However, a loud noise or noxious stimulus will wake us. b. Retention of mucus / sputum in the throat. ‘Coma cocktails’ should be avoided.3 In cases where there is clinical suspicion of toxicity, specific antidotes should be used, eg naloxone in opiate toxicity. Pearce C, Duncan H (2002) Enterai feeding: nasogastric, nasojejunal, percutaneous endoscopie gastrostomy, or jejunostomy: its indications and limitations. If uncorrected this will compromise breathing by wasting respiratory and skeletal muscles (Woodrow 2004). d. The RAS has a large number of projections that are linked to the cerebral cortex (Pemberton 2000) and are concerned with the arousal of the brain during sleep and wakefulness (Fitzgerald 1996) (Figure 1). Pemberton L (2000) The unconscious patient. Physical examination can give many clues as to the cause of unconsciousness. Routledge, London, 115-123. The reader should refer to the article by Moore (2004) to gain a better understanding of this skill. If a nasogastric tube is inserted attention should be paid to the surrounding area as damage to the mucosa from pressure can occur (Bonomini 2003). 13, 22, 49-56. The arm that is uppermost is flexed at the elbow and rested on a pillow to prevent drag on the shoulder and wrist drop. 2019;31(5):356–362. Nursing Standard. Third edition. The unconscious patient is challenging, in terms of immediate care, diagnosis, specific treatment and predicting prognosis. Definition. Early physiological stability and diagnosis are necessary to optimise outcome. Coma may be defined as no eye opening on stimulation, absence of comprehensible speech, a failure to obey commands. It consists of caring for people and their families. There are acute and chronic states of impaired consciousness. Many people who have life-threatening conditions that can precipitate unconsciousness, such as epilepsy or allergies to penicillin, may be wearing bracelets that inform medical practitioners (Fuller 2004). Loosen Clothing at Neck, Chest and Waist. The changes can be subtle at first and difficult to recognise. Hooper M (1996) Nursing care of the patient with a tracheostomy. Nutrition and hydration Nutrition is a fundamental human need and yet evidence suggests that up to 40 per cent of hospital patients remain malnourished (Pearce and Duncan 2002). Effects of prolonged immobility The morbidity of immobility is directly associated with the length of time the patient is immobile and other underlying patient risk factors (Hickey 2003a), such as incontinence, poor nutrition, hypotension, infection, obesity, old age and organ failure (Wunderlich 2002a, Hickey 2003a). Lethargy is characterised by slow and sluggish speech, mental processes and motor activities. Churchill Livingstone, London, 637-656. Colquhoun M, Hadley A, Evans T (2004) ABC of Resuscitation. Management of the Patient with Reduced Consciousness Primary topic: Initial management of the patient with reduced consciousness. Attention is given to good body alignment, to help prevent contractures, foot and wrist drop, muscle strain, joint injury and interference with circulation and chest expansion. A conscious person is capable of responding to sensory stimuli. A Plan for Reform. In patients who remain physiologically unstable or where the cause of coma is not immediately clear or reversible, help from critical care colleagues must be sought at a very early stage.4,5,14, If raised intracranial pressure is suspected the patient should be managed in a 30° head tilt position. Green A (1996) An exploratory study of patients’ memory recall of their stay in an adult intensive therapy unit. In your own words describe the function of the reticular activating system and define consciousness. 15, 43, 33-36. Eye movements cannot be fully assessed in an unconscious patient. This helps to retain patient dignity, allows close monitoring of urinary output and prevents skin breakdown. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. Repeat the patient’s blood glucose level after 1 hour. NS309 Geraghty M (2005) Nursing the unconscious patient. The patient may require the administration of oxygen therapy. In Barker E (Ed) Neuroscience Nursing. The nurse skilled in phlebotomy will be required to take blood for laboratory tests that will ascertain the presence of drugs if overdose is suspected. The GCS meas\ures the degree of consciousness under three distinct categories, and each category is further subdivided and given a score as shown in Box 1 (see also the version adapted by NICE 2003). Nurses should be verbally reassuring and explain all procedures to unconscious patients. 20, 2, 53-59. There are four main categories (see Table 1): diffuse physiological brain dysfunction eg drugs or alcohol. Defining consciousness and aspects of anatomy and physiology. The Adult. The lower the score the poorer the prognosis. Unless the cause of coma is immediately obvious and reversible, input from senior physicians and critical care colleagues is necessary. All of the same great people, writers and editors but now with more firepower. Awareness is the result of the combined activity of the RF, RAS and higher cortical function. 10, 34, 40-43. Witnessing the events leading to someone losing consciousness can be very distressing. Supportive care and specific treatments must not be delayed. Woodrow P (2004) Nutrition. Thrombus formation is caused by venous stasis, decreased vasomotor tone, pressure on the blood vessels and a hypercoagulable state (Hickey 2003a). Another example of altered metabolism is the increased excretion of calcium from bones as a result of reduced weight bearing and inactivity (Hickey 2003a). The unconscious patient is dependent on the healthcare team to deliver the correct nutritional requirements. Fifth edition. Sixth edition. The skills required to care for unconscious patients are not specific to critical care and theatres as unconscious patients are nursed in a variety of clinical settings. Constipation not only causes discomfort, but also increases intra-abdominal pressure which will result in an unwanted rise in intracranial pressure and the potential of further neurological impairment (Cree 2003). Management of unconscious patient By: Nidhi Maurya Era’s college of nursing M.Sc. The possible underlying cause will dictate immediate medical management which may include: the administration of oxygen to maintain tissue perfusion; fluids to support cardiovascular function and correct metabolic derangement; and the administration of intravenous (IV) medications, such as phenytoin in the presence of seizures. Third edition. However, it is not without risks. However, there is evidence that patients can recall with accuracy conversations that have taken place while unconscious (Pemberton 2000). In Perry A, Potter P (Eds) Clinical Nursing Skills and Techniques. Airway. Nursing Standard. Patient is a UK registered trade mark. The accumulation of secretions over time can contribute to the development o\f atelectasis and hypostatic pneumonia (Hickey 2003a). Dentures should be removed and note made of any loose teeth or crowns that may become dislodged and compromise the airway. Alterations in blood pressure need to be viewed in relation to pulse rate, pulse quality and pulse pressure (Hickey 2003a). Understanding a patient’s perception and interpretation of his or her experience when consciousness is impaired is not always possible. In Alexander M, Fawcett J, Runciman P (Eds) Nursing Practice, Hospital and Home. In Walsh IVl (Ed) Watson’s Clinical Nursing and Related Sciences. The insertion of a nasogastric tube in the early stages of unconsciousness will allow removal of gastric contents, thus reducing the risk of aspiration. Pupil examination can aid diagnosis:3–5, small pupils (<2 mm) – opioid toxicity or a pontine lesion, midsize pupils (4–6 mm) unresponsive to light – midbrain lesion, maximally dilated pupils (>8 mm) – drug toxicity, eg anticholinergic overdose. Clinically, patients appear to stare into space with nystagmus-like eye movements, lip smacking or myoclonic jerks.13. Hickey J (2003b) Neurological assessment. How confident do you feel in using the tool in practice? Churchill Livingstone, London. Postgraduate Medical Journal. Read the case example in Box 3. International Journal of Palliative Nursing. Unconscious patients are nursed in a variety of clinical settings and therefore it is necessary for all nurses to assess, plan and implement the nursing care of this vulnerable patient group. Liaison with dieticians will assist in the ongoing assessment and planning the patient’s nutritional needs. Immobility also alters glucose-insulin intolerance. Mouth care in the unconscious patient is paramount due to the inability to swallow plust having an ETT in situ. The use of an artificial airway, such as a Guedel, and the removal of secretions through suction will ensure that the airway remains patent (Pemberton 2000). Stupor describes a state of near unrousability that requires vigorous or repeated stimulus to illicit a response (Hickey 2003b). 4, 4, 173-177. Physiological changes that occur over short periods of immobility are less severe and potentially reversible. The collapse of lung tissue and the effects of secretions will impair gaseous exchange. Mickey J (2003a) Management of the unconscious patient. The pattern of breathing should be assessed as well as the respiratory rate. All sensory pathways link into the RF (Fitzgerald 1996). Do they meet the NICE (2003) guidelines? Delirium is similar to clouding of consciousness, although a person who is delirious may also present with psychological manifestations, such as illusions, hallucinations and delusions. Secondary topics: Differential diagnosis Management of DKA. Try to be holistic in your approach. Death will occur soonest when the airway and breathing are compromised; therefore, intubation should be considered in patients with a GCS of 8 or less, or those who cannot protect their own airway or have ineffective respiratory drive and poor oxygenation. commencing appropriate oxygen therapy if indicated. The RAS serves as a point of convergence for signals from our external environment and our internal thoughts and feelings. An IV insulin sliding-scale regimen may be required to maintain blood glucose levels within the normal range of 4-7mmol/l (Cowan 1997). There are many different causes of unconsciousness. Early physiological stability and diagnosis are necessary to optimise outcome. The Lancet. Read the case study in Box 4. Nursing Standard. Associate Professor of Anesthesiology and Intensive Care. NMC, London. Etiology of Unconsciousness. Bystanders may have witnessed the patient collapse, while paramedics are skilled in surveying the scene for clues, such as empty drug packets, alcohol or a suicide note. Cardiovascular function Monitoring the cardiovascular function in unconscious patients is of high importance. Early communication with the next of kin, family or appropriate advocate is always necessary. The nurse should be aware of betraying, through his or her tone of voice, feelings and opinions that may intimidate or diminish the patient (Webb 1994). Waterlow J (1991) A policy that protects. A clouding of consciousness suggests interference with the integrity of the RAS, with a resultant effect on the arousal response. ABCDE = airway, breathing, circulation, disability, exposure; CT = computed tomography; CXR = chest X-ray. The approach is based on the belief that after a history and a general physical and neurologic examination, the informed physician can, with reasonable confidence, place the patient into one of four major groups of illnesses that cause coma. Greenwich Medical Media, London. Percutaneous endoscopically guided gastrostomy tubes are the most common of this type (Payne-James et al 2001). The first is a diffuse insult to both cerebral hemispheres and the second a disruption of the ascending reticular activating system in the midbrain and pons, where signals are carried to the thalamus and cortex. Fifth edition. the new Fibromyalgia Treating by RedOrbit! Moore T (2004) Suctioning. Alright, now that you’ve gone through some basic tips, let’s go through a systematic way to approach assessing an unconscious neuro patient. Routledge, London, 290-300. Suctioning has associated contraindications and unwanted effects, for example, a rise in intracranial pressure (Moore 2004). Gentle cleaning of the nasal mucosa with gauze and water will help remove the build up of debris and maintain a moist environment. The breath may exhibit the musty smell of hepatic encephalopathy or the garlic smell of organophosphate poisoning.9,10 When the breath suggests alcohol consumption, a thorough search for other causes of unconsciousness should continue. Diagnosis and treatment of unconscious patient Definition. Studies exploring the recollection of the unconscious patient following a return to consciousness are predominantly concerned with sedated critical care patients, for example, Green (1996). Risk for complications – pressure sore, contractures, DVT, hypostatic pneumonia, constipation – related to immobility. Older patients in particular are vulnerable to the detrimental effects of prolonged immobility. Ataxic breathing (Biot's respiration) – groups of quick, shallow inspirations followed by regular or irregular periods of apnoea, suggesting a lesion in the lower pons.11, Central neurogenic hyperventilation – breathing characterised by deep and rapid breaths at a rate of at least 25 breaths per minute indicating a lesion in the pons or midbrain.12. The literature suggests that using a toothbrush and toothpaste is the most effective way of removing dental plaque but care should be taken not to damage the gingiva by using excessive force (Dougherty and Lister 2004). Churchill Livingstone, London, 851-871. The Stationery Office, London. The aim of this article is to explore the long-term care needs of the unconscious patient and the related nursing management. psychiatric or functional – considered when organic causes have been excluded. We now have access to an enormous amount of additional research information In Moore T1 Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. They encourage healthcare practitioners to maintain verbal communication with the unconscious patient. Copyright © 2020 by the Royal College of Physicians, DOI: https://doi.org/10.7861/clinmedicine.18-1-88, Sign In to Email Alerts with your Email Address, A systematic approach to the unconscious patient, Joint Royal Colleges of Physicians Training Board, Specialty training curriculum for Acute Internal Medicine, Specialty training curriculum for General Internal Medicine, Coma of unknown origin in the emergency department: implementation of an in-house management routine. The unconscious patient is a medical emergency (Pemberton 2000). You are all experienced health care professionals who have given 1000's of episodes of care, there are a couple of things you need to consider before commencing mouth care. Personal hygiene is considered part of The Essence of Care (Department of Health (DH) 2001a) and needs to be carried out to an uncompromising standard. Journal of Vascular Nursing. However, as with any aspect of care, this needs to be assessed individually as touch can also be interpreted as invasive or threatening (Woodrow 2000). nurse play and important role in the care of unconscious (comtosed) patient to prevent p otential complications respiratory eg;distress, pneumonia,a spiration,p ressure ulcer.this achived by: 1. This can be demoralising for the nurse, especially after a long period of committed nursing care. We are here for you and now, better than ever so sit back and enjoy Juggling such demands while ensuring that a safe and caring environment is maintained are managerial challenges. Previous hospital records must be requested urgently and the next of kin contacted. The nurse must become familiar with the tool and studies suggest that its use should be taught in detail to ensure accuracy of rating by nurses (Heron et al 2001). If unconsciousness is prolonged and an artificial airway is still required then a tracheostomy should be considered (Hooper 1996). 2. Nursing management of the unconscious patient . The following five strategies may help. The accuracy of the GCS is dependent on the assessor using and interpreting it correctly. Unconscious patients are nursed in a variety of clinical settings and therefore it is necessary for all nurses to assess, plan and implement the nursing care of this vulnerable patient group. McConnell EA (2001) Communicating to get results: an interview with Jacob Weisberg. A Spectrum of Care. Depending on the underlying condition, the unconscious patient may never fully recover or may die from complicating factors. Urgent imaging of the brain is important and a structural pathology should always be considered if the cause of unconsciousness is not obvious from the initial rapid assessment.3–6 Computed tomography (CT) of the brain is the investigation of choice to exclude common pathologies such as intracranial blood, stroke or space-occupying lesions. Enterai feeding can prevent this by averting atrophy of the villi that absorb nutrients and produce protective mucus and immunoglobuhns. Casey G (2003) Haemostasis, anticoagulants and fibrinolysis. Our emotional response and reasoning to such a stimulus will ‘modify’ the RAS positively or negatively as the RAS is also stimulated by the cerebral cortex (Pemberton 2000). The four core components of care, history, examination, investigation and treatment/management should occur in parallel.3–6 A systematic and structured ABCDE (airway, breathing, circulation, disability, exposure) approach should be employed by teams caring for unconscious patients (Fig 1). Blackwell Science, Oxford. Management of unconscious patient. Communication between individuals is a broad and varied experience. To understand consciousness it is necessary to have an appreciation of the complexity of the related anatomy and physiology, as normal conscious behaviour is dependent on an intact and fully functioning brain (Pemberton 2000). In Alexander M, Fawcett J, Runciman P (Eds) Nursing Practice, Hospital and Home: The Adult. Following any washing procedure, it is important to ensure that the skin is dry as this will minimise the risk of loss of skin integrity. However, it is important that the benefits of these interventions are considered against the associated risks of compromised skin integrity and poor fluid monitoring. If the CT brain scan is normal and the diagnosis remains unclear, further imaging with a magnetic resonance scan may be required. Unconscious patients with an acute neurological condition should be discussed with either a neurosurgeon, neurologist or stroke physician to determine further management.4,14 Concussion results in neurological signs and symptoms following a force injury to the brain, which may be minor, with the absence of macroscopic neural damage.15. Nutritional requirements may be affected by underlying conditions that increase normal metabolic demand or require further supplements, for example, sepsis, loss of fluids and electrolytes from diarrhoea or drainage, or tissue repair following trauma ( Woodrow 2004). Date of acceptance: July 18 2005. The management of an unconscious patient is a medical emergency, requiring prompt assessment and the appropriate use of first aid and life support procedures. Differential diagnoses in a patient with non-traumatic coma. Pulse oximetry will aid the ongoing monitoring of respiratory function. Learning Objectives Definition of unconsciousness Common causes Diagnosis and treatment of unconscious patient 3. Lippincott Williams & Wilkins, Philadelphia PA, 133-162. Nov. 21, 2020. Cyanosis. Although unconscious patients most commonly present to the Emergency Department, the competencies to care for these patients are required by acute and general physicians.1,2 Unless the cause of unconsciousness is immediately obvious and reversible, both early senior physician and critical care input are required, especially when the prognosis is poor and decisions regarding ceiling of care or cardiopulmonary resuscitation are needed. Now that you have completed this article, you might like to write a practice profile. Unconscious patients have no control over themselves or their environment and thus are highly dependent on the nurse. A shadow on the wall that takes the form of an animal, or a noise that is misinterpreted as a stranger coming to cause harm, are examples of illusional states (Pemberton 2000). Nursing Management of unconsciousness patient:-a. Early physiological stability and diagnosis are necessary to optimise outcome. The two main identified parts of the RAS are the mesencephalon (upper pons and mid-brain) and the thalamus. If any doubt exists, the cervical spine should be immobilised. The administration of an anticoagulant will also reduce the risks of venous thromboembolism (Casey 2003). Appropriate measures to resuscitate, stabilise and support an unconscious patient must be performed rapidly. A full examination must be performed, although there are areas of specific relevance in the unconscious patient. For patients with impaired consciousness touch, combined with kind and comforting words, can be a valuable means of providing reassurance. Nursing Standard. Care of the unconscious patient suffers from fragmentation because of its emphasis on the physical. When the prognosis is poor these discussions will include ceiling of care, consideration of future withdrawal of treatment and cardiopulmonary resuscitation. In Moore T, Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. Sustained pressure from immobilisation remains the most important cause of skin breakdown (Hickey 2003a). Max Geraghty is senior staff nurse, Intensive Care Unit, North Middlesex University Hospital, London. This article has been subject to double-blind review. However, the effects of immobility can cause changes in cardiovascular function with increased cardiac workload and central fluid shifts from the legs to the thorax and head (Dougherty and Lister 2004). Research supports the existence of unconscious bias and its effect on patient care. Sarah J. Neill, Review : Developing children's nursing through action research, Journal of Child Health Care, 10.1177/136749359800200103, 2, 1, (11-15), (2016). nursing assignment help nursing help nursing assignment. What did you find challenging about nursing this patient? Increased water in the gut or a decreased ability to absorb fluid can result in diarrhoea. Intensive and Critical Care Nursing. The reticular activating system (RAS) is a feature of the RF and is responsible for arousal from sleep and maintaining consciousness (Fitzgerald 1996). Nursing Standard. Lippincott Williams & Wilkins, Philadelphia PA, 277-293. However, with a good knowledge base to initiate the assessment, planning and implementation of quality care, nursing patients who are unconscious can prove highly rewarding, and the skills acquired can promote confidence in the care of all patients. The thalamus plays a crucial role in maintaining arousal. This process of selection prevents the cerebral cortex from receiving too much information at once, thus possibly playing a part in directing an individual’s attention to specific mental activities (Hickey2003b). 29, 6, 1412-1420. A 2012 study found that primary care physicians with an unconscious bias toward white patients tended to dominate conversations with black patients during routine visits and pay less attention to these patients’ social and emotional needs. In Sheppard M, Wright M (Eds) Principles and Practice of High Dependency Nursing. Delusions are more persistent misperceptions that are held to be real, however illogical they may seem (Hickey 2003b). Ensuring that the skin is dry between the toes will help to minimise fungal infection. If nitrogen loss exceeds supply then catabolism (muscle breakdown) occurs. In hypoglycaemic patients at risk of Wernicke's encephalopathy, such as those with a history of alcohol excess, intravenous thiamine should be coadministered. Nurses are advocates of a patient. What is visual communication and why it matters; Nov. 20, 2020. The use of a respirator muscles. Investigations aid diagnosis, assessment of severity and monitoring of ongoing care. Therefore, an assessment tool, such as the Waterlow scale, should be used to aid early identification of the risks (Waterlow 1991, 1998). Nasoduodenal, nasojejunal, percutaneous endoscopie gastrostomy or jejunostomy tubes may be indicated if the patient’s condition contraindicates direct gastric feeding, for example, acute pancreatitis (Pearce and Duncan 2002). Coma is defined as having a GCS <8 or scoring U on the AVPU (Alert, responsive to Voice, responsive to Pain, Unresponsive) scale.7 A focused neurological examination should be undertaken. In Moore T, Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. Signals from specific parts of the thalamus initiate activity in specific parts of the cerebral cortex, as opposed to the diffuse flow of impulses from the mesencephalon that causes generalised cerebral activity (Pemberton 2000). All rights reserved. Curriculum mapping Foundation programme 7.1 (Core skills in relation to acute illness) Knowledge. The Waterlow Pressure Sore Prevention/Treatment Policy. Care of unconscious patient . The supine position compromises the mechanics of breathing and lung volumes (Hickey 2003a). How unconscious bias can discriminate against patients and affect their care Published by British Medical Journal, 03 November 2020 Article raises awareness of unconscious bias in healthcare, i.e. Number of times cited according to CrossRef: 9. Fifth edition. Systematic team approach to the unconscious patient. Unconsciousness is a condition in which there is depression of cerebral function ranging from stupor to coma. Close monitoring of the patient’s respiratory function is important and any changes should be reported. Diarrhoea is caused when there is more fluid entering the bowel than the bowel can absorb during transit. Please consult an expert before taking any action. The delivery of nutritional requirements is best achieved enterally as the parenteral route has the disadvantages of expense, increased risk of infection from IV cannulation, and gut atrophy and translocation of gut bacteria from non-use of the digestive tract (Woodrow 2004). Guidelines to help you are on page 68. Patients not responding to initial treatment and who remain comatose are likely to require critical care admission unless withdrawal of treatment and palliation of symptoms is more appropriate. Maintaining patent airway. They are easy to insert, prevent the tongue from obstructing the airway, provide a passage that allows the patient to breathe, and allows the nurse to remove secretions from the trachea through suctioning. A gastrostomy may be more appropriate if enterai feeding is required for longer periods, thus removing the risks associated with nasally inserted tubes. To avoid foot drop the feet are positioned at a 90 degree angle to the leg with caretaken to avoid any unnecessary pressure. Allan D (2002) Caring for the patient with a disorder of the nervous system. In assessing the eyes, observe for signs of irritation, corneal drying, abrasions and oedema. how personal assumptions which we may not be aware of can lead to erroneous clinical decisions. Prolonged periods result in increased pathophysiological changes associated with increased morbidity and permanent disabilities (Hickey 2003a). If the patient does not regain immediate consciousness then his or her ongoing needs will need to be assessed. Anyone accompanying an unconscious patient to hospital will require support and information. * Discuss the various levels of impaired consciousness. This is the process of looking inward to recognize beliefs and values that can lead to unconscious bias. Acute states are potentially reversible, whereas chronic states indicate underlying brain damage and hence are irreversible (Pemberton 2000). Knowing that unconscious bias leads to disparity, nurses must try to eliminate it. Motor responses can be purposeful, such as the patient pulling on an airway adjunct, or reflexive, including withdraw, flexion or extension responses.3 Motor response to graded stimuli should be assessed in a stepwise approach:8. noxious stimulus – intense but not causing injury, eg pressure on nailbed or supraorbital ridge. Prognosis depends on a number of factors. second edition. second edition. A systematic evaluation of the unconscious patient is recommended. Prolonged loss of consciousness (coma, defined as a Glasgow Coma Score of 8 or less) is seen commonly: (1) following head injury, (2) after an overdose of sedating drugs, and (3) in the situation of ‘nontraumatic coma’, where there are many possible diagnoses, but the most common are postanoxic, postischaemic, systemic infection, and metabolic derangement, e.g. Tone of voice conveys the emotion that is behind what is being communicated. A Clinical and Research Resource. Incontinence, perspiration, poor nutrition, obesity and old age also contribute to the formation of pressure ulcers. Nursing Standard. Gauging appropriate communication requirements demands an understanding of the patient, hence the patient’s family can be a valuable resource in helping the nurse to become more informed about the patient’s life, his or her personality, and his or her wishes and desires. Blackwell Science, Oxford. Client Expected Outcome Unconsciousness may be sudden, for example, following an acute head injury, or it may be gradual, for example, with the onset of poisoning or a deranged metabolism, as in hypoxia or hypoglycaemia. 9. This article focuses on unconscious patients where the initial cause appears to be non-traumatic and provides a practical guide for their immediate care. Bailey K, Wilkinson S (1998) Patients’ views on nurses’ communication skills: a pilot study. 10. Suctioning should be undertaken with care, following appropriate patient assessment to establish the need for intervention. Enterai feeding will not stimulate peristalsis (Hickey 2003a). The arousal reaction is dependent on the stimulation of the RAS. A patient’s medical history is of vital importance and, if not already known, friends and relatives can be of assistance in this endeavour. c. If breathing has stopped or about to stop, turns casual in to the required posture and start CPR (artificial respiration). How to go through your neuro ICU patient assessment. Gauze and water can also be used to clean around the aural canal, although care must be taken not to push anything inside the ear. Consciousness demonstrates that the RAS is functioning and is capable of the screening and discrimination of information (Pemberton 2000). The difference between each definition is the degree and presentation of response to painful stimuli (Hickey 2003b). A urinary catheter should be considered if the state of unconsciousness is not resolved quickly. 20, 6, 24- 27. NICE, London. Nursing Standard. Change can be indicative of neurological deterioration and such observations need to be balanced with neurological assessment to obtain a more accurate evaluation. Seizures. Waterlow J (1998) The treatment and use of the Waterlow card. COMFORT DEVICES USED FOR PATIENT IN HOSPITAL . In one systematic review the mortality rate varied from 25–87%.14 Non-traumatic unconscious patients presenting with a stroke have the highest mortality, while those presenting with epilepsy and poisoning have the best prognosis.14,16,17 A Swedish study of coma patients presenting to the Emergency Department found initial inpatient mortality to be 27%, rising to 39% at 1 year.18 Patients with a lower GCS at presentation, 3–5, have a significantly higher mortality than those with a GCS of 7–10.19. The reader should refer to the referenced literature for more information and seek to gain practical experience in the clinical environment (Shah 1999, Cree 2003,Howarth2004). Communication The NHS Plan (DH 200Ib) calls for the further development of communication skills among healthcare professionals as the need for effective communication is increasingly recognised. The Pupil Exam in Altered Mental Status on PEMBlog Kussmaul respiration – deep, laboured breathing, indicative of severe metabolic acidosis and commonly associated with diabetic ketoacidosis. 20, 1, 54-68. Loose stool can be a result of poorly tolerated enterai feeding. Unconsciousness is … Impaired consciousness can be considered in terms of reduced alertness/ability to be aroused, awareness or both, with coma defined as ‘a completely unaware patient unresponsive to external stimuli with only eye opening to pain with no eye tracking or fixation, and limb withdrawal to a noxious stimulus at best (often with reflex motor movements)’.3 When describing consciousness imprecise terms such as ‘drowsy’ or ‘mildly unconscious’ should be avoided in favour of a clear description of the patient's actual condition and functional abilities.3, There are two main mechanisms to explain coma. Non-verbal communication, such as facial expression, eye contact, posture, personal space and bodily contact, is important in social interaction. 11, 11, 47-54. However, Fader ( 1997) suggests that manual evacuation should only be undertaken when other methods of bowel evacuation have failed. Diagnostic testing, and treatment options. Hospital pharmacists can obtain a drug history from primary-care shared records. The inability to maintain a patent airway means that aspiration of fluids, from oral secretions, blood in the presence of trauma, or vomit is a potential risk that may cause further complications, for example, chest infection. Howarth V (2004) Neurological assessment. Nursing management of the unconscious patient. It is important to remember that unconscious patients will not be able to communicate whether a feeding tube is in the wrong place. The unconscious patient is a medical emergency which can challenge the diagnostic and management skills of any clinician. Patient does not provide medical advice, diagnosis or treatment. Churchill Livingstone, London, 757-774. A nurse not involved in the immediate care of the patient should be allocated to take responsibility for providing this support (Pemberton 2000). Positioning the patient is important and will facilitate the drainage of secretions. Evans G (2001) A rationale for oral care. Examination of the skin may reveal drug injection sites. The risk of venous thromboembolism and pulmonary emboli from the effects of immobility is well recognised (Dougherty and Lister 2004). The RAS receives input signals from a wide range of sources, including the senses (Pemberton 2000). Nursing management of Unconscious patients 2 firstname.lastname@example.org 3. Thus, the effects of immobility give rise to many of the complications in the unconscious patient, hence the need for the implementation of a broad range of nursing skills. To do this he or she needs to understand the effects of prolonged immobility on the main systems of the body. 16, 30, 52-62. Antibiotics can exacerbate this by destroying gut commensals (Woodrow 2004). Correct positioning of the unconscious patient also minimises the risks associated with immobility in terms of circulation and the musculoskeletal system (Wunderlich 2002b). It is important to recognise that such positioning is the ideal and may be contraindicated by an underlying condition, for example, a spinal or an underlying brain injury. Baillire Tindall, London, 665-745. This article aims to assist nurses … Copyright RCN Publishing Company Ltd. Sep 14-Sep 20, 2005, The information provided is no substitite for an informed medical professional. Management of. * Identify the needs of the unconscious patient. The pooling of secretions leads to hypostatic pneumonia which creates an ideal environment for the growth of bacteria (Hickey 2003b). Management of-unconscious-patient 1. Definition of unconsciousness. Enterai laxatives on their own may not be sufficient and the introduction of rectal preparations such as suppositories and enemas may be necessary. 20, 1, 54-64. The regularity with which observations should be undertaken is determined by the severity of the patient’s condition (Cree 2003). Elliott and Wright ( 1999) concluded from their studies of nurse-patient communication that the nurse’s level of interaction with patients is determined by the level of the patient’s responsi veness. Water has many functions within the body that are essential to maintaining health and sustaining life, for example, giving form to body structures and acting as a medium for nutrients and electrolytes. If the patient remains stable on hourly GCS assessment for four hours, the observations can be reduced to every two hours (NICE 2003). They are challenging to manage and in a time sensitive condition, a systematic, team approach is required. Hypotension is rarely characteristic of brain injury alone, except in the terminal stages of herniation (Dawson 2000), and changes in vital signs can be related to other physiological factors, for example, hypovolaemia, sepsis or cardiogenic shock. The challenges of managing unconscious patients lend themselves to standardised multidisciplinary approaches and algorithms. In older people, especially those taking anticoagulant medication, an intracranial bleed remains a strong possibility, even in the absence of a history of falls or external injury. Because many cases of unconsciousness are reversible, the management of unconscious patients necessitates thorough history-taking, patient evaluation, stabilizing treatment, and … Unconsciousness, when a person suddenly becomes unable to respond to stimuli, requires immediate medical attention. Common causes. Fifth edition. Fingernails and toenails also need to be assessed for length and cleanliness, and ongoing care may require consultation by a chiropodist. Consciousness is a function of the reticular formation (RF), which has its origins in the brainstem (Barker 2002). Therefore, regular blood and urine tests to monitor electrolyte and metabolic changes are essential to promote accurate assessment of each individual patient. This can cause unusual behaviour, ranging from irritability and confusion, to poor concentration and drowsiness (Pemberton 2000). Nurses are accountable for their practice and a\ppropriate training should be undertaken before this procedure is carried out. Unconscious patients are commonly seen by physicians. Unconsciousness occurs when the RAS is damaged or inhibited, thus affecting the normal arousal mechanism (Pemberton 2000). This compass can help nurses reco… Unconsciousness is a time-sensitive medical emergency where early physiological stability and diagnosis are vital in optimising patient outcomes, An initial assessment of airway, breathing, and circulation must be performed to identify and manage the most immediate threats to life, All facets of care, history, examination, investigation and treatment/management should be delivered in parallel by a team working in a systematic way, Even in the apparent absence of trauma, especially in older patients or patients taking anticoagulants, brain injury or trauma should still be considered, Senior physicians must be involved early in the care of an unconscious patient, to liaise with critical care and speak with the patient's relatives or advocates, especially when decisions regarding cardiopulmonary resuscitation or ceiling of care are required. Discussion Points Definition of Unconsciousness. Noisy snoring or harsh breathing sounds may be a sign that the airway is being compromised. If there is no concern regarding a neck injury, the doll's eyes or oculocephalic reflex can be performed. Specific treatment depends on the underlying aetiology of the coma. Medsurgical Nursing. Bed rest also increases urinary stasis in the renal pelvis and urinary bladder further exacerbating the risk of urinary tract infection (Hickey 2003a). Gratitude in the workplace: How gratitude can improve your well-being and relationships In so doing the nurse should be able to provide a clear rationale for all care procedures. BMJ Books, London. Reflect on what you have learnt about the nursing management of unconscious patients. It also provides some cushioning to bony prominences. Completion of a risk assessment may help to highlight any potential compromise to the maintenance of a safe environment. The lower limb that is uppermost is flexed at the hip and knee, and supported by a pillow with the other lower limb slightly flexed. It is more common in older patients. It is also important to remember that unconsciousness may be induced, for example, the use of anaesthetics for surgical or medical intervention. Oxygen can be delivered using different types of equipment and humidification is advised, where possible, to warm and moisten its delivery and to prevent drying of secretions (Dougherty and Lister 2004). Getliffe K (1996) Care of urinary catheters. Abnormal breath sounds: stridor, wheezing, wheezing, etc.. However, these recommendations cannot be generalised and each patient needs to be individually assessed. 17 52, 45-50. Routledge, London, 46-55. Intrinsic factors that affect the nervous system directly can be seen as primary causes. Before considering any further investigations, a bedside capillary blood glucose must be performed to exclude hypoglycaemia (Box 1). Another example of this is in critical care units, such as intensive care, where an anaesthetist will intervene and induce unconsciousness pharmacologically to allow for emergency intervention to stop a decline in a patient’s condition. 78, 918, 198-204. 12. After the initial ABC assessment, the level of consciousness should be formally measured and documented using the Glasgow Coma Scale (GCS) (see Table 2). We are excited to announce that FibromyalgiaTreating.com is now part of RedOrbit.com. Cheyne–Stokes breathing is seen with many underlying pathologies and is not helpful in making a firm diagnosis. European Journal of Cancer Care. The Adult. 94, 7, 63-67. Nursing Standard. Oxygen saturation is a measure of the percentage of haemoglobin molecules that combine with oxygen. It is not only the content of what is said that is important but also how it is said. Assessment of the mouth and teeth is also important. The arm that is down is drawn slightly forward from under the body, bent at the elbow to lie on the bed parallel with the neck and head, or across the chest. What policies are available in your workplace to assist and guide its application? Neurological assessment in nursing is a critical skill for a neuro ICU nurse. If the weather is cold wrap the blankets around the patient body. Therefore, the manifestation of impaired or absent consciousness points towards an underlying brain dysfunction. Wunderlich R (2002b) Body mechanics, transfer and position. A systematic and logical approach is necessary to make the correct diagnosis; the broad diagnostic categories being neurological, metabolic, diffuse physiological dysfunction and functional. Genitourinary function An unconscious patient will be incontinent of urine. BASICS 3 email@example.com 4. Obtaining a 24-hour urine collection is an important means of assessing the protein needs of the unconscious patient. Blog. Either way, a committed focus on maintaining a high standard of care and promoting dignity throughout, regardless of the outcome, remain paramount. A pillow at the foot of the bed can facilitate this position (Allan 2002, Wunderlich 2002b). Hourly interventions will help to moisten the membranes of patients who mouth breathe or require oxygen therapy (Krishnasamy 1995). In Dolman M, Getliffe K (Eds) Promoting Continence. The GCS gives practitioners an internationally accepted format that assists communication, minimises user interpretation, and rapidly detects change in the patient’s condition (Howarth 2004). For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed. Payne-James J, Grimble G, Silk D (2001) Enterai nutrition. Heron R, Davie A, Gillies R, Courtney M (2001) Inter-rater reliability of the Glasgow Coma Scale scoring among nurses in sub- specialities of critical care. Guidelines for the head-injured patient are geared towards identification of any potentially rapid deterioration and suggest that observations should be undertaken every 30 minutes until the GCS reaches 15 or the patient’s condition stabilises (NICE 2003). Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative, Joint Royal Colleges of Physicians Training Board / Health Education England Expert Group on Simulation in Core Medical Training, Enhancing UK Core Medical Training through simulation based education: an evidence-based approach, Ambulatory emergency care – improvement by design, When psychiatric symptoms reflect medical conditions, Training in the care of unconscious patients. Fundoscopy should be performed; important findings include papilloedema in posterior reversible encephalopathy syndrome (PRES) or subhyaloid haemorrhage in subarachnoid haemorrhage. Respiratory function Maintaining a patent airway and promoting adequate ventilation are nursing priorities. Follow these steps for your next neuro assessment. © 2002-2018 redOrbit.com. For example, when a person is asleep he or she can be aroused by external stimuli, but this does not occur when a person is in a coma. However, reported experiences describe threatening and frightening hallucinations. * Reflect on how the nursing skills needed to care for the unconscious patient can be used to enhance practice in other areas of nursing. Rationale and key points Eye care is an important aspect of the nursing management of patients who are critically ill. All patients in acute care settings with absent or compromised eye defence mechanisms are at risk of eye complications and ocular surface disease. The presence of generalised tremor or myoclonus points towards a metabolic cause. Krishnasamy M (1995) Oral problems in advanced cancer. Elliott R, Wright L (1999) Verbal communication: what do critical care nurses say to their unconscious patients? The Stationery Office, London. Cerrahpasa School of Medicine Learning Objectives. Active listening is one of the most important communication skills in the healthcare setting (Bailey and Wilkinson 1998, McConnell 2001). Reversible causes of coma are generally more likely when a CT scan of the brain is unremarkable and the patient has no focal neurology. However, between the poles of consciousness and unconsciousness there is a continuum of differing states of impaired consciousness. Self-care deficit-bathing, feeding, grooming, toileting related to unconscious state as evidenced by unkempt and poorly nourished look, bed soiling. Personal awareness. Fine bore tubes should be used where possible as they are associated with a lower incidence of complications, such as rhinitis, oesophageal irritation and gastritis, than wide bore tubes (Payne-James et al 2001). Gastrointestinal function Bowel action is likely to become irregular in the unconscious patient, thus monitoring and observation are important. However, terms such as semi-coma and deep coma are still used in clinical practice. The causes of unconsciousness may dictate the length of the coma and the prognosis (Mallett and Dougherty 2000). This chapter has presented a physiologic approach to the differential diagnosis and the emergency management of the stuporous and comatose patient. Head injuries; Nursing: role; Patient assessment; Unconsciousness. Nursing Standard. 11, 4, 163-167. The A (airway), B (breathing), C (circulation), D (disability) approach to resuscitation should be adopted, and the maintenance of a clear airway is the first priority (Colquhoun et al 2004). Research focusing on oral problems associated with cancer suggests a minimum of four-hourly interventions to reduce the potential of infection from micro- organisms. Therefore, care must be taken to ensure that it has been inserted correctly. Care should be taken to examine the skin properly, noting any areas which are red, dry or broken. Australian Critical Care. Nursing Standard. The GCS has been used as a prognostic device during immediate assessment following a head injury. from doctors and scientists. Hayes JM, Lehman CA, Castonguay P (2002) Graduated compression stockings: updating practice, improving compliance. Cough. It will also discuss the emergency priorities that may arise. First edition. Cowan T (1997) Blood glucose monitoring devices. The causes of unconsciousness will dictate the length of the coma and the prognosis. A nasopharyngeal airway also allows the clearance of secretions using suction (Moore 2004), can be inserted if the use of an oropharyngeal airway is contraindicated, for example, in patients with trauma to the mandible or oral cavity. Non-verbal cues are often the first elements of communication that help us to form immediate impressions about someone (Webb 1994). Routledge, London. Nasogastric feeding is the most commonly used method and is recommended for short-term feeding (less than four weeks) (Dougherty and Lister 2004). Sixth edition. Decisions, such as ceiling of care, are required at an early stage in patients with a poor prognosis. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. Killer coma cases part 1 (the found down patient) and part 2 (the intoxicated patient) on Emergency Medicine Cases. 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