the patient is unrousable and unresponsive to external stimuli; there are varied states of altered consciousness in between the two extremes (Box 28.1). Nov. 21, 2020. The verbal response may contain indistinct mumbling but no intelligible words. Coma is an impaired state where the patient is totally unaware of themselves and their environment. B. Trapezius pinch. help of pillow or sand bags to prevent foot drop. Extension to pain. The patient who is unconscious from cerebral catastrophe must depend upon others to detect or anticipate his needs and to institute the appropriate measures to assure his recovery if the pathological insult can be overcome. The pattern and rate of respiration is directly affected by increasing brain injury that may produce an ataxic irregular or Cheyne–Stokes respiratory pattern characterised by periods of tachypnoea interspersed with periods of apnoea. The nurse observes and describes three aspects of the patient’s behaviour: Each of these is independently assessed and recorded on a chart (Figure 28.4). The RAS is also affected by signals from the cerebral cortex, i.e. The clinical condition of unconsciousness is one of complex physiology. For further information about the use of the neurological observation chart and GCS in practice, see Woodward (1997a-d), NICE (2003), Waterhouse (2005) and Palmer & Knight (2006). C. Flexing to pain. Common causes of altered level of consciousness are illustrated in Figure 28.3 (see, Cognitive disabilities, e.g. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. patient. or catheterization can be done according to Doctor' s order to record the When an individual is in a deep sleep, the RAS is in a dormant state. Neurological assessment in nursing is a critical skill for a neuro ICU nurse. A. Supraorbital ridge pressure. Maintenance The response usually includes spastic hand and wrist movements, with an inward rotation of the shoulders and forearms. Therefore, Signals from different areas in the thalamus initiate selective activity in the cortex protecting the higher centres from sensory overload (, Sleep is induced by a hormone called melatonin which is synthesised from serotonin in the pineal gland. The nurse must be able to assess and observe the patient accurately so that appropriate intervention can be instituted if the level of consciousness deteriorates. incontinency retention and constipation, report to the physician. The responses described below are shown in Figure 28.6. Unconsciousness is a condition in which there is depression Protect the airway of the unconscious patient. Unconscious patients are nursed in a variety of clinical settings and therefore it is necessary for all nurses to assess, plan and implement the nursing care of this vulnerable patient … Consciousness cannot be measured directly but can be estimated by observing behaviour in response to stimuli. and the inability to respond to external stimuli. Medical management will vary according to the original cause of the patient’s condition, but nursing care will be constant. Normal conscious behaviour is dependent upon the functioning of the higher cerebral hemispheres and an intact reticular activating system (see below). Deterioration or improvement will depend on a number of factors such as the mechanism, extent and site of injury, age, previous medical history and length of coma. After a prolonged period of wakefulness, the synapses in the feedback loops become increasingly fatigued, reducing the level of stimulation and activity directed to the reticular activating system and thereby inducing a state of lethargy, drowsiness and eventually sleep (Guyton & Hall 2000). Localised damage to the cerebral hemispheres can affect consciousness to a lesser degree. straightening the elbows and hyperpronation of the forearms, otherwise known as decerebrate posturing. Coma may be defined as no eye opening on stimulation, In cycle A, the RAS excites the cerebral cortex and the cortex in turn re-excites the RAS. Figure 28.2 The feedback mechanism, showing two feedback cycles passing through the RAS. practicals), 7 or less generally indicates coma observe the patient' s condition and prevent any complications. Spontaneously = scores 4. Copyright © 2018-2021 BrainKart.com; All Rights Reserved. Compendium …more CCC. It must be necessary to hold the patients jaw forward or place the patient in the lateral position to prevent the tongue obstructing airway by falling back. Impaired, reduced or absent consciousness implies the presence of brain dysfunction and demands urgent medical attention. It provides a standardised approach to observing and recording adverse changes in the patient’s level of consciousness, so that appropriate action can be taken (National Institute for Health and Clinical Excellence [NICE] 2003) (Box 28.3). Pressure is gradually increased for a maximum of 15 seconds. Although dementia is an irreversible condition, new drug therapies such as donepezil (Aricept®) are being used successfully to delay onset of the disease. Nursing the unconscious patient. Formulate a differential diagnosis. 2. secretion in the patients pharynx. Physiologically, the brain stem is functioning but the cerebral cortex is not, and patients can survive for several years requiring full-time nursing care. Inappropriate words = scores 3. More questions related to this article: What do you understand by a head injury? Acute states, for example drug or alcohol intoxication, are potentially reversible whereas chronic states tend to be irreversible as they are caused by invasive or destructive brain lesions. Applying a central painful stimulus. Although dementia is an irreversible condition, new drug therapies such as donepezil (Aricept®) are being used successfully to delay onset of the disease. The primary care team plays a major role in supporting patients following acquired brain injury, facilitating referral to specialist agencies (see www.bann.org.uk). Patient obtunded, assisting respirations. Asses the patient' s level of consciousness by Glasgow coma Even during normal sleep, an individual can be roused by external stimuli, in comparison to the person in a coma. The patient offers monosyllabic words, usually in response to physical stimulation. It is difficult to classify levels of consciousness exactly, but this is a useful guide to help to describe various levels. Perineal care, vaginal douch, catheter care to be provided. Score = 2. It is concerned with the arousal of the brain in sleep and wakefulness (Marieb 2004). B. Trapezius pinch. Neurological Status Glasgow Coma Scale this is a tool used to evaluate three categories of behaviour that reflect activities in the high centre of the brain. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient … Therefore, it is the best response that should be scored; for example, if the patient localises to pain on the left side but flexes to pain on the right, the localising response is recorded. It will help in partially emptying the bladder. However, almost any type of sensory signal can immediately activate the RAS and waken the individual, for example when daylight is detected by the retina of the eye, impulses are sent to the suprachiasmatic nucleus of the hypothalamus, activating sympathetic nerve fibres that will inhibit the secretion of melatonin in the pineal gland. The chronic states of impaired consciousness tend to be irreversible as they are caused by invasive or destructive brain lesions. B. Localising to pain. Some neuro-rehabilitation units use a structured technique for assessing various sensory aspects of communication, movement awareness and wakefulness, known as SMART (sensory modality assessment and rehabilitation technique – www.smart-therapy.org.uk/), to enable clinicians to make a more accurate diagnosis of patients they suspect may be in PVS. Critical Care. Obeys commands. Poisonous drugs (stomach wash, refer If the patient has incontinence of urine - provide bedpans (Changes from baseline are most important). None = scores 1. tube feeding. It necessary insert oral airway for easy breathing. In cycle B, impulses are sent down the spinal cord to activate skeletal muscles. The individual is awake, alert and aware of their personal identity and of the events occurring in their surroundings. place the patient in the lateral position to prevent the tongue obstructing The individual is awake, alert and aware of their personal identity and of the events occurring in their surroundings. Early diagnosis and treatment with medication, and environmental changes such as reducing noise or sensory input may help to alleviate some of the symptoms. They are: This condition is caused by a generalised and progressive loss of cortical tissue in the brain. J R Soc Med. Explain the nursing management of head injury patient. poor concentration or short-term memory problems, may only become apparent when a patient returns home. Acute states, for example drug or alcohol intoxication, are potentially reversible whereas chronic states tend to be irreversible as they are caused by invasive or destructive brain lesions. Pamela Mountjoy SRN, RMN, Barbara Wythe SRN, SCM, Nursing Care of the Unconscious Patient, 1970, Williams and Wilkins Co., Baltimore, 89 Palpate the abdomen for distension Ascultate bowel sounds. It is concerned with the arousal of the brain in sleep and wakefulness (Marieb 2004). It must be necessary to hold the patients jaw forward or The words and phrases make little or no sense and may express obscenities. CHAPTER 28 Nursing the unconscious patient. drop: Sponging is performed as frequently as necessary. 13) must also be taken into account. 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… Physiologically, the brain stem is functioning but the cerebral cortex is not, and patients can survive for several years requiring full-time nursing care. Eye Opening Verbal Response Motor Response GCS cont: The first score provides a base line for future scorings. Develop an interpersonal relationship with the family. Rationale: meets nutritional requirements of coma clients. Signs of deterioration in a patient’s level of consciousness are usually the first indications of further impending brain damage. 5. Figure 28.2 illustrates a number of activating pathways passing from the mesencephalon upwards. Unconscious patients are nursed in a variety of clinical settings and therefore it is necessary for all nurses to assess, plan and implement the nursing care of this vulnerable patient group. In cycle A, the RAS excites the cerebral cortex and the cortex in turn re-excites the RAS. The patient is able to produce phrases or sentences but the conversation is rambling and inappropriate to the questions being asked. Both require a thorough assessment to determine the level of nursing care that they will need. Understanding what may trigger your reactions … of personal hygiene and care of pressure areas including prevention of foot Such localised defects are not generally regarded as a true altered state of consciousness, but this example highlights the difficulties in defining true conscious behaviour. To speech = scores 3. If the patient has retention of urine, apply gentle pressure Common causes of altered level of consciousness are illustrated in Figure 28.3 (see www.headway.org.uk). Side railing on both sides are helpful to protect the There are numerous pathways to both mesencephalic and thalamic areas, arising from the sensory, motor and cortical regions of the cerebral cortex, that deal with a range of emotions. Management of-unconscious-patient 1. What is meant by a head injury patient? Unconscious clients have increased metabolic needs (immunodeficiency, proteins wasting, lung tissue, catabolism, negative nitrogen state). electrolyte balance and nutrition : The diet must contain an adequate supply of all nutrients However, the patient is able to control vertical eye movements and blinking and may be able to use these movements to develop a simple communication system. Minor disturbance such as irritability can easily go undetected and comments from a relative such as ‘she does not seem to recognise me today’ may denote a subtle change in behaviour that requires further investigation. The verbal response may also be compromised by the presence of an endotracheal or tracheostomy tube. For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed. Author Max Geraghty is senior staff nurse, Intensive Care Unit, North Middlesex University … Score = 1. The patient opens their eyes when first approached, which implies that the arousal response is active. Sleep is induced by a hormone called melatonin which is synthesised from serotonin in the pineal gland. Irrigate the eye with sterile prescribed solution to remove The primary care team plays a major role in supporting patients following acquired brain injury, facilitating referral to specialist agencies (see. Score = 6. the RAS may first stimulate the cerebral cortex, and the cortical areas responding to reason and emotion may ‘modify’ the RAS, either positively or negatively, according to the ‘decision’ of the cerebral cortex. of cerebral function ranging from stupor to coma. This assesses the integrity of the RAS in the brain stem and is observed and recorded using the following categories. As the condition develops, speech and communication becomes difficult and behaviour becomes increasingly inappropriate until control of basic and vital processes is completely disorganised. It may vary in degree but in its worse stage, no reaction of any kind is obtainable from the patient. D. Abnormal flexion. A. Supraorbital ridge pressure. Always assume that an unconscious patient is able to hear and understand what you say, particularly if you need to discuss sensitive issues with their relatives. In 1974, Teasdale and Jennett developed the Glasgow Coma Scale (GCS), a process used throughout the UK and worldwide as part of the neurological assessment and ongoing observation of the patient (see Figure 28.4). Appropriately handover to a colleague. Tamer's Management of the unconscious patient emergency medicine. Figure 28.5 Applying a peripheral painful stimulus: fingertip stimulation. How to go through your neuro ICU patient assessment. 9). To pain = scores 2. Be advised we are en route with a 23-month-old child found submerged in a swimming pool. No response may indicate a compromised airway or unconscious patient LOOK for symmetrical chest and abdominal movements. The unconscious patient is a medical emergency which can challenge the diagnostic and management skills of any clinician. how personal assumptions which we may not be aware of can lead to erroneous clinical decisions. This is called the ‘arousal reaction’ and is the mechanism by which sensory stimuli wake us from deep sleep (Guyton & Hall 2000).