SEMINAR ON SEMINAR ON UNCONSCIOUSNEUNCONSCIOUSNE

SSSS

// PRESENTED BY – MR SURESH PRESENTED BY – MR SURESH

KUMAR SHARMAKUMAR SHARMA

RN, MSN (PSYCHIATRY)RN, MSN (PSYCHIATRY)

INTRODUCTIONINTRODUCTION

The brain requires a constant supply The brain requires a constant supply of oxygenated blood and glucose to of oxygenated blood and glucose to function. Interruption of this supply function. Interruption of this supply will cause loss of consciousness will cause loss of consciousness

within a few seconds and permanent within a few seconds and permanent brain damage in minutes.brain damage in minutes.

MEANING OF CONSCIOUSNESSMEANING OF CONSCIOUSNESS

It is a state of that has three important aspects-

1)wakefulness;

2) Awareness of self,

3)Awareness of Environment and time.

REVIEW OF ANATOMYREVIEW OF ANATOMYBRAIN :-

1.Cerebrum

– Cerebral cortex

– Corpus callosum

2.Diencephalon

– Thalamus

– Pineal body

– Hypothalamus

3.Brain stem

– Midbrain

– Pons

– Medulla oblongata

4.cerebellum

• Specialized sensory tract • E.g.. Spinothalamic. Auditory, visual etc.

Spinal reticular tract collateral fibers

Spinal cord

Reticular formation

Perception of Cerebral cortex Thalamus

Consciousness

MEANING OF UNCONSCIOUSNESSMEANING OF UNCONSCIOUSNESS

• Unconsciousness implies that is a stage of

depressed cerebral function that result

impairment in response to sensory stimuli;

abnormal loss of awareness of self &

surroundings

• Its onset is both sudden and gradual.

LEVELS OF UNCONSCIOUSNESSLEVELS OF UNCONSCIOUSNESS

• Excitatory unconsciousness

• Stuporous

• Fainting

• Somnolent

• Coma

• Vegetative stage

Contd…• 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.

Cont…..Cont…..• 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 awakning.

Cont…..Cont…..ComaComa

• 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.

Cont….. Cont….. Vegetative stateVegetative state

• Clinical condition of complete unawareness of self & environment with damage to CNS.

• No chance to recover back.

ETIOLOGY ETIOLOGY • Structural lesions

1.Supratentorial lesions (causing brain stem dysfunction)

E.g.

EDH/SDH

Brain abscess

Cerebral infarction

Etiology Cont….Etiology Cont….

• CEREBRAL HEMORRHAGE

• BRAIN TUMOR

Etiology Cont….Etiology Cont….

2. Subtentorial lesions

compressing/destroying

the reticular formation

E.g.. Cerebellar abscess infarction

cerebellar hemorrhage/tumor

Etiology Cont…..Etiology Cont…..Metabolic disorder & diffuse lesionsMetabolic disorder & diffuse lesions

• Diabetic coma :- • cellular starvation, ketone bodies

• Hepatic coma :- – accumulation of waste product in systemic

circulation.• Fluid and electrolyte imbalance

– Na+ and osmolar imbalance in CNS• Nutritional deficiency• Anoxia or ischemia :- Po2<25mmhg

• Disease of neuron e.g.. Lesions of motor neuron

Etiology cont…Etiology cont…

• Concussion and postictal states• Drug overdose e.g. Sedatives, analgesic,

alcohol– Decrease HR, BP, RR, Tempt.

• Anesthetic agent• RTI • UTI • Psychogenic causes

• hysteria or catatonia

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Diabetic comaDiabetic coma

HEPATIC COMAHEPATIC COMA

CLINICAL CLINICAL MANIFESTATIONSMANIFESTATIONS

RESPIRATORY SYSTEMRESPIRATORY SYSTEM• STRIDOR

• RALES

• RHONCHI

• PROGRESSIVE CYANOSIS

• CHEYNE STOKES RESPIRATION

• ASSYMETRICAL CHEST WALL MOVEMENTS

• DECREASED RESPIRATORY RATE, DECREASED DEPTH

CARDIOVASCULAR SYMPTOMSCARDIOVASCULAR SYMPTOMS

BRADYCARDIAHYPOTENSIONVENTRICULAR TACHYCARDIAATRIAL FIBRILLATIONHYPERKALEMICARRYTHMIASDECREASED CARDIAC OUTPUT

NEUROLOGICAL SYSTEMNEUROLOGICAL SYSTEM

• ASTEREXIS• MYOCLONUS• SEIZURES• CRANIAL NERVE PALSIES• LETHARGY• UNEQUAL PUPILLAR DIALATION• ABSENT DEEP TENDON REFLEXES• ABSENT DOLL’S EYE REFLEX

GASTROINTESTINAL SYSTEMGASTROINTESTINAL SYSTEM

Due to the disruption of CN -10th (vagus) function

• ABDOMINAL DISTENSION

• DECREASED BOWEL SOUNDS

• CONSTIPATION

• ASCITES

• HYPERLIPEDEMIA

URINARY SYSTEMURINARY SYSTEM

• URINARY INCONTINENCE

• HIGH CREATININE INDEX

• OLIGURIA

• KETONURIA

• UTI

• PYURIA

NURSING NURSING ASSESSMENTASSESSMENT

Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)

• Assess neurological function by using Glasgow Coma Scale (GCS)

• Score range - 3 to 15• Abnormal - <10• Normal - >10

Parameter Eye opening

Best verbal response

Best motor response

GCS contd…GCS contd…

1.

2. Best verbal response Oriented 5

confused 4

inappropriate speech 3

incomprehensible sound 2

no verbalization 1

PARAMETER FINDINGS SCORE

Eye opening spontaneous 4

to speech 3

To pain 2

do not open 1

contd…contd…Best motor response obeys command 6

localizes pain 5

withdraws from pain 4

Abnormal flexion(decorticate posture)

3

abnormal extension (decerebrate posture)

2

No motor response 1

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

• Voluntary movement- strength and asymmetry in the upper extremities

• Deep tendon reflexes- biceps, triceps & patella.

• Posture:-– Decerebrate– Decorticate

• contd…

BRAIN STEM REFLEXBRAIN STEM REFLEX

• Pupillary light reflex

• Corneal/lash reflex

• OCULAR Reflex• 1. Oculocephalic reflex(Doll’s Eye Reflex)• 2. Oculovestibular Reflex/caloric testing

• Gag swallowing reflex

BRAIN STEM REFLEXBRAIN STEM REFLEX• Pupillary light

reflex– Assess pupil size,

symmetry, and reaction to light.

– Reflex eye movement elicited by head turning

• Corneal/lash reflex

• Absent eye close indicate compression of CN 5th(trigeminal) nerve

OCULAR OCULAR Reflex Reflex 1. Oculocephalic reflex(Doll’s Eye Reflex)

Assess of CN- 3rd , 4th, 6th.

2. Oculovestibular Reflex/caloric2. Oculovestibular Reflex/caloric testing testing

• CN 8th (acoustic) sense of equilibrium tests of vestibular portion

• Sense of hearing of cochlear portion

Gag swallowing reflexGag swallowing reflex

• Assess CN 9th (glossopharyngeal) ,11th. (spinal accessory) to evaluate gag, swallowing reflex, tongue protrusion and ability to handle secretions.

DIAGNOSTIC TESTSDIAGNOSTIC TESTS

CT:- Cerebral edemaInfarctionsHydrocephalousShift of brain

structure

DIAGNOSTIC TESTSDIAGNOSTIC TESTS

MRI:-Types of tissueTumorsVascular

abnormalitiesIntracranial bleeding

cont…cont…LUMBAR PUNCTURE

Cerebral meningitisCSF evaluation

HAEMATOLOGICAL– Complete blood count– BSL– Level of drugs in blood e.g.. Aspirin,

paracetamol

• EEG:- electrical activity of cerebral cortex layer

Intra cranial pressure(ICP)Intra cranial pressure(ICP)• Combined volume of 3 intracranial

compartment:-– Blood– CSF– Brain tissue

• Normal - 5-15mmhg

Medical managementMedical management

• Obtain And Maintain Airway.

• Insert oral airway

• Monitor Circulatory Status To Ensure Adequate Perfusion To The Body And Brain.

• Central Line Catheterization• Foley’s Catheterization• Ryle’s Tube Insertion

• Prevention Of Complication

EMERGENCY NURSING EMERGENCY NURSING CARECARE

• 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.

cont…cont…

• 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.

SURGICAL MANAGEMENTSURGICAL MANAGEMENT• CRANIOTOMY • SHUNTING

– CSF DRAINAGE

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

• DECOMPRESSIVE SURGERY– Removal of skull

Part– Allow a swelling brain

To expand without being

squeezed

NURSING CARE OF NURSING CARE OF UNCONSCIOUS UNCONSCIOUS

PATIENTPATIENT

NURSING MANAGEMENTNURSING MANAGEMENT

• Nsg diagnosis-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

Risk for aspiration R/T altered Risk for aspiration R/T altered LOCLOC

Intervention—

• Monitor ABG

• Keep suctioning equipment available

• Observe cardiac monitoring for dysrhythmias

• Positioning

Impaired oral mucus membrane,Impaired oral mucus membrane, R/T mouth breathing absence R/T mouth breathing absence of pharyngeal reflex, & altered fluid of pharyngeal reflex, & altered fluid intakeintakeIntervention----

• Inspect pt’s mouth every 8 hours

• Apply water-soluble lubricant to prevent cracking, drying.

• Oral hygiene( to avoid parotities, aspiration and RTI)

Deficient fluid volume r/t inabilityDeficient fluid volume r/t inability to take fluids by mouth 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, diarrhea, vomiting)

• Avoid overhydration in a patient receiving IV fluids because of risk of cerebral edema

Imbalanced nutrition less thanImbalanced nutrition less than body requirements R/T inability body requirements R/T inability to feed to feed

Intervention—

• IV fluids

• NG Tube feeding

• Maintain intake output chart

Risk for injury R/T decreasedRisk for injury R/T decreased LOC LOCIntervention-• Side rails • Seizure precautions ( use padded side rails,

keep the patient’s nail short)• Protect patient’s 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 oversedation (which increases ICP)

• Do not leave unattended.

Impaired urinary elimination R/T Impaired urinary elimination R/T impairment in neurologicimpairment in neurologic sensing and control sensing and control

Intervention—• Catheterization• Catheter care• Maintain aseptic technique • Monitor urine color• Initiate bladder training as soon as

consciousness regained.

Bowel incontinence R/TBowel incontinence R/Tchanges in nutritional delivery changes in nutritional delivery methods.methods.Intervention—

• Monitor

• Auscultate for bowel sounds;

• palpate lower abdomen for distention

• Maintain food hygiene.

Risk of skin integrity R/TRisk of skin integrity R/TimmobilityimmobilityIntervention—• Personal hygiene • Skin care, care of pressure points• Keep nails trimmed• Repositioned every 2 hours• Put on special mattress or bed

RESEARCH STUDIESRESEARCH STUDIES• Topic:- Communicating with unconscious

patients RESEARCHER :- KAREN LEIGH BSC,DIPHE,RN

Staff nurse, royal surrey county

hospital, Guildford

PUBLISHED- NURSINGTIMES.NET• “ hearing is the last sense to go and first one to

come” SISSON(1990)• There for health professionals evaluate the way

in which they communicate with unconscious patients

Contd…Contd…• METHODOLOGY:-

Assessment is depend on different theme-– Verbal communication– Patients memories– Psychological distress– Technology barrier e.g.. Cardiac monitor– touch

Contd…Contd…• The nurse’s role

– One way communication from the nurse– Individualized care to the patient by preferred

name, create family voice.– Aware about the nagative relationship effect

of visitors

• Conclusion– It indicate that this process help to patient

meet their psychological need & prevent unnecessory stress

RESEARCH STUDIESRESEARCH STUDIES• Topic:- use of behavioural pain scale

(BPS) to assess pain in ventilated, unconscious and/or sedated patients.

• RESEARCHER:- YOUNG J., SIFFLEET J.Intensive critical care nurse,

22 Feb. 2006

Sir Charles gairder hospital,

Centre for nursing, Australia

PUBLISHED:- PUBMED.GOV

RESEARCH STUDIES contd……..RESEARCH STUDIES contd……..

• Abstract- – Validate the BPS for assessment of pain in

critically ill patient.

• Parameter:-– Facial expressions– Upper limb movement– Compliance with mechanical ventilation

Contd….Contd….• Methods:-

– Prospective, descriptive study design was use to check validity & reliability of assessment.

– Routine painful stimuli = repositioning

– Non painful = eye care

• Results:-

– 73% BPS score increased = indicating pain after repositioning

– 14% BPS score shows = no pain after eye care

– Pre & post procedure assessment 25 times higher for repositioning than eye care, after controlling for analgesic & sedative.

• Conclusion:-– BPS was found to be valid & reliable tool in

the assessment of pain in unconscious patient.

– Result also highlights that traditional pain indicators such as fluctuation in hemodynamic parameter are always not accurate measure for assessment of pain.

Contd….Contd….

REFERENCEREFERENCE• Donina D. Ignatavicius, medical surgical nursing, a

nursing process approach, W. B. Saunders company• Brunner & suddarth “ a textbook medical surgical

nursing, vol. 2, 10th edition, lippincott williams & willinknson.

• Phipps cassmeyar, sande lehman, medical surgical nursing concept and clinical practice, 5th edition, mosby

• The lippincott manual of nursing practice, 7th edition, vol 2

• Gary a. Thibodue, kevin t. Patton, anatomy and physiology, 5th edition mosby.

• Sharon mantic, idolia cox, assessment and management of clinical problems, 3rd edition, mosby.

ANY DOUBT…?????????????ANY DOUBT…?????????????DISCUSHION..????????????DISCUSHION..????????????