View
244
Download
0
Category
Preview:
Citation preview
8/13/2019 Shalini Joshi
1/15
1
Subject :- advanced nursing practice
Assignment
on
unconciousness
Submitted to submitted by
Mrs.Aparna Shalini Joshi
(Lecturer) M.Sc.nursing 1styear
Submitted on
19/11/201
8/13/2019 Shalini Joshi
2/15
2
index
s.No. Content Page no.
1 Introduction 1
2 Definition 1
3 Meaning of unconsciousness 1
4 Levels of unconsciousness 1-2
5 Causes 2-3
6 Pathophysiology 4
7 Sign and symptoms 5-6
8 Complications of unconsciousness 6
9 Assessment 7-9
10 Management
-medical
-surgical
-nursing
1010-11
14
8/13/2019 Shalini Joshi
3/15
3
INTRODUCTION
Unconsciousness: Loss of consciousness that may result from a wide variety of
causes. An unconscious person is usually completely unresponsive to their environment or
people around them. Unconsciousness can occur as a result of brain injury, lack of oxygen or
poisoning as well as numerous other conditions.
Nursing the unconscious patient can be a challenging experience. unconscious
patient have no control over themselves or their environment and thus are highly dependent
on the nurses. The skill required to care for unconscious patient are not specific to critical
care. With good knowledge base nurse initiate the assessment, planning and implementation
of quality care.
DEFINITION
A state of impaired consciousness in which one shows no responsiveness to environmental
stimuli but may respond to deep pain with involuntary movements.
Medical dictionary
Or
A state in which the cerebral functions are decreased, the individual are unresponsive to
sensory stimuli.
Or
an abnormal state of lack of response to sensory stimuli, resulting from injury, illness, shock
or some other bodily disorder.
Or
By dictionary meaningUnconsciousnessis the condition of being notconsciousin
a mental state that involves complete or near-complete lack of responsiveness to people and
other environmental stimuli. Being in a comatose state orcomais a type of unconsciousness.
Fainting due to a drop in blood pressure and a decrease of the oxygen supply to the brain is a
temporary loss of consciousness.
-From Wikipedia
Or
Unconsciousness is a state of complete or partial unawareness or lack of response to
sensory stimuli as a result of hypoxia caused by respiratory insufficiency or shock; from
http://en.wikipedia.org/wiki/Consciousnesshttp://en.wikipedia.org/wiki/Consciousnesshttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Consciousness8/13/2019 Shalini Joshi
4/15
4
metabolic or chemical brain depressants such as drugs, poisons, ketones, or electrolyte
imbalance; or from a form of brain pathologic condition such as trauma, seizures,
cerebrovascular insult, brain tumor, or infection. Various degrees of unconsciousness can
occur during stupor, fugue, catalepsy, and dream states.
MEANING OF UNCONSCIOUSNESS
The word unconscious means a person is lacking awareness and the capacity for
sensory perception as if asleep or dead. This word describes a person who has passed out due
to sickness. It can also be defined as a dramatic alteration of mental state that involves
complete lack of responsiveness.
LEVELS OF UNCONSCIOUSNESS
Excitatory unconsciousness Stuporous Fainting Somnolent Coma Vegetative stage
Exicitatory unconsciousness
Does not respond coherently but is disturbed by sensory stimuli such as bright light, noise.
Stupor
In stupor, patient responds to external stimuli and shows the symptoms of annoyance when
stimulated by pinprick or loud noise such as clapping of hands.
Fainting
In fainting, there is a momentary loss of consciousness and the patient usually recoversspontaneously Somnolent a sate when patient feels drowsy or sleepy or we can say it is a
state between sleeping and awakening.
Coma
Coma is a clinical state of unconsciousness in which the patient is unaware of himself and his
environment. The patient may respond to deep painful stimuli. In deep coma, there is no
arousal.
Vegetative state
8/13/2019 Shalini Joshi
5/15
5
Clinical condition of complete unawareness of self & environment with damage to CNS, No
chance to recover back.
CAUSES
Unconsciousness is when a person suddenly become unresponsive. he or she will not be ableto communicate and will not respond to stimulation. unconsciousness can be brought on by a
major illness or injury, or complication from drug use or alcohol abuse.
A person may become temporarily unconscious when sudden changes occur within
the body. common causes of temporary unconsciousness include:
-low blood sugar
-low blood pressure
-syncope
C-erebral:
-haemorrhage
-infarction
-tumour
-infection
-trauma
O-verdose
-alcohol
-alcohol withdrawal
-drugs
.sedatives
.narcotics.
.psychotropic
-poisons
.CN
.CO
-venom-snakes
M-etabolic
-endocrine
.hypoglycaemia
.hyperglycaemia
-environmental
.hypothermia
.hyperthermia
-organ failure
-electrolytes
-acid-base disorders
-vitamine deficiencies
-sepsis
A-
-arrhythmia
-asphyxia
-anaemia
-any cause of shock
8/13/2019 Shalini Joshi
6/15
6
-dehydration
-problems with heart rhythm neurologic syncope(caused by a seizure)
-straining
-hyperventilating
PATHOPHYSIOLOGY
Due to any cause
Changes in cardiovascular system,
Decrease venous return and delayed loading
Decrease cardiac out put and
Increased cardiac workload
Insufficient oxygen and nutrition supply
(Deprivation)
Insufficient tissue perfusion
Alteration in cell/tissue functioning
Multi organ dysfunction
8/13/2019 Shalini Joshi
7/15
7
Sign and symptoms of unconsciousness
Signs (that a person may become unconscious)-sudden inability to respond
-slurred speech
-a rapid heart beat
-confusion
-dizziness or light headness
Symptoms1-unresponsiveness
2-lack of awareness of self
3-lack of awareness of surrounding
Systematically clinical manifestation
RESPIRATORY SYSTEM
Stridor rales rhonchi progressive cyanosis cheyne stokes respiration Assymetrical chest wall movements decreased respiratory rate, decreased depth
CARDIOVASCULARSYMPTOMS
Bradycardia Hypotension Ventricular tachycardia Atrial fibrillation Hyperkalemic Arrythmias Decreased cardiac output
8/13/2019 Shalini Joshi
8/15
8
NEUROLOGICAL SYSTEM
Asterexis
myoclonus
seizures
cranial nerve palsies
lethargy
unequal pupillar dialation
absent deep tendon reflexes
absent dolls eye reflex
GASTROINTESTINAL SYSTEM
Due to the disruption of CN -10th (vagus) function Abdominal distension Decreased bowel sounds Constipation Ascites Hyperlipedemia
Urinary system
Urinary incontinence High creatinine index Oliguria ketonuria UTI& Pyuria
Complications of unconsciousnessPotential complications of being unconscious for a long period of time include:
1-coma
2-brain damage
3-chocking
4-injuries
5-respiratory compromises
8/13/2019 Shalini Joshi
9/15
9
Assessment
First of all make sure quickly that they are unconscious and not just asleep. Primary care is
exactly the same as basic life support airway breathing circulation.
1-history collection:
Historyshould be obtained from whatever sources are available, including friends,bystanders, police, and EMS personnel.Accurate and early identification of poison(s),
time of ingestion, vomiting history etc can critically assist in management.Crucial points
include the following:
recent head trauma, even seemingly trivial drug use (including alcohol), recent or past past medical history, including a history of seizures, diabetes, cirrhosis, or other
neurologic disease precomatose activity and behaviour (headache, confusion, vomiting) sudden versus gradual onset of coma other individuals with similar symptoms (indicates food poisoning, carbon monoxide
poisoning, bioterrorism etc..)
scenario- location/environment, suicide note, pills/bottles etc. Present family history social history and personal history
2-Physical examination
8/13/2019 Shalini Joshi
10/15
10
Neurologic assessment in unconscious patients is of paramount importance, and a
structured evaluation should be conducted as soon as possible once immediate threats
to life have been addressed. Although originally developed for traumatic brain injury,
the Glasgow Coma Scalehas been shown to have predictive value in many different
types of coma. Both total and component (eye, verbal, motor) scores should be
documented:
.
Cranial nerve examination (especially papillary response) is an essential part of the
neurologic examination and may assist in determining the level of brainstem dysfunction.
Symmetrically reactive pupils that are unusually large or small are commonly secondary to
drug ingestions.
Diagnostic evaluation
1-Laboratory Evaluation
8/13/2019 Shalini Joshi
11/15
11
o Electrolytes, LFTs, CBC, UA, urine/serum toxicology screens, thyroid functionstudies, BUN/Cr, and ABG should be obtained early in the evaluation of coma.
o Lumbar puncture and CSF analysis should be performed if not contraindicated (e.g.,mass lesions or other evidence of increased ICP) in patients for whom the cause of
coma is unclear or in whom an infectious cause is suspected.
o ECG should be obtained and cardiac monitoring instituted to eliminate cardiacarrhythmias as a contributing factor.o An EEG should be obtained when possible, especially in intubated patients receiving
paralytics and in those for whom nonconvulsive status epilepticus is a consideration.
2-Imaging
Not indicated when unconsciousness is obviously relate to hypoglycaemia, overdose or other
metabolic causes, but a noncontrast head CT is an integral part of the workup for coma and
should be strongly considered in any patient who remains comatose after dextrose and
naloxone.
3-MRI
Types of tissue, Tumors, Vascular abnormalities, Intracranial bleeding can be easily assessed.
4- LUMBAR PUNCTURE
Cerebral meningitis, CSF evaluation
5-EEG :- Electrical activity of cerebral cortex layer
Management
Medical management
Obtain And Maintain Airway. Insert oral airway Monitor Circulatory Status To Ensure Adequate Perfusion To The Body And
Brain.
Central Line Catheterization Foleys Catheterization Ryles Tube Insertion Prevention Of Complication
Empiric therapy,
Often referred to as the "coma cocktail, " consists of IV dextrose, thiamine, naloxone.
8/13/2019 Shalini Joshi
12/15
12
Naloxone (0.42.0 mg IV) rapidly reverses coma and respiratory depression secondary to
narcotic overdose but has a short half-life and multiple doses may be required.
Dextrose (50 mL of 50% solution in adults) reverses coma secondary to hypoglycemia and is
indicated if rapid testing of blood glucose is unavailable.
Thiamine (100 mg IV) is commonly given along with dextrose to avoid precipitating
Wernicke encephalopathy in predisposed patients.
Flumazenil (0.2 mg/min IV) specifically antagonizes benzodiazepines but is not routinely
given empirically as it may precipitate seizures that are then refractory to benzodiazepines.
SURGICAL MANAGEMENT
CRANIOTOMY
SHUNTING CSF DRAINAGE
DECOMPRESSIVE SURGERY Removal of skull PartAllow a swelling brain To
expand without being squeezed
EMERGENCY NURSING CARE
- Check clues and causes of unconsciousness
- NBM
-Loosen clothes
-Ease breathing by turning head to side
-- keeping neck straight, chin forward
-drain and clean mouth secretion
- remove artificial teeth if any.
- Keep warm and comfortable
- Observe LOC-Keep his extremities and joints in functional position
It is important to remember that hearing sense is the last one to go and first one to come
back, so avoid unnecessary talk
NURSING MANAGEMENT
the unconscious patient is assessed immediately upon arrival in order to initiate emergency
intervention as needed.
1-Asses adequacy of airway and ventila tory status.
8/13/2019 Shalini Joshi
13/15
13
A) .keep the neck in a neutral position, when indicated, based on mechanism of injury,
maintain cervical spine immobilization until cervical spine injury has been ruled out.
B). if the patient is brething spontaneously and does not require further airway management,
position patient ,when staff is not in attendance, in a lateral recumbent position with the head
is slightly elevated to prevent obstruction and aspiration.
C).assess need for oral suctioning to clear secretions.
2-Assess vital signs and neurologic vital signs utilizing GCS every 15 min unless otherwise
indicated until the patient condition stabilizes.
3-Monitor EKG and pulse oximetry .
4-Administer oxygen per provider order.
5-Lab work, ABG, EKG, X-Ray per provider order.
6-Stablish IV access and draw routine blood including toxicology screen as ordered. Initiate
IV fluids as ordered.
7-administer medication as provider order and assess response.
8-reorient patient to his/her environment as he/she awakens.
Nursing diagnosis-
1-Ineffective airway clearance R/t inability to swallowing
-Intervention
Airway management, an oral airway can be inserted
Care of ETT/ tracheostomy
Suctioning
Positioning
Chest physiotherapy Nebulization
2-Risk for aspiration R/T altered LOC
Intervention
Monitor ABG
Keep suctioning equipment available
Observe cardiac monitoring for dysrhythmias
Positioning
8/13/2019 Shalini Joshi
14/15
14
3- Impaired oral mucus membrane, R/T mouth breathing absence of pharyngeal reflex,
& altered fluid intakeIntervention----
Inspect pts mouth every 8 hours
Apply water-soluble lubricant to prevent cracking, drying.
Oral hygiene( to avoid parotities, aspiration and RTI)
4- Deficient fluid volume r/t inability to take fluids by mouth
intervention-
Accurate documentation of intake and output
Assessment and documentation of conditions that might increase fluid volume
deficit (diaphoresis, polyuria, diarrheal, vomiting)
Avoid over hydration in a patient receiving IV fluids because of risk of cerebral
edema
5-Imbalanced nutrition less than body requirements R/T inability to feed
Intervention
IV fluids NG Tube feeding
Maintain intake output chart
6-Risk for injury R/T decreased LOC
Intervention-
Side rails
Seizure precautions ( use padded side rails, keep the patients nail short)
Protect patients head
Usecaution when moving
Always turn an unconscious patient toward you or someone else to prevent fall.
Do not restrain the patient unless absolutely necessary, if restraints are used, they
must be released at least every 2hours for skin check. Avoid over sedation (which increases ICP)
Do not leave unattended.
7-Impaired urinary elimination R/T impairment in neurologic sensing and controlIntervention
Catheterization
Catheter care
Maintain aseptic technique
Monitor urine colour Initiate bladder training as soon as consciousness regained.
8/13/2019 Shalini Joshi
15/15
15
8- Bowel incontinence R/T changes in nutritional delivery methods
Intervention
Auscultate for bowel sounds; palpate lower abdomen for distension
Maintain food hygiene.
9-Risk of skin integrity R/T immobility
Intervention
Personal hygiene
Skin care, care of pressure points
Keep nails trimmed
Repositioned every 2 hours Put on special mattress or bed
Recommended