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Moderator: Dr. Rachel AndrewsPresenter: Mr. Mahesh Kumar Sharma
M.Sc.(Neurosciences Nsg.) 1st yr.
Consciousness
It is defined as a state of awareness of oneself and of one’s environment , as well as a state of responsiveness to that environment or adaptation to the external milieu.
Components of consciousness
It comprises of two components :Arousal Awareness
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 etc.
Any abnormality of the following areas can cause unconsciousness:
Bilateral hemispheric abnormalityBrainstem abnormalityThalamic abnormality
Structural brain lesions: Supratentorial lesions Infratentorial lesions
Metabolic causesPsychogenic causes
ABNORMALITIES
Supratentorial lesions
Destructive lesions :result indirectly from interruption of the blood
supply, leading to infarction, or from direct injury to the brain.
Compressive lesions:can compress or distort brain tissue and
arteries, resulting in shifting or herniation of brain tissue from one compartment to another.
Supratentorial lesions
Supratentorial lesions:Large cerebral infarct with edemaIntracerebral , subdural , extradural,
Subarachnoid hemorrhageCerebral tumorCerebral abscessCerebral edema
Contd ….
Infratentorial lesions :Brainstem infarcts or hemorrhageBrain stem tumorBrainstem traumaCerebellar abscessCerebellar hemorrhage
Cavernoma of brain stem
Metabolic /diffuse causes Diseases of neurons Metabolic encephalopathy Diseases of other organs e.g. liver, lungs etc. poisons, alcohol and drugs Fluid and electrolyte imbalance Concussion and Postictal states Infections Nutritional deficiency Hypoglycemia Anoxia or ischemia Common fainting Temperature regulation disorders
Psychogenic causes
Hysteria
Catatonia
Continuum of unconsciousness
disorientedshortened attention span memory deficitsdifficulty in following commands alteration in perception of stimuli.
Disoriented to time, place and personIncreased motor activities.Illusion, hallucinations
Reduced ability to be aroused & limited response to environment.Sleeps unless stimulated with speech or touchVerbally a grunt or nod
Deep sleep or unresponsiveness Can be aroused only with painful stimuliResponds by withdrawing or grabbing at the source of pain
Coma
State in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli.
Contd…..Totally unconscious, unresponsive, unaware, and unarousable.
Do not respond to external stimuli, such as pain or light
Do not have sleep-wake cycles.
Coma usually lasts a few days to a few weeks.
After this time, some patients gradually come out of the coma, some progress to a vegetative state, and some die.
Related terms
Vegetative statePersistent vegetative statesLocked in syndromeAkinetic mutismBrain death
Vegetative state
Opens eyes spontaneouslyDoes not follow commandsNo intentional movements Show spontaneous roving eyes Sleep awake cyclescan result from diffuse injury to the cerebral hemispheres of the brain without damage to the cerebellum and brainstem
Persistent vegetative state
Many patients emerge from a vegetative state within a few weeks, but those who do not recover within 30 days are said to be in a persistent vegetative state (PVS).
Locked in syndrome Caused by damage to specific portions of the lower brain and brainstem with no damage to the upper brain. Eye opening is well sustainedBasic cognitive abilities are evident on examinationMode of communication is eye movements or clinking of the upper eyelid
Akinetic mutism Patients are immobile and usually lie with their eyes closed. Sleep wake cycles exists. There is little or no vocalization. Motor response to noxious stimuli is absent or minimalCommand following or verbalization can be elicited but occur infrequently
Brain death
Irreversible damage of the brain, including the brainstem and cerebellum, and cessation of functions. Pulmonary and cardiac functions can be maintained by artificial means.
Untreated coma causes it.
Diagnostic criteria of brain death
THE HARVARD CRITERIA
Criteria Confirmation Duration Absence of hypothermia and drug intoxication
Unresposive comaApneaAbsent reflexes
Isoelectric electroencephalogram
24 hours
THE MINNESOTA CRITERIA Criteria confirmation Duration
Irrepairable intracranial lesion
-No spontaneous movements-Apnea when off respirator for 4 min.-Absent brainstem reflexes-Dilated and fixed pupils-Absence of corneal, ciliospinal, vestubular, tonic neck and doll’s eye
-Conventional angiography with no filling of intracranial vessels-Cerebral blood flow studies demonstrates no cerebral blood flow
12 hours
Stringent criteria
A pupillary light responseB testing the corneal responseC injection of ice-cold water to test the vestibulo-ocular reflexD stimulating the glabella with the knuckleE stimulating the trachea with a suction catheter
Confirmatory tests
Conventional angiography EEGTranscranial dopplerNuclear brain scan Single photon emission computed tomography Somatosensory evoked potential
Syncope/blackouts
Temporary loss of consciousness and posture, described as "fainting" or "passing out."
Causes of syncope
Diminished venous return to the heart Disorders of the pump ( decreased cardiac output ) Disorders of pathways Disorders of blood
when it is important?
Some forms of syncope suggest a serious disorder:those occurring with exercise those associated with palpitations or
irregularities of the heart those associated with family history of
recurrent syncope or sudden death
Do’ s for syncopeCatch the person before falls.
Have the person lie down with the head below the level of the heart.
Raise the legs 8 to 12 inches.
If a victim knows who is about to faint can lie down right away, he or she may not lose consciousness.
Do’s Turn the victim's head to the side so the tongue doesn't fall back into the throat.
Loosen any tight clothing.
Apply moist towels to the person's face and neck.
Keep the victim warm
Don’ts for syncope
Don't slap or shake anyone who's just fainted.
Don't try to give the person anything to eat or drink, not even water, until they are fully conscious.
Don't allow the person who's fainted to get up until the sense of physical weakness passes.watch for a few minutes to be sure he or she doesn't faint again.
Examination of an unconscious patient
History Level of consciousness: assessed with the help of glass gow coma scale.
EYE OPENING RESPONSE (E)- Spontaneous eye opening - 4- Opens to voice - 3- Opens to painful stimuli - 2- No response - 1
VERBAL RESPONSE (V)- Oriented, normal conversation -5- Confused, disoriented -4- Inappropriate words -3- Incomprehensible sounds -2- No response - 1
BEST MOTOR RESPONSE (M) - Obeys command -6 - Localizes pain -5 - Withdraws to pain -4 - Abnormal flexion -3
- Abnormal extension -2 - No response -1
Research input : Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness.
Holdgate A, Ching N, Angonese L.Department of Emergency Medicine, Emergency
Medicine Research Unit, Liverpool Hospital, Liverpool BC, NSW, Australia.
. A senior ED doctor (emergency physicians and trainees) and registered nurse each independently scored the patient's GCS in blinded fashion within 15 min of each other
, a significant proportion of patients had GCS scores which differed by two or more points. This degree of disagreement indicates that clinical assessment with GCS should not be considered as the only mean of deciding treatment.
Contd……..
Neurogenic respiration :
Apneustic breathing:
Ataxic respiration:
Pupils examination
Eye examination
Extraocular movements
Brain stem reflexes
Doll’s eye reflex:
Doll’s eye reflex
Oculovestibular test
40 to 60 mL of ice water is used to irrigate the ear. If the brainstem is intact, the eyes deviate to the side of the cold water.
1)Corneal reflex:Blinking indicates 5 th and 7 th cranial nerve functioning.
2)Gag reflex
Motor response
DECORTICATE / DECEREBRATE POSTURING
Myoclonic jerks
Diagnostic tests
ELECTROLYTES : BUN, creatinine, liver enzymes, CBC, PT, PTT
ABG analysisURINE SCREEN for alcohol and drug levelsARTERIAL AMMONIA LEVELSTHYROID STUDIES
Contd…..
CT/MRI: scan for history of head trauma
CARDIAC STUDY: 12-lead studyTRANSCRANIAL DOPPLER: to rule out vasospasm.PET : if available
Differential diagnosis b/w different causes of coma
FOCAL LESIONS: 1) Motor signs unilateral & asymmetrical2) Signs of dysfunction progress rostral to caudal3) Comma follows motor abnormalities4) Pupils unilaterally non reactive; later B/L non
reactive5) Sudden onset
Metabolic coma
1)Confusion and stupor commonly precede motor signs
2)Motor signs usually are symmetric3)Pupillary reactions are preserved in most cases4)Asterixis, Myoclonic, tremor, and seizure are
common5)Acid-base imbalances are common
Psychiatric causes
1)EEG is normal2)No pathologic reflexes3)Eupnea or hyperventilation is usual4)Motor tone is inconsistent or normal5)Pupils reactive or dilated6)Lids close actively
Syncope :Vasovagal syncope
Lower head end at onsetPostural hypotensionHyperventilation
Reassurance & exercises to control breathing Cardiac arrhythmias
Pharmacological or implanted pacemaker control of cardiac rhythm.
Contd …Hypoglycemia
Attention to drug regime in diabetes Removal of insulinoma of pancreas
Vertebro basilar TIAs Treat source for emboli—Aspirin
Epilepsy Anticonvulsant drugs
Hysterical attacks Try to establish the reason for this behaviour Careful explanation to the patient
Initial management for coma
ABC:
A achieve optimal oxygen and glucose transport to the brain
B minimize the adverse effects of metabolic and structural disturbances, with particular reference to raised intracranial pressure (ICP)
Contd…….
Hyperventilation Helps to reduce raised ICP by removing extra CO2 and causing vasoconstriction ,thus decreasing raised ICP.
Pharmacological treatment Mannitol : 0.5 mg/kg over 15 min and repeat
after 4 hrs.
Steroids : DexamethasoneLoop diuretics : inj. Lasix 40 mg statAntihypertensives
Surgical interventions: ventriculostomy for draining CSF.
Treatment of underlying causes
Hypoglycemia : 50 ml of 50% D IV pushwernicke’s encephalopathy :thiamine Drug overdose :naloxoneSeizures : antiepilepticInfection :antibioticsHyperglycemia: insulinPoison ingestion: gastric lavage
Monitoring : ongoing for vital signs and neurological examination.
Nursing Assessment LOCRR, rhythmPupils Cornea Eye movementsDoll’s eye reflexVitals Skin Bladder function Intake and outputPulmonary functions
Nsg .problems
high risk for Airway obstruction r/t loss of swallowing, gag and coughing reflexes. Clear the airways of any foreign body and loosen
any tight clothing If suspecting spinal injury, do not move the patient
without neck collar. Use jaw thrust method to resuscitate the patient . Place the patient in lateral or semi prone position. Intubation may be required to maintain the airways
High risk for aspiration r/t ineffective airway clearance and absent gag reflex.
place in lateral position to allow the drainage of secretions
assess for breath sounds every 2-4 hourly do trachoebronchial suctioning while giving mouth care, place the patient with the
head turned to one side. Monitor ABG and other parameters.
high risk for altered cerebral tissue perfusion r/t increased ICP.
assess LOC including alertness and orientation 2-4 h.
assess pupillary size, position, response to light and consensual response
assess EOM 1-4 h cognitive function may be impaired by edema and
inadequate blood flow note verbalization and response to verbal
commands by checking hand grip and release, leg movements dorsiflexion and plantar flexion 1-4 h
in unconscious client note spontaneous movements, withdrawal to pain 1-4hs
report if any deterioration occurs monitor temperature 2 h and give hydrotherapy if it
is more than 38.5c monitor cardiovascular and pulmonary status, vital
signs elevate the head end of the bed by 30 degrees monitor intake and output 4h avoid extreme hip flexion monitor Hb and Hct assess for sign of bleeding check for hematuria administer blood and blood products
research input : The relationship of selected nursing activities to ICP.Rising CJ.Dakota Hospital, Fargo, North Dakota 58103-6014.Selected nursing measures--turning, suctioning and bathing--were recorded on the data collection tool as they occurred. Suctioning and turning were noted to be associated with an increase in ICP; however, a sustained increase in ICP was not observed. These findings further support the need for nurses to be aware of the patient's ICP prior to turning and suctioning.
high risk for injury r/t unconscious state
provide padded side rails prevent injury due to invasive lines a nd
equipments any kind of restrain is likely to be countered by the
patient with resistance, leading to self injury or to a dangerous increase in ICP
give adequate support to the limbs when moving an unconscious patient
protect them from external source of heat protect during seizures or periods of agitation
high risk for altered oral and nasal mucous membrane r/t NPO status, inability to swallow and unconsciousness
inspect the pt.’s mouth keep the lips coated with water soluble lubricant give oral hygiene 8 h avoid agents with lemon and alcohol as they cause
dryness suction the secretions clear the nostrils with swab
high risk for impaired skin integrity r/t immobility and loss of protective reflexes
-check for any signs of redness and excoriations at the pressure points
-Turn the patient from side to side every 2 h -unconscious women need perineal care -apply protective eye coverings with adhesive tape -use water mattresses and water filled bags to
protect form pressure sores
High risk for contractures r/t immobility
maintain the extremities in functional position by providing support
hand rolls prevent flexion contractures of the fingers
Cock up arm splints prevent wrist drop Splints, casts or high topped tennis shoes help
properly supprt feet Remove these support devices 4 h for skin care
and passive exercises.
Altered nutrition ;less than body requirement r/t inability to eat secondary to unconsciousnes
IV fluids are given initially Nutritional and fluid needs are met through NG feed but only
when: Patient does not have paralytic ileus or delayed gastric emptying Bowel sounds are audible Gastric residual volume is less than 100 ml/hr Nursing responsibilities in tube feeding are critical as the patient:
– Cannot communicate– May have lost protective cough and gag reflexes
As consciousness returns test the client’s ability to suck and swallow
Once a client can safely swallow, begin small oral liquid feedings
High risk for fluid volume deficit r/t inability to drink and respond to normal thirst mechanism
monitor intake and output every 4 h assess and document any sweating, diarrhea,
polyuria and vomiting assess blood urea, creatinine, sodium and potassium Over hydration and intravenous fluids with glucose
are always avoided because cerebral edema may follow
high risk for bowel incontinence r/t unconsciousness examine the patient for abdomen distension small and frequent stool may indicate fecal
impaction maintain a regular schedule of stool softners,
suppositories and digital removal begin a programme of bowel training
altered elimination r/t unconscious state there can be urinary retention
or incontinence if any sign of retention then
place an indwelling catheter palpate the bladder for
distension an external drainage for the
male patient and absorbent pad for female can be used
as soon as patient regain consciousness, start bladder training
altered communication r/t unconsciousness
explain all the procedures before carrying out them.Do not whisper at the bed side.Never shout or blame the patientDon’t discuss about the patient’s condition with the
relative at the bed sidelocked in syndrome patients communicate via blinking so
respond to them appropriatelybe calm , gentle and patient help the family members to communicate with the patient
and encourage them to talk effectively.
Communication with critically ill patients.Alasad J, Ahmad M.Department of Clinical Nursing, University of Jordan, Amman, Jordan. [email protected] study that investigated the experiences of a group of critical care Jordanian nurses concerning verbal communication with critically ill patients. : Communication with sedated or unconscious patients in intensive care units should not be viewed as only an interactive process. Rather, it should be perceived as the means to give the information and support that such patients need.
altered family process r/t family member in coma
explain about the condition of the patient
encourage them to clear their doubts and involve them in patient care
when a patient is not expected to survive then explain the family members about prognosis
COMA STIMULATION PLAN
TACTILE stimulationKINESTHETIC stimulationOLFACTORY stimulationORAL stimulationAUDITORY stimulationVISUAL stimulation
Research input : The effect of familiar and unfamiliar voice treatments on intracranial pressure in head-injured patients.Treloar DM, Nalli BJ, Guin P, Gary R.University of Florida, College of Nursing, Gainesville 32610.to investigate effects of verbal stimulation on ICP in head-injured patients. The familiar voice message was played to each subject. After a rest period, the unfamiliar voice message was played. ICP was recorded before, during and after playing both taped messages. suggest families of head-injured patients with normal ICP can verbally interact with the patients for short periods without significant increases in ICP.
Organ donation
Organ donation : is the removal of the tissues of the human body from a person who has recently died, or from a living donor, for the purpose of transplanting or grafting them into other persons.
Types of donationsBrain death donationsNon heart beating donations (cardiac
death)
Three most common causes for this non donation or mismatch are
family refusal non recognition or delayed determination of brain death loss of donors due to profound cardiopulmonary and metabolic instability
Nurses role in organ donation: to identify potential donors and contact the appropriate source to verify if the patient is eligible for tissue or organ donation.
A thorough assessment to be done by taking history and doing physical examination, to confirm with the diagnosis.
Contd….
A nurse must be familiar with types of donation and donation criteria .offer the family the option for donation, and provide bereavement support .become familiar with different religious positions regarding tissue and organ donation
Organ and tissue donation: a trustwide perspective or critical care concern?Elding C, Scholes J.Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Road, Brighton, UK. [email protected] assess the current level of knowledge, confidence and value system staff have, working in all areas of the hospital setting in relation to organ and tissue donation . Education strategies that adopt an experiential approach should be developed in order to create confidence in healthcare
Conclusion
Altered level of consciousness place a client at the risk of injury.Nurse play a very important role in caring for an unconscious patient, helping the patient in carrying out ADL.Proper assessment and prompt intervention can improve the prognosis.
References
Luck Mann’ s “medical and surgical nursing” 4th edition, Saunders's publications .page no.673-670.Barker’s “neuro sciences nursing” 2nd edition, mosby publications. Page no.698-712.www.google.com
