Subject

:-

advanced nursing practice

Assignment on unconciousness

Submitted to
Mrs.Aparna (Lecturer)

submitted by
Shalini Joshi M.Sc.nursing 1st year

Submitted on 19/11/201

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Introduction Definition Meaning of unconsciousness Levels of unconsciousness Causes Pathophysiology Sign and symptoms Complications of unconsciousness Assessment Management -medical -surgical -nursing

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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 meaning Unconsciousness is the condition of being not consciousin a mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli. Being in a comatose state or coma is 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

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 recovers spontaneously 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

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 able to 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. 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

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
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-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

Sign and symptoms of unconsciousness

Signs (that a person may become unconscious)

Symptoms
1-unresponsiveness 2-lack of awareness of self 3-lack of awareness of surrounding

Systematically clinical manifestation

Stridor rales rhonchi progressive cyanosis cheyne stokes respiration Assymetrical chest wall movements decreased respiratory rate, decreased depth

CARDIOVASCULAR SYMPTOMS
Bradycardia Hypotension Ventricular tachycardia Atrial fibrillation Hyperkalemic Arrythmias Decreased cardiac output

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 unconsciousness
Potential complications of being unconscious for a long period of time include: 1-coma 2-brain damage 3-chocking 4-injuries 5-respiratory compromises
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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:
History should 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

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 Scale has 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
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o Electrolytes, LFTs, CBC, UA, urine/serum toxicology screens, thyroid function studies, 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 cardiac arrhythmias 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.

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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 Part Allow 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.
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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 diagnosis1-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

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3- Impaired oral mucus membrane, R/T mouth breathing absence of pharyngeal reflex, & altered fluid intake Intervention--- 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 Use caution 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 control Intervention Catheterization Catheter care Maintain aseptic technique Monitor urine colour Initiate bladder training as soon as consciousness regained.
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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

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