The nurse plays a pivotal role working with the multidisciplinary team to plan, implement and evaluate specific treatment regimens, whilst providing emotional support and reassurance to the patient and their relatives. The patient opens their eyes when first approached, which implies that the arousal response is active. It is concerned with the arousal of the brain in sleep and wakefulness (Marieb 2004). Tamer's Management of the unconscious patient emergency medicine. Your body language, focused attention, or level of care can be directly impacted by your feelings toward the patient. Impaired, reduced or absent consciousness implies the presence of brain dysfunction and demands urgent medical attention. The nurse must be able to assess and observe the patient accurately so that appropriate intervention can be instituted if the level of consciousness deteriorates. This is termed a ‘positive feedback response’. scale. Although dementia is an irreversible condition, new drug therapies such as donepezil (Aricept®) are being used successfully to delay onset of the disease. B. Trapezius pinch. Blog. In 1974, Teasdale and Jennett developed the Glasgow Coma Scale (GCS), a process used throughout the UK and worldwide as part of the neurological assessment and ongoing observation of the patient (see Figure 28.4). C. Flexing to pain. (Changes from baseline are most important), Cleanse the mouth with the prescribed solution every 2, Pharyngitis: Etiology, Symptoms, Diagnosis, Management, Urinary tract infection: Symptoms, Diagnosis, Management, Complication, Acute renal failure : Symptoms, Diagnosis, Management, Convulsion: Causes, Classification, Symptoms, Diagnosis, Complication, Child health nursing- Principles and practices: Introduction, Preventive paediatric Nursing Nutrition in children, Antenatal Preparation and Physiology of lactation. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. Nursing group presentation. In cycle A, the RAS excites the cerebral cortex and the cortex in turn re-excites the RAS. Elevating the head end of the bed to degree prevents aspiration. Deep coma, the opposite of consciousness, is diagnosed when the patient is unrousable and unresponsive to external stimuli; there are varied states of altered consciousness in between the two extremes (Box 28.1). Nurses are advocates of a patient. Reassess after intervention. Both require a thorough assessment to determine the level of nursing care that they will need. (refer practicals). Orientated = scores 5. observe the patient' s condition and prevent any complications. The unconscious patient presents a special challenge to the nurse. The nurse observes and describes three aspects of the patient’s behaviour: Each of these is independently assessed and recorded on a chart (Figure 28.4). Coma is an impaired state where the patient is totally unaware of themselves and their environment. This occurs when there is damage to the pons in the brain stem, resulting from cerebral vascular disease or trauma, paralysing voluntary muscles without interfering with consciousness and cognitive functions. Common causes of altered level of consciousness are illustrated in Figure 28.3 (see Critical Care. discharge and debris. Following the application of a central painful stimulus, either the trapezius squeeze or supraorbital ridge pressure, the patient responds by flexing their arm normally by bending their elbow and weakly withdrawing their hand; no attempt to localise towards the source of the pain is made. suctioning, nasogastric tube or urinary catheter. Author Max Geraghty is senior staff nurse, Intensive Care Unit, North Middlesex University … airway by falling back. Physiologically, the brain stem is functioning but the cerebral cortex is not, and patients can survive for several years requiring full-time nursing care. If the patient still fails to open their eyes, a painful stimulus must be used. In cycle B, impulses are sent down the spinal cord to activate skeletal muscles. It may be necessary to increase the level of the verbal stimulation to gain a reaction. To pain = scores 2. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. straightening the elbows and hyperpronation of the forearms, otherwise known as decerebrate posturing. The RF is a network of neurones within the brain stem (Waugh & Grant 2001) that connect with the spinal cord, cerebellum, thalamus and hypothalamus. Gratitude in the workplace: How gratitude can improve your well-being and relationships This is a PDF-only article. A person may become unconscious due to oxygen deprivation, shock, central nervous system depressants such as alcohol and drugs, or injury. Self care deficit Attending to the hygiene needs of the unconscious patient should never become ritualistic, and despite the patient's perceived lack of awareness, dignity should not be compromised. Hickey (2003) defines consciousness simply as ‘a state of general awareness of oneself and the environment’ and includes the ability to orientate towards new stimuli. Patients can have a varying degree of recumbency from a patient with osteoarthritis to a dog in a coma. Applying a central painful stimulus. Rationale: meets nutritional requirements of coma clients. Figure 28.7 Applying a central painful stimulus. incontinency retention and constipation, report to the physician. patient. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. Follow these steps for your next neuro assessment. Early diagnosis and treatment with medication, and environmental changes such as reducing noise or sensory input may help to alleviate some of the symptoms. Injury to, or disease of, the cerebral hemispheres may cause diffuse damage that can inhibit or block the signals from the RAS, depressing the level of consciousness. Stimulation produces a diffuse flow of nerve impulses which pass upwards through the thalamus and hypothalamus, radiating out across the cerebral cortex to provoke a general increase in cerebral activity and wakefulness (see Figure 28.1). When an individual is in a deep sleep, the RAS is in a dormant state. Appropriately handover to a colleague. Incomprehensible sounds = scores 2. These disorders interfere with the integrity of the RAS, affecting the patient’s arousal response. Flexion to pain. Activation of the muscle stimulates proprioceptors to transmit sensory impulses upward to re-excite the RAS. Clean the ear with swab and dry carefully especially behind Abnormal flexion. Fingernails and toenails also need to be assessed Chronic illnesses, such as diabetes needs more attention Minimum two nurses should bathe an unconscious patient as turning the patient may block the airway… Only the best response from the arms is recorded as leg responses to pain are less consistent and may be confused with a simple spinal reflex. This can be misleading and be a source of false optimism for relatives. 5. This indicates more severe dysfunction of the brain and is a poor prognostic sign. Unconsciousness is a condition in which there is depression A. Supraorbital ridge pressure. In order to function, the RAS must be stimulated by input signals from a wide range of sources. drop: Sponging is performed as frequently as necessary. There is no international definition of levels of consciousness but, for assessment purposes, differing states of consciousness can be considered on a continuum between full consciousness and deep coma (Hickey 2003) (see, Impaired states of consciousness can be categorised as acute or chronic. How to go through your neuro ICU patient assessment. The chronic states of impaired consciousness tend to be irreversible as they are caused by invasive or destructive brain lesions. There is ongoing debate, both in the UK and other countries, about the moral, ethical and legal issues surrounding the care and treatment of these individuals and the dilemma posed by some patients to ‘the right to die’ and withdrawal of treatment has received considerable professional, public and political attention over recent years (Porter 2005) (see After the rapid assessment and management of immediate life threats, the next step is to ensure the patient is adequately resuscitated before the inevitable trip to the CT scanner. Patients with normal pressure hydrocephalus may be helped by insertion of a ventricular shunt (Wilson & Islam 2004, Dalvi 2010; see also Life NPH in Useful websites, p. 756). B. Localising to pain. 13) must also be taken into account. The patient offers monosyllabic words, usually in response to physical stimulation. The National Institute for Health and Clinical Excellence (NICE) developed clinical guidelines for ‘Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults’ (2003), revised 2005. Acute states, for example drug or alcohol intoxication, are potentially reversible whereas chronic states tend to be irreversible as they are caused by invasive or destructive brain lesions. Explain the nursing management of head injury patient. This is called the ‘arousal reaction’ and is the mechanism by which sensory stimuli wake us from deep sleep (Guyton & Hall 2000). The damaged cortex is unable to interpret the incoming sensory impulses and therefore cannot transmit them to other areas for appropriate action. E. Extending to pain. 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. It is important for the nurse to observe the ABCD approach to assessment, ensuring the patient has a clear airway, removing any obstructions (e.g. The nurse should speak to the patient by calling their name and asking them to open their eyes. Score = 6. If the patient does not obey commands, an external stimulus must be applied. Management of unconscious patient By: Nidhi Maurya Era’s college of nursing M.Sc. Nursing the unconscious patient. required for life. The RAS is a physiological component of the RF and the neurones which radiate via the thalamus and hypothalamus to the cerebral cortex and ocular motor nuclei. Variations in the motor response may occur during the assessment. (BS) Developed by Therithal info, Chennai. Frequent suction is required to prevent the pooling of By Donna, Gill, Sharon and Catherine. Patients will present with a range of symptoms including: Delirium is very distressing for the patient and their relatives who may witness their altered behaviour. Palpate the abdomen for distension   Ascultate bowel sounds. A systematic and logical approach is necessary to make the correct diagnosis; the broad diagnostic categories being neurological, metabolic, diffuse physiological dysfunction and functional. accurate output. A. Supraorbital ridge pressure. In cycle A, the RAS excites the cerebral cortex and the cortex in turn re-excites the RAS. C. Flexing to pain. If the patient is constipated, a glycerine suppository or For further information about the use of the neurological observation chart and GCS in practice, see Woodward (1997a-d), NICE (2003), Waterhouse (2005) and Palmer & Knight (2006). Impaired states of consciousness can be categorised as acute or chronic. Review the contributory causes of altered consciousness shown in Figure 28.3 and consider the underlying mechanism for each of them. Neurological assessment in nursing is a critical skill for a neuro ICU nurse. Management of-unconscious-patient 1. Providing the patient has not sustained a cervical fracture, the ‘trapezius pinch’ (Figure 28.7b) is a useful alternative; the trapezius muscle (the large triangular muscle of the neck and thorax) is squeezed between the nurse’s fingers and thumb. Figure 28.3 Common causes of unconsciousness. It provides a standardised approach to observing and recording adverse changes in the patient’s level of consciousness, so that appropriate action can be taken (National Institute for Health and Clinical Excellence [NICE] 2003) (Box 28.3). This assesses the integrity of the RAS in the brain stem and is observed and recorded using the following categories. Inability to open the eyes due to bilateral orbital oedema, tarsorrhaphy (where upper and lower eyelids are sutured together), or ptosis (palsy of cranial nerve III) should be recorded as ‘C’ (closed) on the chart. The legs are generally straight, with the feet pointing outwards. Maintenance Following painful stimulation, the patient responds by rigid extension, i.e. The individual is awake, alert and aware of their personal identity and of the events occurring in their surroundings. However, if the eyelids are drawn back, the eyes may remain open. Consciousness cannot be measured directly but can be estimated by observing behaviour in response to stimuli.
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