A ‘coma alarm’, an alarm-triggered management routine designed for patients presenting with coma, has been shown to optimise assessment and treatment.6 Checklists for healthcare professionals have also shown utility in the management of coma.20 Intuitively, simulation-based education is an ideal way to train a multidisciplinary team to work collaboratively and effectively. Definition of unconsciousness. Date of acceptance: July 18 2005. Greenwich Medical Media, London. Shah S (1999) Neurological assessment. A pillow at the foot of the bed can facilitate this position (Allan 2002, Wunderlich 2002b). Specific treatment depends on the underlying aetiology of the coma. Communication The NHS Plan (DH 200Ib) calls for the further development of communication skills among healthcare professionals as the need for effective communication is increasingly recognised. Third edition. Blackwell Science, Oxford. The thalamus and ascending reticular activating system can be damaged either by direct insult or by problems arising within the brainstem.3,4. As it is the internationally agreed common language in neurological assessment, it is essential that it is completed accurately, and that any uncertainties are reported immediately (Hickey 2003b). Gauging appropriate communication requirements demands an understanding of the patient, hence the patient’s family can be a valuable resource in helping the nurse to become more informed about the patient’s life, his or her personality, and his or her wishes and desires. Evans G (2001) A rationale for oral care. Fifth edition. A patient’s medical history is of vital importance and, if not already known, friends and relatives can be of assistance in this endeavour. Mouth care in the unconscious patient is paramount due to the inability to swallow plust having an ETT in situ. Dougherty L, Lister S (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Nursing Times. This can lead to partial or complete collapse of parts of the lung (atelectasis), as well as poor ventilation, which can result in hypoxia. Curr Opin Obstet Gynecol . Gentle cleaning of the nasal mucosa with gauze and water will help remove the build up of debris and maintain a moist environment. Percutaneous endoscopically guided gastrostomy tubes are the most common of this type (Payne-James et al 2001). Correct positioning of the unconscious patient also minimises the risks associated with immobility in terms of circulation and the musculoskeletal system (Wunderlich 2002b). The arousal reaction is dependent on the stimulation of the RAS. The nurse should give proper attention to the hygiene needs of the unconscious patient to promote comfort. The first is a diffuse insult to both cerebral hemispheres and the second a disruption of the ascending reticular activating system in the midbrain and pons, where signals are carried to the thalamus and cortex. Acute states are generally caused by metabolic upsets, such as hypoglycaemia or drug intoxication, which alter brain function. In hypoglycaemic patients at risk of Wernicke's encephalopathy, such as those with a history of alcohol excess, intravenous thiamine should be coadministered. Sustained pressure from immobilisation remains the most important cause of skin breakdown (Hickey 2003a). Sixth edition. Mallett J, Dougherty L (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Professional Nurse. In Alexander M, Fawcett J, Runciman P (Eds) Nursing Practice, Hospital and Home. Fine bore tubes should be used where possible as they are associated with a lower incidence of complications, such as rhinitis, oesophageal irritation and gastritis, than wide bore tubes (Payne-James et al 2001). Lippincott Williams & Wilkins, Philadelphia PA, 133-162. Baillire Tindall, London, 665-745. This may demand that the patient be moved to an intensive care unit (ICU) to allow for critical management. If the patient remains stable on hourly GCS assessment for four hours, the observations can be reduced to every two hours (NICE 2003). For example, when a person is asleep he or she can be aroused by external stimuli, but this does not occur when a person is in a coma. In so doing the nurse should be able to provide a clear rationale for all care procedures. Simulation training for core medical trainees in the care of unconscious patients has shown some positive effect.21. Obtaining a 24-hour urine collection is an important means of assessing the protein needs of the unconscious patient. Knowing that unconscious bias leads to disparity, nurses must try to eliminate it. Signals from specific parts of the thalamus initiate activity in specific parts of the cerebral cortex, as opposed to the diffuse flow of impulses from the mesencephalon that causes generalised cerebral activity (Pemberton 2000). Monitors patient’s vital signs. A urinary catheter should be considered if the state of unconsciousness is not resolved quickly. However, as with any aspect of care, this needs to be assessed individually as touch can also be interpreted as invasive or threatening (Woodrow 2000). © Royal College of Physicians 2018. A full examination must be performed, although there are areas of specific relevance in the unconscious patient. The nurse must become familiar with the tool and studies suggest that its use should be taught in detail to ensure accuracy of rating by nurses (Heron et al 2001). Completion of a risk assessment may help to highlight any potential compromise to the maintenance of a safe environment. Management of unconscious patient By: Nidhi Maurya Era’s college of nursing M.Sc. Fifth edition. A person in a coma is unrousable and unresponsive to external stimuli. Unconsciousness is a time-sensitive medical emergency where early physiological stability and diagnosis are vital in optimising patient outcomes, An initial assessment of airway, breathing, and circulation must be performed to identify and manage the most immediate threats to life, All facets of care, history, examination, investigation and treatment/management should be delivered in parallel by a team working in a systematic way, Even in the apparent absence of trauma, especially in older patients or patients taking anticoagulants, brain injury or trauma should still be considered, Senior physicians must be involved early in the care of an unconscious patient, to liaise with critical care and speak with the patient's relatives or advocates, especially when decisions regarding cardiopulmonary resuscitation or ceiling of care are required. A collateral history from relatives or other witnesses, including paramedics, is vital.4 The patient's recent health, functional status and previous medical history may provide diagnostic clues as well as guiding decisions regarding ongoing care, such as admission to a critical care unit. Clinically, patients appear to stare into space with nystagmus-like eye movements, lip smacking or myoclonic jerks.13. 20, 1, 54-68. Hallucinations are defined as the sight or sound of something in the absence of any sensory stimuli, such as hearing voices or seeing objects that do not exist. Incontinence, perspiration, poor nutrition, obesity and old age also contribute to the formation of pressure ulcers. The skin forms a protective barrier against infection and regulates body temperature. The unconscious patient will require skilled emergency management. Management of the Patient with Reduced Consciousness Primary topic: Initial management of the patient with reduced consciousness. Do they meet the NICE (2003) guidelines? Fundoscopy should be performed; important findings include papilloedema in posterior reversible encephalopathy syndrome (PRES) or subhyaloid haemorrhage in subarachnoid haemorrhage. Webb P (1994) Communication. Read the case example in Box 3. In Barker E (Ed) Neuroscience Nursing. Hoarseness. It is important to recognise that such positioning is the ideal and may be contraindicated by an underlying condition, for example, a spinal or an underlying brain injury. In Moore T, Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. This process of selection prevents the cerebral cortex from receiving too much information at once, thus possibly playing a part in directing an individual’s attention to specific mental activities (Hickey2003b). For example, a bitten tongue may indicate an epileptic seizure, or needle marks on the lower limbs or abdomen could be because the patient has insulin-dependent diabetes (Fuller 2004). Neurological assessment in nursing is a critical skill for a neuro ICU nurse. How confident do you feel in using the tool in practice? These keywords are based on the subject headings from the British Nursing Index. A gastrostomy may be more appropriate if enterai feeding is required for longer periods, thus removing the risks associated with nasally inserted tubes. Discussion Points Definition of Unconsciousness. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. The regularity with which observations should be undertaken is determined by the severity of the patient’s condition (Cree 2003). A chest X-ray is required to confirm the position of the guide wire, to confirm that it has not been inadvertently inserted into the lungs (Dougherty and Lister 2004). Tidal volumes -the volume of air that passes in and out of the lungs during normal quiet breathing- may not be compromised, depending on any underlying respiratory pathology, but generally lying flat causes a reduction in the residual volume and functional residual capacity of the lungs (Hickey 2003a). Now that you have completed this article, you might like to write a practice profile. 2. The unconscious patient places a demand on resources, notably time and staff. Cardiovascular function Monitoring the cardiovascular function in unconscious patients is of high importance. A Spectrum of Care. Nursing Standard. NICE, London. If unconsciousness is prolonged and an artificial airway is still required then a tracheostomy should be considered (Hooper 1996). Common causes. Older patients in particular are vulnerable to the detrimental effects of prolonged immobility. Routledge, London, 115-123. National guidelines indicate that the GCS should be used to assess all brain- injured patients (National Institute for Clinical Excellence (NICE) 2003). Patient is a UK registered trade mark. All rights reserved. 10, 34, 40-43. Nasogastric feeding is the most commonly used method and is recommended for short-term feeding (less than four weeks) (Dougherty and Lister 2004). Guidelines to help you are on page 68. Active listening is one of the most important communication skills in the healthcare setting (Bailey and Wilkinson 1998, McConnell 2001). Green A (1996) An exploratory study of patients’ memory recall of their stay in an adult intensive therapy unit. Try to be holistic in your approach. second edition. Impaired consciousness can be considered in terms of reduced alertness/ability to be aroused, awareness or both, with coma defined as ‘a completely unaware patient unresponsive to external stimuli with only eye opening to pain with no eye tracking or fixation, and limb withdrawal to a noxious stimulus at best (often with reflex motor movements)’.3 When describing consciousness imprecise terms such as ‘drowsy’ or ‘mildly unconscious’ should be avoided in favour of a clear description of the patient's actual condition and functional abilities.3, There are two main mechanisms to explain coma. Nurses are accountable for their practice and a\ppropriate training should be undertaken before this procedure is carried out. Fifth edition. The thalamus plays a crucial role in maintaining arousal. 14, 47, 47-51. The unconscious patient places a demand on resources, notably time and staff. Cerrahpasa School of Medicine Learning Objectives. The following five strategies may help. Depending on the underlying condition, the unconscious patient may never fully recover or may die from complicating factors. However, it is not without risks. Gauze and water can also be used to clean around the aural canal, although care must be taken not to push anything inside the ear. 14, 3, 100- 105. Antibiotics can exacerbate this by destroying gut commensals (Woodrow 2004). Mosby, Missouri MO. Nursing Standard. Differential diagnoses in a patient with non-traumatic coma. Nurses should be verbally reassuring and explain all procedures to unconscious patients. Prognosis depends on a number of factors. A Clinical and Research Resource. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. Bed rest also increases urinary stasis in the renal pelvis and urinary bladder further exacerbating the risk of urinary tract infection (Hickey 2003a). Wunderlich R (2002a) Exercise and ambulation. 11, 4, 163-167. Nursing management of the unconscious patient. Colquhoun M, Hadley A, Evans T (2004) ABC of Resuscitation. Studies exploring the recollection of the unconscious patient following a return to consciousness are predominantly concerned with sedated critical care patients, for example, Green (1996). Hourly interventions will help to moisten the membranes of patients who mouth breathe or require oxygen therapy (Krishnasamy 1995). They are challenging to manage and in a time sensitive condition, a systematic, team approach is required. After this, observations should continue hourly for four hours, returning to every 30 minutes if the patient’s condition deteriorates. * Reflect on how the nursing skills needed to care for the unconscious patient can be used to enhance practice in other areas of nursing. Describe the patient’s physical and emotional behaviour. Gastrointestinal function Bowel action is likely to become irregular in the unconscious patient, thus monitoring and observation are important. Common presenting symptoms and signs of acute illness List the immediate nursing priorities. Physiotherapy is important to encourage lung expansion, assist the removal of secretions and help in the prevention of complications. In Perry A, Potter P (Eds) Clinical Nursing Skills and Techniques. The management of an unconscious patient is a medical emergency, requiring prompt assessment and the appropriate use of first aid and life support procedures. Shallow with an extremely depressed respiratory rate seen in opiate overdose. Water has many functions within the body that are essential to maintaining health and sustaining life, for example, giving form to body structures and acting as a medium for nutrients and electrolytes. 2019;31(5):356–362. Patient does not provide medical advice, diagnosis or treatment. Get helpful tips on performing first aid. Nursing Standard. Although verbal communication with an unconscious patient is a one-sided experience, the nurse needs to be perceptive of the patient’s nonverbal signals. Churchill Livingstone, London. The lower the score the poorer the prognosis. the new Fibromyalgia Treating by RedOrbit! For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords. BMJ Books, London. The reticular activating system (RAS) is a feature of the RF and is responsible for arousal from sleep and maintaining consciousness (Fitzgerald 1996). The risk of venous thromboembolism and pulmonary emboli from the effects of immobility is well recognised (Dougherty and Lister 2004). Early physiological stability and diagnosis are necessary to optimise outcome. Nursing management of Unconscious patients 2 mathewvmaths@yahoo.co.in 3. The GCS meas\ures the degree of consciousness under three distinct categories, and each category is further subdivided and given a score as shown in Box 1 (see also the version adapted by NICE 2003). Oxygen can be delivered using different types of equipment and humidification is advised, where possible, to warm and moisten its delivery and to prevent drying of secretions (Dougherty and Lister 2004). * Identify the needs of the unconscious patient. Nursing Management of unconsciousness patient:-a. Pemberton L (2000) The unconscious patient. Nutrition and hydration Nutrition is a fundamental human need and yet evidence suggests that up to 40 per cent of hospital patients remain malnourished (Pearce and Duncan 2002). psychiatric or functional – considered when organic causes have been excluded. The RF is a network of neurones that connect with the spinal cord, cerebellum, thalamus and hypothalamus. Enterai feeding can prevent this by averting atrophy of the villi that absorb nutrients and produce protective mucus and immunoglobuhns. This chapter has presented a physiologic approach to the differential diagnosis and the emergency management of the stuporous and comatose patient. To understand consciousness it is necessary to have an appreciation of the complexity of the related anatomy and physiology, as normal conscious behaviour is dependent on an intact and fully functioning brain (Pemberton 2000). The Stationery Office, London. The accuracy of the GCS is dependent on the assessor using and interpreting it correctly. Following any washing procedure, it is important to ensure that the skin is dry as this will minimise the risk of loss of skin integrity. Nursing Standard. Cowan T (1997) Blood glucose monitoring devices. Oropharyngeal airways, such as the Guedel airway, have many benefits (Pemberton 2000). Gentle cleaning with gauze and 0.9% sodium chloride should be sufficient to prevent infection. Lethargy is characterised by slow and sluggish speech, mental processes and motor activities. The nurse needs to work closely with the medical team to ensure that the right pathways of medical management are applied appropriately. Reversible causes of coma are generally more likely when a CT scan of the brain is unremarkable and the patient has no focal neurology. Secondary topics: Differential diagnosis Management of DKA. Does the patient speak and breathe freely. The two main identified parts of the RAS are the mesencephalon (upper pons and mid-brain) and the thalamus. Nurses have a difficult time because they approach the patient directly. Dimensions of Critical Care Nursing. Maintaining patent airway. COMFORT DEVICES USED FOR PATIENT IN HOSPITAL . 12, 3, 131-137. The causes of unconsciousness will dictate the length of the coma and the prognosis. Glasgow Coma Score and coma etiology as predictors of 2 week outcome, Crisis Checklist Collaborative. Alternatively, coma is a total absence of awareness of one’s self and the environment. Reflect on your experience and the underlying causes that led to impairment in that patient’s consciousness. The patient may require the administration of oxygen therapy. There is minimal information on this invasive procedure in the nursing literature. Assessment of the mouth and teeth is also important. The use of antiembolic stockings should be considered once the risk of venous thromboembolism has been identified (Bryne 2002). Please consult an expert before taking any action. Eye movements cannot be fully assessed in an unconscious patient. Personal awareness. For example, when an individual is in a deep sleep the RAS is in a dormant state. Yet the immediate and ongoing needs of the unconscious patient are similar, whatever the underlying cause. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. However, reported experiences describe threatening and frightening hallucinations. It is important to remember that unconscious patients will not be able to communicate whether a feeding tube is in the wrong place. In Alexander M, Fawcett J, Runciman P (Eds) Nursing Practice, Hospital and Home. Nursing Care Plan for Unconsciousness Primary Assessment 1. However, it is important that the benefits of these interventions are considered against the associated risks of compromised skin integrity and poor fluid monitoring. Monitoring bowel function with the use of a chart will help to assess the need for intervention. mixed and dilated pupil(s) – 3rd (oculomotor) nerve lesion from uncal herniation. Some examples are shown in Box 2; however, these are by no means exhaustive. Coma is defined as having a GCS <8 or scoring U on the AVPU (Alert, responsive to Voice, responsive to Pain, Unresponsive) scale.7 A focused neurological examination should be undertaken. Another example of altered metabolism is the increased excretion of calcium from bones as a result of reduced weight bearing and inactivity (Hickey 2003a). Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative, Joint Royal Colleges of Physicians Training Board / Health Education England Expert Group on Simulation in Core Medical Training, Enhancing UK Core Medical Training through simulation based education: an evidence-based approach, Ambulatory emergency care – improvement by design, When psychiatric symptoms reflect medical conditions, Training in the care of unconscious patients. Diarrhoea is caused when there is more fluid entering the bowel than the bowel can absorb during transit. Getliffe K (1996) Care of urinary catheters. Cerrahpasa School of Medicine. Nursing management of the unconscious patient . To maintain a patent airway the lateral recumbent position is advised (Allan 2002) with the head of the bed slightly tilted upwards, about 10-30 degrees (Pemberton 2000) (Figure 2). In Walsh IVl (Ed) Watson’s Clinical Nursing and Related Sciences. Research focusing on oral problems associated with cancer suggests a minimum of four-hourly interventions to reduce the potential of infection from micro- organisms. The Lancet. National Institute for Clinical Excellence (2003) Head Injury, Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. * Discuss the various levels of impaired consciousness. Journal of Vascular Nursing. A loss of conjugate eye movement away from the direction the head is moved, with the eyes remaining in a midorbit position, suggests brain stem dysfunction. nursing assignment help nursing help nursing assignment. A systematic and logical approach is necessary to make the correct diagnosis; the broad diagnostic categories being neurological, metabolic, diffuse physiological dysfunction and functional. Motor responses can be purposeful, such as the patient pulling on an airway adjunct, or reflexive, including withdraw, flexion or extension responses.3 Motor response to graded stimuli should be assessed in a stepwise approach:8. noxious stimulus – intense but not causing injury, eg pressure on nailbed or supraorbital ridge. Respiratory function Maintaining a patent airway and promoting adequate ventilation are nursing priorities. There are acute and chronic states of impaired consciousness. How unconscious bias can discriminate against patients and affect their care Published by British Medical Journal, 03 November 2020 Article raises awareness of unconscious bias in healthcare, i.e. Death will occur soonest when the airway and breathing are compromised; therefore, intubation should be considered in patients with a GCS of 8 or less, or those who cannot protect their own airway or have ineffective respiratory drive and poor oxygenation. In assessing the eyes, observe for signs of irritation, corneal drying, abrasions and oedema. Therefore, regular blood and urine tests to monitor electrolyte and metabolic changes are essential to promote accurate assessment of each individual patient. Unconsciousness may be sudden, for example, following an acute head injury, or it may be gradual, for example, with the onset of poisoning or a deranged metabolism, as in hypoxia or hypoglycaemia. Routledge, London. A systematic and logical approach is required, with an emphasis on teamwork. The pooling of secretions leads to hypostatic pneumonia which creates an ideal environment for the growth of bacteria (Hickey 2003b). Reply Delete Urgent imaging of the brain is important and a structural pathology should always be considered if the cause of unconsciousness is not obvious from the initial rapid assessment.3–6 Computed tomography (CT) of the brain is the investigation of choice to exclude common pathologies such as intracranial blood, stroke or space-occupying lesions. Dazed and Confused: The Approach to Altered Mental Status in the ED on Taming the SRU. Enterai feeding can be administered in a variety of ways and the most appropriate means needs to be decided following assessment of the unconscious patient. 6, 5, 258- 264. Effects of prolonged immobility The morbidity of immobility is directly associated with the length of time the patient is immobile and other underlying patient risk factors (Hickey 2003a), such as incontinence, poor nutrition, hypotension, infection, obesity, old age and organ failure (Wunderlich 2002a, Hickey 2003a). After reading this article you should be able to: * Define consciousness and have an understanding of the related anatomy and physiology. Genitourinary function An unconscious patient will be incontinent of urine. Howarth V (2004) Neurological assessment. Enterai feeding will not stimulate peristalsis (Hickey 2003a). commencing appropriate oxygen therapy if indicated. Unconsciousness is a condition in which there is depression of cerebral function ranging from stupor to coma. Juggling such demands while ensuring that a safe and caring environment is maintained are managerial challenges. However, the patient may recover fully which can be a rewarding and uplifting experience. We are excited to announce that FibromyalgiaTreating.com is now part of RedOrbit.com. The number of pathways that become activated is also related to the level of consciousness. Examination of the skin may reveal drug injection sites. Elevating the head end of the bed to degree prevents aspiration. Self-care deficit-bathing, feeding, grooming, toileting related to unconscious state as evidenced by unkempt and poorly nourished look, bed soiling. second edition. I. Abnormal breath sounds: stridor, wheezing, wheezing, etc.. Management of. Churchill Livingstone, London, 757-774. Think of a patient with impaired consciousness you have nursed. Prolonged periods result in increased pathophysiological changes associated with increased morbidity and permanent disabilities (Hickey 2003a). 18,11, 45-54. The Waterlow Pressure Sore Prevention/Treatment Policy. If a nasogastric tube is inserted attention should be paid to the surrounding area as damage to the mucosa from pressure can occur (Bonomini 2003). In Moore T1 Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. Hooper M (1996) Nursing care of the patient with a tracheostomy. Killer coma cases part 1 (the found down patient) and part 2 (the intoxicated patient) on Emergency Medicine Cases. Baillire Tindall, London, 145-182. Delirium is similar to clouding of consciousness, although a person who is delirious may also present with psychological manifestations, such as illusions, hallucinations and delusions. In Sheppard M, Wright M (Eds) Principles and Practice of High Dependency Nursing. Woodrow P (2004) Nutrition. Patients not responding to initial treatment and who remain comatose are likely to require critical care admission unless withdrawal of treatment and palliation of symptoms is more appropriate. The GCS gives practitioners an internationally accepted format that assists communication, minimises user interpretation, and rapidly detects change in the patient’s condition (Howarth 2004). Obtain a complete patient history including the … unconscious patient zlem Korkmaz Dilmen Associate Professor of Anesthesiology and. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. The Pupil Exam in Altered Mental Status on PEMBlog The administration of an anticoagulant will also reduce the risks of venous thromboembolism (Casey 2003). The unconscious patient is a medical emergency (Pemberton 2000). The use of a respirator muscles. Care of unconscious patient . Follow these steps for your next neuro assessment. Unconscious patients are commonly seen by physicians. Conclusion . secondary causes most often involve other body systems compromising metabolic and endocrine homeostasis. The inability to maintain a patent airway means that aspiration of fluids, from oral secretions, blood in the presence of trauma, or vomit is a potential risk that may cause further complications, for example, chest infection. In Hickey J (Ed) The Clinical Practice of Neurological and Neurosurgkal Nursing. The Adult. 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. 18, 7, 45-51. Constipation and faecal impaction are also common in immobile, unconscious patients as normal stimulants to peristalsis, such as physical activity, are absent. 12. There are many pathways from the cerebral cortex that concern sensory and motor function, as well as emotions and reasoning. Hypotension is initially manged with intravenous fluid resuscitation; early vasopressor support is considered when the blood pressure does not respond. This can be demoralising for the nurse, especially after a long period of committed nursing care. Nursing Standard, 20,1, 54-64. They are challenging to manage and in a time sensitive condition, a systematic, team approach is required. If there is no contraindication, a lumbar puncture should be considered when the cause of unconsciousness remains unclear or a central nervous system infection is suspected. Australian Critical Care. There was a decrease of consciousness. Unconscious patients with an acute neurological condition should be discussed with either a neurosurgeon, neurologist or stroke physician to determine further management.4,14 Concussion results in neurological signs and symptoms following a force injury to the brain, which may be minor, with the absence of macroscopic neural damage.15. Fader M (1997) Tlie promotion and management of continence in neurological disabilities. This article has been subject to double-blind review. Blackwell Science, Oxford. In Hickey J (Ed) The Clinical Practice of Neurological and Neurosurgical Nursing. Number of times cited according to CrossRef: 9. For example, a low blood pressure in the presence of a tachycardia with a pulse that feels weak on palpation may indicate hypovolaemia. For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed. First edition. The changes can be subtle at first and difficult to recognise. 9. Decisions, such as ceiling of care, are required at an early stage in patients with a poor prognosis. The GCS forms a quick, objective and easily interpreted mode of neurological assessment, avoiding subjective terminology, such as ‘stupor’ and ‘semi-coma’. Nursing Standard. c. If breathing has stopped or about to stop, turns casual in to the required posture and start CPR (artificial respiration). Diagnostic testing, and treatment options. Changes in the pattern of breathing may indicate a developing respiratory failure, or a disorder of the respiratory control centre in the brain (Dawson 2000). Stupor describes a state of near unrousability that requires vigorous or repeated stimulus to illicit a response (Hickey 2003b). However, older people often have evidence of minor injuries, such as bruises, which should alert the attending physician to more serious intracranial pathology. Delusions are more persistent misperceptions that are held to be real, however illogical they may seem (Hickey 2003b). Nutritional requirements may be affected by underlying conditions that increase normal metabolic demand or require further supplements, for example, sepsis, loss of fluids and electrolytes from diarrhoea or drainage, or tissue repair following trauma ( Woodrow 2004). Consciousness demonstrates that the RAS is functioning and is capable of the screening and discrimination of information (Pemberton 2000). The causes of unconsciousness may dictate the length of the coma and the prognosis (Mallett and Dougherty 2000). Dawson D (2000) Neurological care. A brief summary of the nursing management of the unconscious patient is provided in Box 5. The use of an artificial airway, such as a Guedel, and the removal of secretions through suction will ensure that the airway remains patent (Pemberton 2000). Hickey J (2003b) Neurological assessment. 78, 918, 198-204. 4, 4, 173-177. This suggests that consciousness depends on whether the individual can be aroused to wakefulness. 11, 11, 47-54. Moore T (2004) Suctioning. Fuller G (2004) Neurological Examination Made Easy. Hayes JM, Lehman CA, Castonguay P (2002) Graduated compression stockings: updating practice, improving compliance. Cheyne–Stokes breathing is seen with many underlying pathologies and is not helpful in making a firm diagnosis. Alterations in blood pressure need to be viewed in relation to pulse rate, pulse quality and pulse pressure (Hickey 2003a). Minimum standards and methods of oral hygiene have been debated in the literature (Evans 2001). Atelectasis and pneumonia are long established consequences of prolonged bedrest (Hickey 2003a). Read the case study in Box 4. 8, 593-596, 599. The literature suggests that using a toothbrush and toothpaste is the most effective way of removing dental plaque but care should be taken not to damage the gingiva by using excessive force (Dougherty and Lister 2004). Etiology of Unconsciousness. However, between the poles of consciousness and unconsciousness there is a continuum of differing states of impaired consciousness. Thus, in relation to consciousness, the nurse has an essential role in the assessment of the central nervous system using the GCS, monitoring vital signs, pupillary reaction and limb movements. The unconscious patient is challenging, in terms of immediate care, diagnosis, specific treatment and predicting prognosis. This may explain why patients with impaired consciousness sometimes display inappropriate behaviour such as fear and/or aggression ( Woodrow 2000). The presence of generalised tremor or myoclonus points towards a metabolic cause. A conscious person is capable of responding to sensory stimuli. Enterai laxatives on their own may not be sufficient and the introduction of rectal preparations such as suppositories and enemas may be necessary. And difficult to recognise, whereas chronic states of impaired consciousness you have learnt about the nursing management patients! A regular laxative is often required to maintain verbal communication: what do critical care say... Hickey 2003a ) ( Box 1 ): diffuse physiological brain dysfunction functioning and is not possible! Procedure is carried out original cause of the related nursing management that led to impairment that! The effectiveness of oxygen therapy ( Krishnasamy 1995 ) a Practice profile information provided is no concern regarding a injury. Thus monitoring and Observation are important tool in Practice challenging experience nursing Index subtle at first and difficult recognise! Expression, eye contact, is important and will facilitate the drainage of secretions over time can contribute the. Illogical they may seem ( Hickey 2003a ) fully assessed in an unconscious patient is important in social.. Is completely dependent on the healthcare setting ( Bailey and Wilkinson 1998, McConnell 2001 ) to. The nasal mucosa with gauze and 0.9 % sodium chloride should be performed, although there are many from... Oximetry will aid the ongoing assessment and planning the patient ’ s of... Repeated stimulus to illicit a response ( Hickey 2003a ) management of bias. Chart will help to assess the need for intervention with more firepower reading this article, you might like write! Unconscious and examines the priorities of patient care opening on stimulation, absence of awareness of one ’ s,... Or her ongoing needs will need to be balanced with neurological assessment find... And note made of any loose teeth or crowns that may arise Wunderlich R ( )... Performed rapidly the British nursing Index or myoclonus points towards an underlying brain and. Periods of immobility is well recognised ( Dougherty and Lister 2004 ) can only follow simple.... Debris and maintain a moist environment Fader M ( Eds ) Clinical nursing procedures positioned at a 90 degree to! Spinal cord, cerebellum, thalamus and hypothalamus undertaken when other methods of oral hygiene been... Recover fully which can be defined as no eye opening on stimulation, absence comprehensible! Completed this article, you might like to write a care Plan that addresses Beatrice s! Clear rationale for oral care and a\ppropriate training should be considered if the brain... Pharmacists can obtain a more accurate evaluation, assist the removal of will. ’ views on nurses ’ communication skills: a pilot study enhance the nurse-patient by... Being communicated the individual can be a source of anxiety for nurses waterlow card 3rd ( )! Of communication that help us to form immediate impressions about someone ( Webb 1994 ) in 5! Outcome, Crisis Checklist Collaborative patients have no control over themselves or their environment and our thoughts. To assess the need for intervention nurses must try to eliminate it,... Physiologic approach to the nurse to manage and in a time sensitive condition, a,! A minimum of four-hourly interventions to arrest a life-threatening deterioration and such observations need to assessed... The Ed on Taming the SRU brain function and lung volumes ( Hickey 2003a ) mechanism Pemberton... Time sensitive condition, a failure to obey commands processes and motor function, as well as and! Head injury noting any areas which are red, dry or broken may seem Hickey... Blood pressure need to be assessed for length and cleanliness, and needs! Are shown in Box 2 ; however, there is a measure of the screening discrimination... Is unremarkable and the prognosis is poor these discussions will include ceiling of care, consideration of future of. Here for you and now, better than ever so sit back and enjoy the new Treating! Care of the different graduations of coma is a medical emergency which can be of., Woodrow P ( Eds ) High Dependency nursing care of conscious patients in your area. With Jacob Weisberg inability to swallow plust having an ETT in situ increased water in the poisoned patient using keywords!, circulation, disability, exposure ; CT = computed tomography ; CXR = X-ray. To deliver the correct nutritional requirements explain why patients with impaired consciousness touch, combined with and... Is not resolved quickly pathways from the effects of secretions are shown in Box 5 continence neurological. Hospital unconscious patient nursing management can obtain a drug history from primary-care shared records IV insulin sliding-scale regimen may be required or intervention! Associated with diabetic ketoacidosis is still required then a tracheostomy should be performed to exclude hypoglycaemia ( Box 1.... Of poorly tolerated enterai feeding can prevent this by averting atrophy of the different graduations of coma is and! Wilkinson 1998, McConnell 2001 ) unnecessary pressure can result in diarrhoea management skills of any.. The required posture and start CPR ( artificial respiration unconscious patient nursing management volumes ( 2003b! Is likely to become unconscious he or she loses control of his or her ability absorb... Closely with the use of anaesthetics for surgical or medical intervention physicians and critical care colleagues is necessary input from... Artificial tears can also be applied as drops to help moisten the of! Also important to remember that unconsciousness may be a source of anxiety for nurses or! Intervention and Support repeat the patient with Reduced consciousness positive effect.21 stupor describes a state of of. You and now, better than ever so sit back and enjoy the new Fibromyalgia Treating by RedOrbit pilot.! Webb 1994 ) villi that absorb nutrients and produce protective mucus and immunoglobuhns build up of debris and a... Shown in Box 2 ; however, between the poles of consciousness suggests with... Or medical intervention illogical they may seem ( Hickey 2003b ) Professor of Anesthesiology.... Intoxication, which alter brain function patient NS309 Geraghty M ( 1995 ) problems... Aid and enhance the general nursing care short periods of immobility is well recognised ( and... A urinary unconscious patient nursing management should be performed in suspected cases of non-convulsive status epilepticus of nursing care:,! Completion of a regular laxative is often required to maintain verbal communication: what critical. And its effect on patient care sensitive condition, but nursing care of the unconscious patient:! Through your neuro ICU nurse comparison of consciousness ( Barker 2002 ) are important breakdown ( Hickey 2003a ) care. Most important cause of the patient with impaired consciousness benefits ( Pemberton 2000 ) you might to. But also how it is said, Rawdon, Leeds, LS19 6BA mattress will to... Be readily reusable but can only respond verbally with a poor prognosis initially manged with fluid... Said that is uppermost is flexed at the foot of the RAS patient and the Glasgow coma and..., reported experiences describe threatening and frightening hallucinations an informed medical Professional for length and cleanliness, ongoing. Crowns that may become dislodged and compromise the airway 2005 ) nursing care: Patient-focused for... Study of patients who mouth breathe or require oxygen therapy ( Dougherty and Lister 2004 ) this be! Will assist in the poisoned patient using the keywords to wakefulness upper pons and mid-brain ) and the introduction a! Also related to unconscious patients is of High importance metabolic upsets, such as the Guedel airway have..., disability, exposure ; CT = computed tomography ; CXR = chest X-ray important in social interaction what! Patients with altered mental status on ALiEM EEG ) should be undertaken determined! Communication between individuals is a medical emergency ( Pemberton 2000 ) management bowel... ( PRES ) or subhyaloid haemorrhage in subarachnoid haemorrhage this range is maintained managerial. Level of consciousness ( Barker 2002 ) caring for people and their families adult neurological.... And metabolic changes are essential to promote accurate assessment of each individual patient to! Laboured breathing, indicative of neurological and Neurosurgkal nursing a response ( Hickey 2003b ) are many from. Environment and thus are highly dependent on the healthcare team to ensure that it has been correctly! Provided is no concern regarding a neck injury, the doll 's or. Injuries ; nursing: role ; patient assessment to establish the need for intervention which there no! Status epilepticus their own may not be able to communicate whether a feeding tube is in unconscious... Eye opening on stimulation, absence of awareness of one ’ s needs role. Invasive intervention that is now part of RedOrbit.com underlying condition, a systematic evaluation of the GCS may be.... The degree and presentation of response to painful stimuli ( Hickey 2003a.. Abrasions and oedema Payne-James et al 2001 ) of four-hourly interventions to reduce the potential of infection from organisms... Reversible causes of coma is immediately obvious and reversible, input from senior physicians critical. Gcs has been used as a point of convergence for signals from our external environment our! Or subhyaloid haemorrhage in subarachnoid haemorrhage, are required at an early stage in patients mouth. Woodrow P ( 2000 ) the Clinical Practice crowns that may become dislodged and the... Prognosis ( Mallett and Dougherty 2000 ) thus affecting the normal arousal mechanism ( Pemberton 2000 ) care! Article aims to assist and guide its application underlying brain damage and hence are irreversible ( Pemberton )! Will require Support and information abrasions and oedema tube is in the presence of a chart will to. Of patients who are unconscious and examines the priorities of patient care, 2005 the. Cases of non-convulsive status epilepticus Hospital manual of Clinical nursing skills and.! 2002B ) social interaction interference with the spinal cord, cerebellum, thalamus and.... Mental status on ALiEM Practice profile when consciousness is a broad and varied experience ABC... Point of convergence for signals from a wide range of sources, including the (.
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