UNCONSCIOUSNESS

PRESENTED TO: PRESENTED BY:

MS. SHILPI MAM MS. AKRITI

ASSISTANTPROFESSOR M.Sc 1 st YEAR
 INTRODUCTION
CONSCIOUSNESS
• A state of awareness of yourself and your
surroundings
• Ability to perceive sensory stimuli and respond
appropriately to them.
UNCONSCIOUSNESS
• Unconsciousness is a term used widely to denote a state of
unresponsive of an individual or external stimuli.

• Means that the patient is unaware of what is going on around

him and is unable to make purposeful movement.
 DEFINITION
 Unconsciousness is a term used widely to
denote a state of unresponsive of an individual
or external stimuli.

 Other definition of unconsciousness is “ A

state in which patient doesn’t oriented of
Time, place and person as well as external
environment.”
 LEVEL OF UNCONSCIOUSNESS
1. Alertness, oriented: opens eyes spontaneously, responds to stimuli
appropriately.

2. Lethargy, sleepy: slow to respond but appropriate response: opens eyes to

stimuli, oriented.

3. Stupor: Aroused by and opens eyes to painful stimuli: never fully awake:
confused: unclear conversation.

4. Semi-coma stage: Moves in response to painful stimuli: no conversation,

protective blinking/swallowing: pupillary reflex present.

5. Coma: Unresponsive except to severe pain: no protective reflexes: fixed

pupils: no voluntary movements
 ETIOLOGY
 INTRA CRANIAL CAUSES
 EXTRA CRANIAL CAUSES
METABOLIC CAUSES
RESPIRATORY INSUFFICIENCY
DECREASED CARDIAC OUTPUT
ENDOCRINE CAUSES
DRUG ABUSE)
TOXINS ….PSYCHOGENIC CAUSES
 INTRA CRANIAL CAUSES
◦ Head Trauma
◦ SAH
◦ Cerebral infarction
◦ Intra cranial Neoplasm
◦ CNS infection
◦ Epilepsy
EXTRA CRANIAL CAUSES
METABOLIC CAUSES
Hepatic failure
Uraemia
Hypoglycaemia/ Hyperglycaemia
RESPIRATORY INSUFFICIENCY
Hypoventilation
Anaemia
Hypoxia
Hypercapnia
DECREASED CARDIAC OUTPUT
MI
Cardiac arrthymia
Blood loss
 ENDOCRINE CAUSES
Diabetes-hyperglycaemiaS
Hypopituitarism
Adrenal crisis
Hypo/Hyperparathyroidism
Hypothyroidism
 DRUG ABUSE (drug poisoning)- sedatives ,hypnotics,

Anti- depressants, Anticonvulsants, Anaesthetic agents .

 TOXINS –alcohol ,carbon monoxide
 PATHOPHYSIOLOGY
Underlying Cause due to neurologic dysfunction

Increased ICP

Diffused damage to the cerebral tissues

Block the signal to the RAS(reticular

activating system)

Unconsciousness
 SIGNS AND SYMPTOMS
 The person will be unresponsive
 Is unaware of his surroundings
 Makes no purposeful movements
 Does not respond to questions or to touch
 Drowsiness
 Inability to speak or move parts of his or her body
 Loss of bowel or bladder control (incontinence)
 Stupors
Respiratory changes (cheyne stroke respiration,
ataxic breathing, hyperventilation)
Abnormal pupil reactions
 ASSESSMENT OF UNCONSCIOUS CLIENT:-

• For the care to be effective, a nurse should perform frequent,

systematic and objective assessment on the comatose client.
• During the first few hours of coma neurological assessment is
to be done as often as every 15 minutes.



 PHYSICAL ASSESSMENT
LEVEL OF CONSCIOUSNESS:-
• Thus, the client’s responses are rated on a scale from 3 to
15.

• A score of 3 indicates severe neurologic impairment.

• A score of 15 indicates that the client is fully

responsive.

• A score less than 7 requires frequent assessment.

 GCS ≤ 8 – Severe brain injury
 GCS 9 – 12 - Moderate brain injury
 GCS ≥ 13 – Mild brain injury
 ASSESSMENT OF LOC
Evaluation of mental status.
Cranial nerve functioning.
Reflexes.
Motor and sensory functioning.
Scanning, imaging, tomography, EEG.
 Diagnostic test
 X-ray
 MRI (magnetic resonance imaging): tumors, vascular
abnormalities, IC bleed
 CT (computerized tomography): cerebral edema,
infarctions, hydrocephalus
 Lumbar puncture: cerebral meningitis, CSF evaluation
 PET (positron emission tomography)
 EEG: electric activity of cerebral cortex
 Blood test like CBC, LFT, RFT, ABG etc.
Diagnostic test
 MANAGEMENT

1. Medical management-
Emergency management
Symptomatic management

2. Surgical management

3. Nursing management
Emergency management
Circulation
Airway
Breathing
 Medical Management
The goal of medical management are to preserve brain
function and prevent further damage.
Ventilator support
Oxygen therapy
Management of blood pressure
 Management of fluid balance
Management of seizures : anti epileptic sedatives,
paralytic agents
Treating Increased ICP : mannitol, corticosteroids
 Management of temperature regulation (fever):
ice packs, tepid sponging, Antipyretics, NSAIDS
 Management of elimination : laxatives
Management of nutrition: TPN and RT feeds
 DVT prophylaxis
 Surgical management

The patients altered level of conscious is a space – occupying

lesion, surgical removal of the mass may improve the patients
condition.

Craniotomy: A craniotomy may be performed to remove a

tumour, abscess or intracerebral hematoma.
Burr-hole: Created to drain a subdural hematoma.
Ventricular catheter or shunt: May be place to relive
hydrocephalus.
NURSING MANAGMENT
Nursing management of unconscious
patient (emergency care)
Maintaining a patent airway
ABC Management
ABG results must be interpreted to determine the degree of
oxygenation provided by the ventilators or oxygen.
Assess for cough and swallow reflexes
Use an oral artificial airway to maintain patency
Tracheotomy or endo-tracheal intubation and mechanical
ventilation maybe necessary
Preventing airway obstruction
Ineffective cerebral tissue perfusion
 Assess the GCS, SPO2 level and ABG of the patient.
 Monitor the vital signs of the patients (increased

temperature)
 Head elevation of 30 degrees, neutral position

maintained to facilitate venous drainage.

 Reduce agitation .(Sedation.)
 Reduce cerebral edema (Corticosteroids, osmotic or

loop diuretics.) Generally peaks within 72 hrs. after

trauma and subsides gradually.
 Talk softly and limit touch and stimulation.
 Administer laxatives, and antiemetic as ordered
 Manage temperature with antipyretics and cooling

measures.
 Prevent seizure with ordered dilantin.
 Administer mannitol 25-50 g IV bolus if ICP >20, as

prescribed.
Risk for increased ICP.
 Head elevation of 30 degrees, neutral position
maintained to facilitate venous drainage and prevent
aspiration.
 Pre-oxygenation before suctioning should be mandatory

, and each pass of the catheter limited to 10 seconds,

with appropriate sedation to limit the rise in ICP.
 Insertion of an oral airway to suction the secretions.
 As fluid intake is restricted and glucose is avoided to

control cerebral edema and intravenous infusion cannot

be considered as a nutritional support.
Nursing management of unconscious
patient (routine care)
 Nursing Diagnosis
 Ineffective airway clearance related to altered level of
consciousness
 Risk for injury related to decreased level of

consciousness.
 Risk for impaired skin integrity related to immobility
 Impaired urinary elimination related to impairment in

sensing and control.

 Risk for impaired nutritional status.

 1. Maintaining Patent Airway
Elevating the head end of the bed to 30 degree prevents
aspiration.
Positioning the patient in lateral or semi prone position.
Suctioning to remove secretions.
Chest physiotherapy.
Auscultate in every 8 hours.
Care of Endo tracheal tube or tracheostomy.
2. Protecting The Client

 Padded side rails

 Restrains.
 Take care to avoid any injury.
 Talk with the client in-between the procedures.
 Speak positively to enhance the self esteem

and confidence of the patient.

3.Maintaining fluid balance and managing
nutritional needs

 Assess the hydration status.

 More amount of liquid.
 Start IV line.
 Provide Liquid diet.
 Care of NG tube Over hydration and intravenous

fluids with glucose are always avoided in comatose

patients as cerebral edema may follow.
4.Maintaining skin integrity
 Assess the skin
 Regular changing in position.
 Passive exercises.
 Back massage.
 Special beds to prevent pressure on bony

prominences
 Comfort devices should be used.
 Adequate nutritional and hydration status should be

maintained
 Frequent oral hygiene every 4 hourly.
5.Preventing Urinary and Bladder
Retention
 Assess for constipation and bladder distention.
 Auscultate bowel sounds.
 Stool softeners or laxatives may be given.
 Bladder catheterization may be done.
 Monitor the urine output and color.
 Initiate bladder training as soon as consciousness has

regained.
 6.PROPER POSITION:

 Commonly give prone, lateral, or sim’s position as

per according to patient’s condition.
 Upper leg supported on a pillow to maintain

alignment of the hip

 Change position to lie on alternate sides every 2-4hrs
 taking care to prevent injury to soft tissue and nerves,

edema or disruption of the blood supply

 7.HYGIENE:

 Observed the patient and provide personal hygiene

care to the patient.
 Take care of pressure points.
 Give passive exercise to limbs, so that can prevent

stiffening of joints, muscular contraction and venous

static.
 To prevent dryness of mouth and tongue give frequent

mouth care
 Change position frequently.
Oral Hygiene:
 A chlorhexidine based solution is used.
 Airway should be removed when providing oral care. It

should be cleaned and then reinserted.

 If the patient has an endotracheal tube the tube should be

fixed alternately on each side.

 Minimum of four-hourly oral care to reduce the potential of

infection from micro-organisms.

Eye Care:
 In assessing the eyes, observe for signs of irritation, corneal
drying, abrasions and oedema.
 Gentle cleaning with gauze and 0.9% sodium chloride

should be sufficient to prevent infection.

8.CARE OF PRESSURE AREAS & PREVENT FOOTDROPS

 Keep patient on water bed mattress.

 Bed linen keeps dry if moist then immediately change

bed linens.
 Use bed cradle for cut off weight of bed clothes.
 Keep pillow between knee and ankle prominence.
 Change patient’s position every hourly.
 Massage every two hourly on pressure areas.
 Apply splint on hands to prevent wrist drops and keep

in correct position.
 Back care every two hourly and apply Telkom powder.
 If redness or injury so inform immediately.
 Use foot rest for to prevent foot drops.
 Use pillow or foot board at the bottom side to prevent

weight of bed clothes on the feet.

 Passive physiotherapy so that keeps ankle and feet in

good condition.
 Keep skin clean, dry and free of pressure and use

pressure relieving devices like air cushion, air/water

mattress.
 Avoid dragging and pulling the client while changing

position, avoid vigorous massage of bony

prominences
 9.NUTRITION
 Provide high calorie, high protein, vitamin
rich diet and more amounts of fluids such as
porridge, soup, juice etc.
 Give I.V or gastric tube feeding according

to the nutritional status and requirement.

 Complications
 Convulsions
 Bladder and bowel distention
 The Failure of multiple organs, such as the kidneys,

lungs, and heart.

 Fluid electrolyte imbalance
 pneumonia or other life-threatening infections
 Osteoporosis
 bed or pressure sores of the skin
 Deep vein thrombosis/pulmonary embolism
 bed or pressure sores of the skin

 repeated bladder infections,

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