Loosen Clothing at Neck, Chest and Waist. Blog. 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. Bryne B (2002) Deep vein thrombosis prophylaxis: the effectiveness and implications of using below-knee or thigh-length graduated compression stockings. The unconscious patient places a demand on resources, notably time and staff. Therefore, accurate fluid balance should be monitored and recorded to allow the identification of potential fluid or electrolyte imbalances (Gobbi and Torrance 2000). Enterai laxatives on their own may not be sufficient and the introduction of rectal preparations such as suppositories and enemas may be necessary. Nov. 21, 2020. unconscious patient zlem Korkmaz Dilmen Associate Professor of Anesthesiology and. Older patients in particular are vulnerable to the detrimental effects of prolonged immobility. In Alexander M, Fawcett J, Runciman P (Eds) Nursing Practice, Hospital and Home: The Adult. The GCS may be misleading in patients who are hypoxic, haemodynamically shocked, fitting or post-ictal, showing little or no response. Management of unconscious patient. Enterai feeding can be administered in a variety of ways and the most appropriate means needs to be decided following assessment of the unconscious patient. We are here for you and now, better than ever so sit back and enjoy This chapter has presented a physiologic approach to the differential diagnosis and the emergency management of the stuporous and comatose patient. 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. Communication between individuals is a broad and varied experience. 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. UNCONSCIOUS CLIENTS - NURSING CARE PLAN . However, older people often have evidence of minor injuries, such as bruises, which should alert the attending physician to more serious intracranial pathology. The presence of generalised tremor or myoclonus points towards a metabolic cause. You may wish to refer to Box 5. 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. Communicating with relatives can aid and enhance the nurse-patient relationship by fostering understanding and empathy. Routledge, London, 46-55. In this condition there is prolonged seizure activity but in the absence of motor signs. NS309 Geraghty M (2005) Nursing the unconscious patient. Killer coma cases part 1 (the found down patient) and part 2 (the intoxicated patient) on Emergency Medicine Cases. Increased water in the gut or a decreased ability to absorb fluid can result in diarrhoea. The nurse should give proper attention to the hygiene needs of the unconscious patient to promote comfort. 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. Now that you have completed this article, you might like to write a practice profile. The delicate surfaces and structures of the eye are protected by tears that maintain moisture, however, the unconscious patient is at risk of drying of the eye. Nursing Standard. The accumulation of secretions over time can contribute to the development o\f atelectasis and hypostatic pneumonia (Hickey 2003a). All sensory pathways link into the RF (Fitzgerald 1996). The pooling of secretions leads to hypostatic pneumonia which creates an ideal environment for the growth of bacteria (Hickey 2003b). Conclusion . 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). Shah S (1999) Neurological assessment. 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. Colquhoun M, Hadley A, Evans T (2004) ABC of Resuscitation. As a patient starts to become unconscious he or she loses control of his or her ability to maintain a safe environment. Early physiological stability and diagnosis are necessary to optimise outcome. Gentle cleaning of the nasal mucosa with gauze and water will help remove the build up of debris and maintain a moist environment. The unconscious patient is dependent on the healthcare team to deliver the correct nutritional requirements. The RAS receives input signals from a wide range of sources, including the senses (Pemberton 2000). The use of antiembolic stockings should be considered once the risk of venous thromboembolism has been identified (Bryne 2002). 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). 13, 22, 49-56. Restless. Baillire Tindall, London, 145-182. The thalamus and ascending reticular activating system can be damaged either by direct insult or by problems arising within the brainstem.3,4. The difference between each definition is the degree and presentation of response to painful stimuli (Hickey 2003b). 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). Care needs to be taken to ensure that the head and neck are aligned with the spine. First edition. Kussmaul respiration – deep, laboured breathing, indicative of severe metabolic acidosis and commonly associated with diabetic ketoacidosis. Lethargy is characterised by slow and sluggish speech, mental processes and motor activities. 4, 6, 300-305. Close monitoring of the patient’s respiratory function is important and any changes should be reported. Nursing Standard. It also provides some cushioning to bony prominences. 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). For patients with impaired consciousness touch, combined with kind and comforting words, can be a valuable means of providing reassurance. 18, 7, 45-51. To avoid foot drop the feet are positioned at a 90 degree angle to the leg with caretaken to avoid any unnecessary pressure. 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 GCS gives practitioners an internationally accepted format that assists communication, minimises user interpretation, and rapidly detects change in the patient’s condition (Howarth 2004). Please consult an expert before taking any action. Patient is a UK registered trade mark. 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. We are excited to announce that FibromyalgiaTreating.com is now part of RedOrbit.com. Does the patient speak and breathe freely. After this, observations should continue hourly for four hours, returning to every 30 minutes if the patient’s condition deteriorates. Churchill Livingstone, London, 637-656. 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). A Clinical and Research Resource. The regularity with which observations should be undertaken is determined by the severity of the patient’s condition (Cree 2003). 20, 1, 54-68. Thrombus formation is caused by venous stasis, decreased vasomotor tone, pressure on the blood vessels and a hypercoagulable state (Hickey 2003a). 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). 11, 11, 47-54. The lower the score the poorer the prognosis. Maintaining patent airway. Sixth edition. 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). Fifth edition. mixed and dilated pupil(s) – 3rd (oculomotor) nerve lesion from uncal herniation. 20, 2, 53-59. 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. 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). A variety of scales have been devised to describe patients’ level of consciousness (Barker 2002). Research focusing on oral problems associated with cancer suggests a minimum of four-hourly interventions to reduce the potential of infection from micro- organisms. Ensuring that the skin is dry between the toes will help to minimise fungal infection. Physical examination can give many clues as to the cause of unconsciousness. Obtain a complete patient history including the … how personal assumptions which we may not be aware of can lead to erroneous clinical decisions. Unconsciousness spans a broad spectrum (Hickey 2003a), from momentary loss of consciousness as seen with fainting, to prolonged coma that may last weeks, months or even years. Medical management will vary according to the original cause of the patient’s condition, but nursing care will be constant. Appropriate measures to resuscitate, stabilise and support an unconscious patient must be performed rapidly. Therefore, it is important to re-evaluate patients once any underlying acute condition has been corrected (Dawson2000). Gobbi M, Torrance C (2000) Fluid and electrolyte balance. Reflect on your experience of the Glasgow Coma Scale. Cough. The pattern of breathing should be assessed as well as the respiratory rate. Repeat the patient’s blood glucose level after 1 hour. Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale. Cheyne–Stokes breathing is seen with many underlying pathologies and is not helpful in making a firm diagnosis. They encourage healthcare practitioners to maintain verbal communication with the unconscious patient. Number of times cited according to CrossRef: 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. The unconscious patient presents a special challenge to the nurse. Electroencephalography (EEG) should be performed in suspected cases of non-convulsive status epilepticus. Unconscious patients have no control over themselves or their environment and thus are highly dependent on the nurse. Close monitoring of glucose levels is essential to ensure that this range is maintained. Bed rest also increases urinary stasis in the renal pelvis and urinary bladder further exacerbating the risk of urinary tract infection (Hickey 2003a). Supportive care and specific treatments must not be delayed. Department of Health (200Ib) The NHS Plan: A Plan for Investment. Think of a patient with impaired consciousness you have nursed. Date of acceptance: July 18 2005. Involving the family – whether to assist with hygiene practices or in helping to gain an understanding of the patient’s personal hygiene requirements – can help to turn the routine of bed bathing into an opportunity to reflect on the patient’s individual needs. Management of unconscious patient By: Nidhi Maurya Era’s college of nursing M.Sc. Diagnosis and treatment of unconscious patient. This article has been subject to double-blind review. Nursing Standard. Nursing 1st year 2. 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. They are challenging to manage and in a time sensitive condition, a systematic, team approach is required. Common causes. There are many different causes of unconsciousness. It cannot be stressed enough that the nurse has a crucial responsibility to anticipate, where possible, deterioration in a patient’s condition (Nursing and Midwifery Council (NMC) 2004). Cerrahpasa School of Medicine Learning Objectives. 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. If the patient does not regain immediate consciousness then his or her ongoing needs will need to be assessed. ABCDE = airway, breathing, circulation, disability, exposure; CT = computed tomography; CXR = chest X-ray. For example, a bitten tongue may indicate an epileptic seizure, or needle marks on the lower limbs or abdomen could be because the patient has insulin-dependent diabetes (Fuller 2004). Whenever these areas become excited impulses are transmitted to the RAS, further increasing the level of activity, and in turn the RAS stimulates the cerebral cortex, thus increasing the excitation of both regions. It is the field that maintains quality of life in a community. Using a nursing model familiar to your clinical area write a care plan that addresses Beatrice’s needs. In Hickey J (Ed) The Clinical Practice of Neurological and Neurosurgical Nursing. 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). Liaison with dieticians will assist in the ongoing assessment and planning the patient’s nutritional needs. Howarth V (2004) Neurological assessment. Nurses have a difficult time because they approach the patient directly. Correct positioning, regular turning and use of a pressure-relieving mattress will help to reduce these risks (Dougherty and Lister 2004). Airway. The insertion of a nasogastric tube in the early stages of unconsciousness will allow removal of gastric contents, thus reducing the risk of aspiration. Nursing the unconscious patient NS309 Geraghty M (2005) Nursing the unconscious patient. 29, 6, 1412-1420. Non-verbal cues are often the first elements of communication that help us to form immediate impressions about someone (Webb 1994). If uncorrected this will compromise breathing by wasting respiratory and skeletal muscles (Woodrow 2004). Consciousness is a function of the reticular formation (RF), which has its origins in the brainstem (Barker 2002). The following five strategies may help. Suctioning should be undertaken with care, following appropriate patient assessment to establish the need for intervention. Nursing such patients can be a source of anxiety for nurses. A Plan for Reform. All rights reserved. A gastrostomy may be more appropriate if enterai feeding is required for longer periods, thus removing the risks associated with nasally inserted tubes. 94, 7, 63-67. Consciousness can be defined as a state of awareness of one’s self and the environment (Barker 2002). Minimum standards and methods of oral hygiene have been debated in the literature (Evans 2001). 1. A person in a coma is unrousable and unresponsive to external stimuli. Monitoring bowel function with the use of a chart will help to assess the need for intervention. Prognosis depends on a number of factors. WB Saunders, London. Understanding a patient’s perception and interpretation of his or her experience when consciousness is impaired is not always possible. A urinary catheter should be considered if the state of unconsciousness is not resolved quickly. Nursing Standard. Elliott R, Wright L (1999) Verbal communication: what do critical care nurses say to their unconscious patients? In Perry A, Potter P (Eds) Clinical Nursing Skills and Techniques. Churchill Livingstone, London, 757-774. 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. Baillire Tindall, London, 665-745. Early physiological stability and diagnosis are necessary to optimise outcome. Recognition can lead to the development of self-regulatory behaviors to mitigate the influence of bias on patient interactions.3Acquiring personal awareness requires an internal compass that's used to guide daily interactions. If the weather is cold wrap the blankets around the patient body. As it is the internationally agreed common language in neurological assessment, it is essential that it is completed accurately, and that any uncertainties are reported immediately (Hickey 2003b). Management of-unconscious-patient 1. Alternatives to managing incontinence should be considered, for example, the use of a urinary sheath or incontinence pads. Medsurgical Nursing. Unconscious patients are commonly seen by physicians. Mosby, Missouri MO, 51-97. Patients present with a spectrum of altered consciousness. In Hickey J (Ed) The Clinical Practice of Neurological and Neurosurgkal Nursing. Whether the patient is in a critical care bed or on the ward, the ongoing needs and priorities remain unchanged. The unconscious patient is completely dependent on the nurse to manage all their activities of daily living and to monitor their vital functions. Tidal volumes -the volume of air that passes in and out of the lungs during normal quiet breathing- may not be compromised, depending on any underlying respiratory pathology, but generally lying flat causes a reduction in the residual volume and functional residual capacity of the lungs (Hickey 2003a). Simulation training for core medical trainees in the care of unconscious patients has shown some positive effect.21. The risk of venous thromboembolism and pulmonary emboli from the effects of immobility is well recognised (Dougherty and Lister 2004). This suggests that consciousness depends on whether the individual can be aroused to wakefulness. 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). Greenwich Medical Media, London. Some examples are shown in Box 2; however, these are by no means exhaustive. It is also important to remember that unconsciousness may be induced, for example, the use of anaesthetics for surgical or medical intervention. Churchill Livingstone, London. In Perry A, Potter P (Eds) Clinical Nursing Skills and Techniques. Getliffe K (1996) Care of urinary catheters. Nursing management of the unconscious patient . 2019;31(5):356–362. Mosby, Missouri MO. Dougherty L, Lister S (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Fifth edition. The GCS forms a quick, objective and easily interpreted mode of neurological assessment, avoiding subjective terminology, such as ‘stupor’ and ‘semi-coma’. Fifth edition. 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. The GCS has been used as a prognostic device during immediate assessment following a head injury. 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. Sarah J. Neill, Review : Developing children's nursing through action research, Journal of Child Health Care, 10.1177/136749359800200103, 2, 1, (11-15), (2016). 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. It is important to remember that unconscious patients will not be able to communicate whether a feeding tube is in the wrong place. Discuss how such skills could be used to enhance the general nursing care of conscious patients in your clinical area. In Dolman M, Getliffe K (Eds) Promoting Continence. Professional Nurse. In so doing the nurse should be able to provide a clear rationale for all care procedures. b. How to go through your neuro ICU patient assessment. This helps to retain patient dignity, allows close monitoring of urinary output and prevents skin breakdown. As the ABC assessment is undertaken, other team members should be: connecting the patient to a cardiac monitor and oxygen saturation probe. Nursing Management of unconsciousness patient:-a. The arousal reaction is dependent on the stimulation of the RAS. Atelectasis and pneumonia are long established consequences of prolonged bedrest (Hickey 2003a). Krishnasamy M (1995) Oral problems in advanced cancer. Sustained pressure from immobilisation remains the most important cause of skin breakdown (Hickey 2003a). Cardiovascular function Monitoring the cardiovascular function in unconscious patients is of high importance. Physiological changes that occur over short periods of immobility are less severe and potentially reversible. the new Fibromyalgia Treating by RedOrbit! This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. 18,11, 45-54. In Alexander M, Fawcett J, Runciman P (Eds) Nursing Practice, Hospital and Home. Care of unconscious patient . Citing Literature. A systematic and logical approach is required, with an emphasis on teamwork. Journal of Advanced Nursing. Follow these steps for your next neuro assessment. Third edition. Any enterai feeding regimen should encompass a rest period to allow for gastric acidity to return to its normal level (approximately pH 4.0), thus reducing the risks of bacterial colonisation (Woodrow 2004). Nursing Standard. 16, 30, 52-62. Describe the patient’s physical and emotional behaviour. Abnormal breath sounds: stridor, wheezing, wheezing, etc.. Lippincott Williams & Wilkins, Philadelphia PA, 133-162. 8, 593-596, 599. Hygiene needs and skin care 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. Reply Delete Bailey K, Wilkinson S (1998) Patients’ views on nurses’ communication skills: a pilot study. 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. The causes of unconsciousness will dictate the length of the coma and the prognosis. Although flumazenil can be considered in benzodiazepine overdose, it is contraindicated in patients with a history of seizures and can provoke seizures with concomitant tricyclic overdose. 4, 4, 173-177. Decisions, such as ceiling of care, are required at an early stage in patients with a poor prognosis. Nursing Standard, 20,1, 54-64. Curr Opin Obstet Gynecol . Wunderlich R (2002a) Exercise and ambulation. A systematic and logical approach is necessary to make the correct diagnosis; the broad diagnostic categories being neurological, metabolic, diffuse physiological dysfunction and functional. Hypotension is initially manged with intravenous fluid resuscitation; early vasopressor support is considered when the blood pressure does not respond. Definition of unconsciousness. A conscious person is capable of responding to sensory stimuli. Moore T (2004) Suctioning. Department of Health (2001a) Essence of Care: Patient-focused Benchmarks for Clinical Governance. Patient does not provide medical advice, diagnosis or treatment. This compass can help nurses reco… 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. This can be demoralising for the nurse, especially after a long period of committed nursing care. Nurses are accountable for their practice and a\ppropriate training should be undertaken before this procedure is carried out. 12. 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. In Moore T, Woodrow P (Eds) High Dependency Nursing Care: Observation, Intervention and Support. The management of an unconscious patient is a medical emergency, requiring prompt assessment and the appropriate use of first aid and life support procedures. Draw blood for baseline electrolytes. European Journal of Cancer Care. However, introduction of a urinary catheter increases the risk of infection (Getliffe 1996). 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). Nitrogen is lost from the body when protein is broken down. A nurse not involved in the immediate care of the patient should be allocated to take responsibility for providing this support (Pemberton 2000). Fundoscopy should be performed; important findings include papilloedema in posterior reversible encephalopathy syndrome (PRES) or subhyaloid haemorrhage in subarachnoid haemorrhage. The two main identified parts of the RAS are the mesencephalon (upper pons and mid-brain) and the thalamus. Physiotherapy is important to encourage lung expansion, assist the removal of secretions and help in the prevention of complications. Client Expected Outcome What did you find challenging about nursing this patient? Assessment of the mouth and teeth is also important. 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. The changes can be subtle at first and difficult to recognise. Care should be taken to examine the skin properly, noting any areas which are red, dry or broken. 20, 6, 24- 27. The unconscious patient will require skilled emergency management. The arm that is uppermost is flexed at the elbow and rested on a pillow to prevent drag on the shoulder and wrist drop. Unconsciousness occurs when the RAS is damaged or inhibited, thus affecting the normal arousal mechanism (Pemberton 2000). Breathing Initial investigations in an unconscious patient. 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). 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. This article focuses on unconscious patients where the initi … Oxygen saturation is a measure of the percentage of haemoglobin molecules that combine with oxygen. The categorisation of the different graduations of coma is not universally accepted. However, the Glasgow Coma Scale (GCS) (Jennett and Teasdale 1977) is the most universally accepted tool, which decreases the subjectivity and confusion associated with assessing levels of consciousness (Hickey 2003b). Changes in the pattern of breathing may indicate a developing respiratory failure, or a disorder of the respiratory control centre in the brain (Dawson 2000). International Journal of Palliative Nursing. 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. Neurological assessment in nursing is a critical skill for a neuro ICU nurse. Unconscious patients are commonly seen by physicians. Nursing management of the unconscious patient. Intensive and Critical Care Nursing. If the patient is still breathing spontaneously and does not require further resuscitation then appropriate positioning of the patient, using the recovery position, will prevent vomit or any secretion from obstructing the airway, potentially causing aspiration (Colquhoun et al 2004). Nursing Standard. 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). Fader M (1997) Tlie promotion and management of continence in neurological disabilities. Blackwell Science, Oxford. Australian Critical Care. 20, 1, 54-64. Change can be indicative of neurological deterioration and such observations need to be balanced with neurological assessment to obtain a more accurate evaluation. The unconscious patient is challenging, in terms of immediate care, diagnosis, specific treatment and predicting prognosis. Journal of Vascular Nursing. For example, stimulation of the vagus nerve in the rectal wall can slow the patient’s heart (Powell and Rigby 2000). Nurses should be verbally reassuring and explain all procedures to unconscious patients. A full examination must be performed, although there are areas of specific relevance in the unconscious patient. Anyone accompanying an unconscious patient to hospital will require support and information. Self-care deficit-bathing, feeding, grooming, toileting related to unconscious state as evidenced by unkempt and poorly nourished look, bed soiling. 14, 47, 47-51. Nursing Standard. All rights reserved, Elon Musk Questions Reliability of COVID-19 Tests After Receiving Confusing Results, Tesla Releases Winter Tire and Wheel Package for Model Y, NASA Certifies Crew Dragon for Crew-1 Flight. Nasogastric feeding is the most commonly used method and is recommended for short-term feeding (less than four weeks) (Dougherty and Lister 2004). NICE, London. 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. 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). 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. Consciousness demonstrates that the RAS is functioning and is capable of the screening and discrimination of information (Pemberton 2000). The Pupil Exam in Altered Mental Status on PEMBlog The thalamus plays a crucial role in maintaining arousal. 11. Eye movements cannot be fully assessed in an unconscious patient. Therefore, care must be taken to ensure that it has been inserted correctly. However, it is not without risks. A collateral history from relatives or other witnesses, including paramedics, is vital.4 The patient's recent health, functional status and previous medical history may provide diagnostic clues as well as guiding decisions regarding ongoing care, such as admission to a critical care unit. 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). Nursing Standard. Genitourinary function An unconscious patient will be incontinent of urine. Thus, in relation to consciousness, the nurse has an essential role in the assessment of the central nervous system using the GCS, monitoring vital signs, pupillary reaction and limb movements. For example, when an individual is in a deep sleep the RAS is in a dormant state. There is minimal information on this invasive procedure in the nursing literature. 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). Intensive Care. Incontinence, perspiration, poor nutrition, obesity and old age also contribute to the formation of pressure ulcers. 17 52, 45-50. 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. This is the process of looking inward to recognize beliefs and values that can lead to unconscious bias. Seizures. Depending on the underlying condition, the unconscious patient may never fully recover or may die from complicating factors. Casey G (2003) Haemostasis, anticoagulants and fibrinolysis. In Walsh IVl (Ed) Watson’s Clinical Nursing and Related Sciences. Positioning the patient is important and will facilitate the drainage of secretions. Monitors patient’s vital signs. When the prognosis is poor these discussions will include ceiling of care, consideration of future withdrawal of treatment and cardiopulmonary resuscitation. The skin forms a protective barrier against infection and regulates body temperature. 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. If any doubt exists, the cervical spine should be immobilised. Correct positioning of the unconscious patient also minimises the risks associated with immobility in terms of circulation and the musculoskeletal system (Wunderlich 2002b). Fifth edition. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. Discussion Points Definition of Unconsciousness. Elevating the head end of the bed to degree prevents aspiration. Routledge, London, 115-123. Suctioning has associated contraindications and unwanted effects, for example, a rise in intracranial pressure (Moore 2004). Therefore, an assessment tool, such as the Waterlow scale, should be used to aid early identification of the risks (Waterlow 1991, 1998). The Stationery Office, London. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. © 2002-2018 redOrbit.com. Unconsciousness is … 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. Learning Objectives Definition of unconsciousness Common causes Diagnosis and treatment of unconscious patient 3. Care of the unconscious patient suffers from fragmentation because of its emphasis on the physical. Cerrahpasa School of Medicine. 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. Management of. Nursing Standard. Evans G (2001) A rationale for oral care. 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. A brief summary of the nursing management of the unconscious patient is provided in Box 5. 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). nursing assignment help nursing help nursing assignment. Green A (1996) An exploratory study of patients’ memory recall of their stay in an adult intensive therapy unit. Therefore, the manifestation of impaired or absent consciousness points towards an underlying brain dysfunction. 10, 34, 40-43. We can now extend to other conditions that may be part of your everyday lives and help you on a broad level if that is what you need. The unconscious patient is a medical emergency which can challenge the diagnostic and management skills of any clinician. from doctors and scientists. Differential diagnoses in a patient with non-traumatic coma. 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. c. If breathing has stopped or about to stop, turns casual in to the required posture and start CPR (artificial respiration). Interrupted family process related to chronic illness of a family member as evidenced by anger, grief, non-participation in client care. Pulse oximetry assists in monitoring the effectiveness of oxygen therapy (Dougherty and Lister 2004 ). Pearce C, Duncan H (2002) Enterai feeding: nasogastric, nasojejunal, percutaneous endoscopie gastrostomy, or jejunostomy: its indications and limitations. Nursing the unconscious patient can be a challenging experience. National Institute for Clinical Excellence (2003) Head Injury, Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. Previous hospital records must be requested urgently and the next of kin contacted. Either way, a committed focus on maintaining a high standard of care and promoting dignity throughout, regardless of the outcome, remain paramount. Churchill Livingstone, London, 851-871. 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. The human body is designed for physical activity and movement; thus, physiological changes will occur in the unconscious patient, which will be exacerbated by the length of immobility, cause of unconsciousness and the quality of care (Dougherty and Lister 2004). The unconscious patient places a demand on resources, notably time and staff. 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. This article focuses on unconscious patients where the initial cause appears to be non-traumatic and provides a practical guide for their immediate care. Fifth edition. Juggling such … In hypoglycaemic patients at risk of Wernicke's encephalopathy, such as those with a history of alcohol excess, intravenous thiamine should be coadministered. In Payne-James J, Grimble G, Silk D (Eds) Artificial Nutritional Support in Clinical Practice. Nursing Standard. Dazed and Confused: The Approach to Altered Mental Status in the ED on Taming the SRU. Nursing Standard. Copyright RCN Publishing Company Ltd. Sep 14-Sep 20, 2005, The information provided is no substitite for an informed medical professional. Nursing Times. Baillire Tindall, London, 375-409. Fuller G (2004) Neurological Examination Made Easy. 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). Diagnostic testing, and treatment options. Respiratory function Maintaining a patent airway and promoting adequate ventilation are nursing priorities. Powell M, Rigby D (2000) Management of bowel dysfunction: evacuation difficulties. In your own words describe the function of the reticular activating system and define consciousness. BMJ Books, London. 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. 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. 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. This may explain why patients with impaired consciousness sometimes display inappropriate behaviour such as fear and/or aggression ( Woodrow 2000). second edition. List the immediate nursing priorities. Curriculum mapping Foundation programme 7.1 (Core skills in relation to acute illness) Knowledge. If the patient remains stable on hourly GCS assessment for four hours, the observations can be reduced to every two hours (NICE 2003). However, these recommendations cannot be generalised and each patient needs to be individually assessed. 78, 918, 198-204. 14, 3, 100- 105. Common causes. Postgraduate Medical Journal. Nursing management of Unconscious patients 2 firstname.lastname@example.org 3. Acute states are potentially reversible, whereas chronic states indicate underlying brain damage and hence are irreversible (Pemberton 2000). 9. Oropharyngeal airways, such as the Guedel airway, have many benefits (Pemberton 2000). The accuracy of the GCS is dependent on the assessor using and interpreting it correctly. Definition of unconsciousness. The Adult. Cree C (2003) Acquired brain injury: acute management. In hypoglycaemia, intravenous glucose is the immediate treatment of choice as glucagon can take up to 15 minutes to act and is ineffective in patients with liver disease, depleted glycogen stores or malnutrition. Do they meet the NICE (2003) guidelines? Early communication with the next of kin, family or appropriate advocate is always necessary. If one pathway is activated the degree of consciousness may be minimal, however, if many pathways are activated simultaneously then this may result in a high level of consciousness. Pemberton L (2000) The unconscious patient. Waterlow J (1998) The treatment and use of the Waterlow card. We now have access to an enormous amount of additional research information Antibiotics can exacerbate this by destroying gut commensals (Woodrow 2004). Unless the cause of coma is immediately obvious and reversible, input from senior physicians and critical care colleagues is necessary. A Spectrum of Care. psychiatric or functional – considered when organic causes have been excluded. 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. To do this he or she needs to understand the effects of prolonged immobility on the main systems of the body. Non-verbal communication, such as facial expression, eye contact, posture, personal space and bodily contact, is important in social interaction. This may demand that the patient be moved to an intensive care unit (ICU) to allow for critical management. second edition. There was a decrease of consciousness. 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). It will also discuss the emergency priorities that may arise. * Discuss the various levels of impaired consciousness. Glasgow Coma Score and coma etiology as predictors of 2 week outcome, Crisis Checklist Collaborative. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. However, a loud noise or noxious stimulus will wake us. Investigations aid diagnosis, assessment of severity and monitoring of ongoing care. Mallett J, Dougherty L (2000) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Third edition. Management of the Patient with Reduced Consciousness Primary topic: Initial management of the patient with reduced consciousness. However, Fader ( 1997) suggests that manual evacuation should only be undertaken when other methods of bowel evacuation have failed. To maintain a patent airway the lateral recumbent position is advised (Allan 2002) with the head of the bed slightly tilted upwards, about 10-30 degrees (Pemberton 2000) (Figure 2). Secondary topics: Differential diagnosis Management of DKA. Enterai feeding can prevent this by averting atrophy of the villi that absorb nutrients and produce protective mucus and immunoglobuhns. The nurse needs to work closely with the medical team to ensure that the right pathways of medical management are applied appropriately. Enterai feeding will not stimulate peristalsis (Hickey 2003a). There are many pathways from the cerebral cortex that concern sensory and motor function, as well as emotions and reasoning. The RAS serves as a point of convergence for signals from our external environment and our internal thoughts and feelings. The Adult. Delusions are more persistent misperceptions that are held to be real, however illogical they may seem (Hickey 2003b). There are acute and chronic states of impaired consciousness. 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. Associate Professor of Anesthesiology and Intensive Care. Learning Objectives. 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. 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. The RF is a network of neurones that connect with the spinal cord, cerebellum, thalamus and hypothalamus. Artificial tears can also be applied as drops to help moisten the eyes (Dougherty and Lister 2004). 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. Professional Nurse. 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). Dawson D (2000) Neurological care. If unconsciousness is prolonged and an artificial airway is still required then a tracheostomy should be considered (Hooper 1996).
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