Care of unconscious patient

care of unconscious patient

1. UNCONSCIOUSNESS Presented by: Aruna Shastri msc nursing first year

2. Consciousness It is defined as a state of awareness of one’s self and of one’s environment , as well as a state of responsiveness to that environment or adaptation to the external milieu.

3. UNCONSCIOUSNESS Unconsciousness is a condition in which the patient is unresponsive and unaware of environmental stimuli.

4. CLASSIFICATION OF ALTERED LEVELS OF CONSCIOUSNESS 1. Confusional States 2. Delirium 3. Obtundation 4. Stupor 5. Coma

5. CONFUSIONAL STATES People who do not respond quickly with information about their name, location, and the time are considered " confused ". A confused person may be bewildered, disoriented, and have difficulty following instructions . The person may have slow thinking and possible memory loss . This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription ), and infection.

6. DELIRIUM : person may be restless or agitated and exhibit a marked deficit in attention . OBTUNDATION : a person has a decreased interest in their surroundings, slowed responses, and sleepiness . STUPOR : only respond by grimacing or drawing away from painful stimuli .

7. COMA State in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli touch, pain,light etc. 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

8. PERSISTENT VEGETATIVE STATE Can result from diffuse injury to the cerebral hemispheres of the brain without damage to the cerebellum and brainstem . Opens eyes spontaneously Does not follow commands No intentional movements Demonstrate sleep -wake cycle

9. LOCKED IN SYNDROME Patient is listening to you Caused by damage to specific portions of the lower brain and brainstem with no damage to the upper brain. Eye opening is well sustained Basic cognitive abilities are evident on examination Mode of communication is eye movements or clinking of the upper eyelid

10. 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 minimal Command following or verbalization can be elicited but occur infrequently

11. ETIOLOGY INTRA CRANIAL CAUSES EXTRA CRANIAL CAUSES METABOLIC CAUSES RESPIRATORY INSUFFICIENCY DECREASED CARDIAC OUTPUT ENDOCRINE CAUSES DRUG ABUSE (drug poisoning ) TOXINS PSYCHOGENIC CAUSES

12. INTRA CRANIAL CAUSES Head Trauma SAH Cerebral infarction Intra cranial Neoplasm CNS infection Epilepsy

13. EXTRA CRANIAL CAUSES METABOLIC CAUSES Hepatic failure Uraemia Hypoglycaemia/ Hyperglycaemia

14. RESPIRATORY INSUFFICIENCY Hypoventilation Anaemia Hypoxia Hypercapnea

15. DECREASED CARDIAC OUTPUT MI Cardiac arrthymia Antihypertensive Blood loss

16. ENDOCRINE CAUSES Diabetes-hyperglycaemia Hypopituitarism Adrenal crisis Hypo/Hyperparathyroidism Hypothyroidism

17. DRUG ABUSE (drug poisoning) - sedatives ,hypnotics, Anti- depressants, Anticonvulsants, Anaesthetic agents . TOXINS –alcohol ,carbon monoxide

18. PSYCHOGENIC CAUSES Hysteria

19. PATHOPHYSIOLOGY -UNCONSCIOUSNESS Conscious state depends on intact cerebral hemisphere and RAS Exposure to etiological causes diffusely affects the cerebral hemisphere and RAS Impairment of consciousness

20. ASSESSMENT LOC (GCS)

21. Head-eyes Occulocephalic reflex Normal : eyes turn together to side opposite the turn of head Abnormal : the eye do not change in conjugate manner.

22. Pupils assessment Size Unilateral ,dilated .fixed pupil- intracranial mass lesion Bilateral ,dilated fixed pupil- hydrocephalus Diffuse cerebral swelling pinpoint pupils- drugs and pontine hemorrhage

23. Head –ears Assessment Battle sign redness in mastoid process .

24. CONTD………. CSF ottorhea

25. Head –Nose Assessment CSF –Rhinorrhoea

26. MOUTH Look for alcohol smell or poisons smell. Smell of ketones -Diabetic coma Uriniferous odour-Uremic coma Musty smell-Hepatic coma See for tooth's missing to prevent aspiration

27. CHEST Respiration Spo2

28. CVS Rate and rhythm of pulse Rapid or slow rate may be associated with the cerebral hypo perfusion Examination of the heart by auscultation Absent peripheral pulse-peripheral vascular disease

29. skin cyanosis → hypoxia Macculohaemorrhagic rash → meningococcal infection, Staph. Endocarditis, Rocky mountain spotted fever Bullous lesion of barbiturate intoxication

30. SKIN Cherry-red spot →CO poisoning Telangiectasia & hyperemia of face & conjunctiva- alcoholism Multiple bruises,bleeding,CSF leakage from ear,nose,periorbital haemorrhage→skull fracture

31. SKIN Puffy face→myxoedema ↑ sweating→hypoglycaemia , shock Dry skin→diabetic ketosis, uraemia ↓Skin turgour →dehydration

32. ABDOMEN Assessment of abdominal girth is very important -Since distended will impair respiration. Tenderness and guarding – trauma or rupture of abdominal viscera. Enlargement of liver- hepatitis

33. GENITOURINARY Watch for bladder fullness Urine characteristics

34. EXTREMITY Watch for any injection marks –May be drug addiction

35. EXTREMITY Assess for tone ,muscle size in both side Assess for any contracture Asymmetric limb response ( hemi/ mono paresis) – Focal brain damage, e.g. Tumour ,trauma, hematoma, Symmetric limb response, suggest metabolic encephalopathy and drug toxicity.

36. DIAGNOSIS X-ray- Skull CT scan – coma raised ICP and focal neurologic signs

37. Lumbar puncture- Meningitis without coma, focal neurologic sign and fever.

38. 12-lead study TRANSCRANIAL DOPPLER: to rule out vasospasm. PET : if available

39. MANAGEMENT Medical management- Emergency management Symptomatic management Surgical management Nursing management

40. Medical Management Emergency management C irculation A irway B reathing

41. SYMPTOMATIC TREATMENT Wernicke’s encephalopathy :thiamine 100 mg IV as an initial dose followed by 50 to 100 mg/day IM or IV until the patient is on a regular, balanced, diet. Opioid Drug overdose :Naloxone 0.4 to 2 mg/dose IV/IM/subcutaneously. May repeat every 2 to 3 minutes as needed.

42. SYMPTOMATIC TREATMENT Seizures : antiepileptic Infection :antibiotics Poison ingestion: gastric lavage Fever:antipyretics,cold sponge Pain:analgesics

43. SURGICAL MANAGEMENT Hematomas – Surgical evacuation Hemorrhage ,tumor, cerebral abscess-Surgical decompression/ Partial or total resection Cerebral aneurysm - surgically clipping or endovascular coiling

44. NURSING MANAGEMENT

45. Risk for aspiration R/T unconscious state Keep NPO until risk assessment is complete Do not feed if airway protection or swallowing is compromised Position to facilitate oral drainage Follow precautions to prevent enteral feed aspiration

46. Ineffective airway clearance R/T unconsciousness Lateral or semi prone position Frequent position change Suctioning Elevating head end Chest auscultation Maintain patency of ET tube or TT Chest physiotherapy and postural drainage Ventilator settings

47. Risk for injury R/T unconsciousness Check dressings and casts for constriction. To protect the patient from self-injury and dislodging of tubes , use padded side rails or wrap the patient’s hands in mitts Prevent injury from invasive lines and equipment Careful suctioning

48. Ensure that oxygenation is adequate Ensure that the bladder is not distended. Enclosed or floor-level specialty beds may be indicated. Protect the patient from hypothermia and hyperthermia. Lubricate the skin with oil or emollient lotion to prevent irritation due to rubbing against the sheet . Minimize environmental stimuli

49. Risk for hyperthermia R/T brain damage Monitor the body temperature Environmental temperature control Prescribed antipyretic Cold sponge Hyperthermia blanket Prevent shivering

50. Risk for hypothermia R/T brain damage Assess body temperature frequently Provide a warm environment through use of heat shield, space blanket, heat lights, or blankets. Work quickly when any wounds exposed .

51. Altered nutrition less than body requirement R/T unconsciousness Assess the Hydration status by examining tissue turgor and mucous membranes, assessing intake and output trends, and analysing laboratory data. Meet the fluid needs initially by giving the required fluids intravenously. However, intravenous solutions (and blood transfusions) for patients with intracranial conditions must be administered slowly

52. If the patient does not recover quickly and sufficiently enough to take adequate fluids and calories by mouth, a feeding tube will be inserted for the administration of fluids and enteral feedings

53. Altered bowel elimination R/T immobility Assess abdominal distention No. and consistency of stool Rectal examination Measure abdominal girth Listen bowel sounds Stool softener Adequate fluid intake Dietary fibers

54. Risk for contracture R/T immobility Proper positioning Use splints ROM

55. Self care deficit R/T immobility and unconsciousness Provide basic hygiene care Dress and groom patient Provide nutrition Provide for elimination needs of patient

56. Impaired skin integrity R/T immobility and nutritional deficit Assess the skin specially on bony prominences for any color and temperature change Position change Avoid dragging Correct body positioning Use comfort devices Trochanter role Air mattress Back care

57. Sensory / perceptual alterations R/T unconsciousness Communicate with patient Orienting patient Involve family members

58. Altered family process related to disease state Clarify doubts Involve in patient care Encourage ventilation of feelings Supporting in decision making Support groups

59. MAINTENANCE OF CORNEAL INTEGRITY Artificial tears Eye irrigation Cold compress Eye patch

60. Complications Convulsions Bladder and bowel distention

61. Complications The Failure of multiple organs, such as the kidneys, lungs, and heart . Fluid electrolyte imbalance

62. Complications pneumonia or other life-threatening infections osteoporosis

63. Complications bed or pressure sores of the skin Deep vein thrombosis/pulmonary embolism

64. Complications Keratitis repeated bladder infections,

65. CONCLUSION An unconscious patient fully depends on us for his recovery as such it is our responsibility to always think critically before intervening. The more the knowledge we have the greater the difference we can make to life of unconscious patients.

66. REFERENCES Ramamurthi,tendon,Textbook of Neurosurgery,Vol 2, Page no.1225-1229. Michael Swash,John Oxbury,Clinical Neurology,Vol1,Page no.184-203. 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. Hickey ,Neurological and Neurosurgical Nursing,5 th edition ,Page no:345-357 Smelzer.SC,Bare,BG,Medical Surgical Nursing,Lipincot Williams& Williams 10 th edition,Page no: 1851-1856. http//www.google.com http//www.wikipedia.com