Unconcious patient

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Information about Unconcious patient

Published on April 13, 2012

Author: anitarobins

Source: authorstream.com

The Unconscious Client : The Unconscious Client Nursing management 1 Nirmala Roberts India The consciousness…: The consciousness… A state of wakefulness & awareness of self and the environment. Wakefulness - depends on the integrity of the cerebral hemi- spheres and the ascending reticular activating system (RAS) in the brain stem Awareness - of one’s own existence, sensations, thoughts, surroundings…... Capable of responding rationally to stimuli Protective reflexes are on the ready 2 The human brain…: The human brain… The brain requires a constant supply of O2 and glucose for normal function Interruption of this supply will cause loss of consciousness within a few seconds and may also cause permanent brain damage 3 Unconsciousness….: Unconsciousness…. A state of unarousable responsiveness, where the client is unaware of the self or the surroundings and no purposeful response can be obtained to external stimuli. May be - Brief – lasting for few seconds to an hour Sustained – lasting for a few hours or longer 4 Coma: Coma A state of sustained unconsciousness in which the client does not respond to verbal stimuli, does not move voluntarily, does not blink, may have altered respiratory patterns, altered pupillary response to light and varying responses to painful stimuli 5 Levels of Unconsciousness: Levels of Unconsciousness Levels Clinical features Conscious Normal, alert oriented to self, place, and mind Opens eyes spontaneously, responds to stimuli appropriately Confused Impaired or slowed thinking; disoriented Delirious Disoriented, restless, attention deficit , possible incidence of hallucinations and delusions Somnolent Excessive drowsiness; responds-to verbal stimuli although slow and inappropriate Obtunded Decreased alertness, slowed motor responses; sleepiness Stuporous Sleep-like state; can be aroused only by vigorous and repeated noxious stimuli ; little or no activity; responsiveness only to pain Comatose Unarousable and unresponsive, no gag reflex or pupillary response to light 6 PowerPoint Presentation: Somnolent Delirious Comatose Confused 7 Aetiology of Unconsciousness: Aetiology of Unconsciousness Blood oxygenation problems Blood circulation problems Metabolic problems (Diabetes mellitus, over dosage) CNS problems (head injury, stroke, tumour , epilepsy) 8 Aetiology (Causes): Aetiology (Causes) Focal brain dysfunction Brain tumour Vascular events (CVA) Demyelination Infection (brain abscess) Focal head injury Diffuse brain dysfunction Infection – meningitis/ encephalitis Epilepsy Hypoxia and hypercarbia Drugs, poisoning and overdoses ( including alcohol) Metabolic/endocrine causes - diabetic coma, hepatic or renal failure, hypothyroidism, severe electrolyte disturbances Hypotension, or hypertensive crisis Diffuse head injury Subarachnoid haemorrhage Hypothermia, hyperthermia 9 Assessment of Unconscious client: Assessment of Unconscious client 10 Need for frequent systematic and objective assessment…. : Need for frequent systematic and objective assessment…. For effective care Client is unable to report any problem Neurologic assessment x 15 mins 11 Gather history of…: Gather history of… Present illness Past illness/ surgeries – Allergies, medication, illnesses (Epilepsy, Diabetes), last meal, event (what happened?) Personal history Nutritional history Socio-economic and environmental status 12 Physical Assessment : Physical Assessment 13 Signs and Symptoms : Signs and Symptoms Levels of unconsciousness - varied Some are more serious than others Levels include unconscious episodes that are - Brief  fainting or blacking out Longer  V ictim is incoherent when roused Prolonged  Victim is m otionless and not at all aware of his/ her surroundings for a very long time. 14 The Glasgow Coma Scale : The Glasgow Coma Scale A neurological scale – G ive s a reliable, objective record of the level of consciousness (LOC) of a person, for initial as well as continuing assessment A patient is assessed against 3 criteria – E - Eye opening – 4 V - Best Verbal response – 5 M - Best Motor response – _ 6_ Total = _ 15_ GCS 15 = E4 V5 M6 at 10 am 15 Levels of Consciousness (by Glasgow coma scale): Levels of Consciousness (by Glasgow coma scale) 16 Glasgow Coma Scale - Scoring: Glasgow Coma Scale - Scoring Highest score is 15/15 – Good orientation Lowest score is 3/15 - Deep coma. Considered brain dead if client dependant on a ventilator GCS ≤ 8 – Severe brain injury GCS 9 – 12 - Moderate ” GCS ≥ 13 – Mild ” 17 The GCS scoring….: The GCS scoring…. Individual elements as well as the sum of the score are important The score is written as - “GCS 9 = E2 V4 M3 at 07:35 am Brain injury according to the GCS score is classified as: Severe - with GCS ≤ 8 Moderate - GCS 9 – 12 Minor - GCS ≥ 13. 18 Limitations of GCS scoring….: Limitations of GCS scoring…. Tracheal intubation, severe facial/eye swelling  Cannot test verbal and eye responses. Score given as 1 with a modifier attached  'E1c' where 'c' = closed, or 'V1t' where t = tube.  Hence, a c omposite ‘ GCS 5tc’ => Eyes closed = 1, intubated = 1, balance - motor score of 3 for 'abnormal flexion‘.  GCS5tc = Ec Vt M3 (… the 1 is left out) Children < 3 years of age –  Poor verbal expressions even in healthy child  H ence, a separate Paediatric Glasgow Coma Scale 19 Paediatric GCS: Paediatric GCS 20 Pattern of Respiration: Pattern of Respiration Hyperventilation - midbrain and upper pons lesion, metabolic diseases (hepatic coma, diabetes, raised ICP) Hypoventilation - medullary , upper cervical spinal lesion, Drug overdose and later stages of cerebral herniation . Cheyne -Stoke respiration – diencephalic lesion, tentorial herniation and obstructive hydrocephalus. Ataxic respiration (completely irregular breathing) - brain-stem dysfunction 21 Eyes: Eyes Pupillary reaction - PEARL Fixed dilated pupils – Disease of the brain stem. Progressive dilation - Increase in ICP metabolic diseases and drug overdose Unequal dilation of pupil – Toxic/ metabolic disorder of brain Eye movements – Absent in deep coma, abormal in brain stem lesion Corneal reflex – Blink reflex + ve (5 th & 7 th nerve) absent in deep coma 22 Facial symmetry: Facial symmetry Normally symmetric Asymmetry – sagging or decrease in wrinkles in paralysis 23 Swallowing reflex: Swallowing reflex Drooling Vs spontaneous swallowing (10 th & 12 th cranial nerves) – problems in sub- arachnoid hemorrhage, meningitis & deep coma 24 Neck: Neck Stiff neck – sub arachnoid hemorrhage, meningitis Absence of spontaneous neck movement – Fracture or dislocation of cervical spine 25 Motor Responses: Motor Responses Elicited by applying peripheral noxious stimuli e.g. pinching of limbs rubbing the sternum to elicit pain. Appropriate response – brushing away the source of stimulus Inappropriate response - decerebrate or decorticate rigidity Motor response is also of localizing value Paralysed limb will show no response Decerebrate rigidity  brain-stem damage Complete flaccidity with no response to noxious stimuli  S evere CNS depression due to drug overdose . 26 Reflexes: Reflexes Superficial & cutaneous reflexes (– abdominal, plantar, corneal, pharyngeal, cremasteric and anal) – absent in pyramidal tract disorders DTR – Biceps, triceps, ankle & knee jerks Asymmetric  paralysis Pathologic reflexes – Babinski’s , palmo -mental, clonus , snout, rooting, sucking, glabellar , grasp, chewing  indicate disorders of spinal cord & higher centers 27 Investigations….: Investigations…. Blood – CBC, biochemistry, electrolytes, sugar, urea, ammonia, PT, creatinine , ABG, drug levels (PCM/ aspirin/ alcohol, others) Lumbar puncture – Shows infection or bleeding EEG – In suspected epilepsy CAT scan of head– Shows ICSOL, bleeds and swelling of the brain MRI PET 28 Problems of the Unconscious client..: Problems of the Unconscious client.. 29 Nursing diagnoses of the unconscious client and management: Nursing diagnoses of the unconscious client and management 30 1. - Ineffective airway clearance related to (R/T) upper airway obstruction by tongue and soft tissues and secretions: 1 . - Ineffective airway clearance related to (R/T) upper airway obstruction by tongue and soft tissues and secretions Position – Lateral/ semi prone/head end with 30 degrees elevation Insert oral airway – if tongue paralyzed Assess resp rate, pattern, lung sounds, lung expansion, signs of tissue hypoxia, cyanosis, pallor, secretions in airway, obst of airway by tongue/ vomitus / oral secretions Suction airway intermittently/ sos Administer humidified O2 before and after suctioning Initiate chest physiotherapy and postural drainage (unless contraindicated) Prepare for endotracheal (ET tube) intubation / tracheostomy Connect to mechanical ventilator as needed Increase fluid intake – at least 2.5 L/ day Auscultate chest x 6- 8 hrly Monitor ABG 31 PowerPoint Presentation: Respiratory system – Hypostatic pneumonia/ aspiration pneumonia Watch out for – tachypnea, intercostal retractions, fever, noisy breathing, restlessness Suction airway x sos Change of position x 2 hrly Chest physiotherapy & postural drainage (unless contraindicated) Precautions while feeding – Ensure proper placement of RT before starting Ensure no excess residual feed before initiating feeding Feed client in head elevated position Watch out for regurgitation/ vomiting Always keep head turned to one side Give fluids compatible with output 32 2. Ineffective cerebral perfusion R/T increased ICP: 2. Ineffective cerebral perfusion R/T increased ICP Maintain a patent airway Maintain head elevation at 30 degrees Maintain proper alignment of head and neck Suction airway x sos O2 therapy – low flow therapy Monitor ABG values Maintain PaCO 2 values at 35 – 45 mm Hg through hyperventilation Administer osmotic diuretics ( Mannitol ) as advised Administer stool softeners as advised 33 3. Risk for injury R/T unconscious state: 3. Risk for injury R/T unconscious state Assess risk factors – lack of side rails, seizures, loss of corneal reflex, invasive lines & equipment, restraints, tight dressings, environmental irritants, damp bedding or dressings, nails not cut Keep bed in lowest position and side rails up with padding Observe seizure precautions in clients with + ve H/O seizures Administer prescribed anti-seizure drugs Keep client’s nails cut short Move client with caution, and follow right principles Protect from external sources of heat Avoid restrains as far as possible Release restraints (if used) for at least 2 hours Keep bed free of moisture, dust and debris Avoid over sedation Avoid speaking negatively about the client or his condition 34 4. Risk for fluid volume deficit R/T inability to ingest fluids, dehydration from osmotic diuretics: 4. Risk for fluid volume deficit R/T inability to ingest fluids, dehydration from osmotic diuretics Administer fluids as advised. Avoid over hydration and under hydration Assess hydration status – tissue turgor, mucus membrane, i/o changes, BUN, creatinine , S, Na, S.K, S.Cl , CO2 Corticosteroids & diuretics in suspected cerebral edema as advised Monitor intake/ output and urine specific gravity Evaluate peripheral pulses and BP, CVP, PAP, PAWP and CO at regular intervals 35 5. Ineffective thermoregulation R/T damage to hypothalamic center: 5. Ineffective thermoregulation R/T damage to hypothalamic center Monitor temperature frequently or continuously Look for sites of infections – resp., CNS, urinary tract, wound, blood, IV sites Control persistent temperature elevation by use of – Well ventilated room Adequate fluid intake Tepid sponge Cold compress Cooling blankets Antipyretics Control shivering in fever with use of – Blankets Warm environment Heat applications Avoid rapid cooling 36 6. Risk for impaired tissue integrity (cornea) R/T absence of normal blinking reflex, dryness of eyes: 6. Risk for impaired tissue integrity (cornea) R/T absence of normal blinking reflex, dryness of eyes Protect eyes with an eye shield Avoid rubbing of client’s eye with bed linen etc Inspect the eye with flash light for – corneal drying, irritation, ulceration. Check corneal blink response Remove contact lenses if worn Irrigate eyes with sterile saline or solution as advised Instill artificial tears (methyl cellulose) as advised Apply eye patches when indicated Prepare for temporary tarsorrhaphy (suturing of eyelids in closed position) 37 7. Risk for infection due to poor body defenses: 7. Risk for infection due to poor body defenses Regular TPR checking and recording Regular skin care Catheter care Care of infusion sites Restrict visitors Discourage flowers in the unit Keep unit clean Report any signs of infection Periodic lab testing of blood and urine Avoid exposure to persons having infections of the resp tract etc 38 8. Altered oral mucosa, R/T mouth breathing, absence of pharyngeal reflex and inability to ingest fluids: 8. Altered oral mucosa, R/T mouth breathing, absence of pharyngeal reflex and inability to ingest fluids Inspect oral cavity x 8 hrly . Remove dentures if present before inspection Look for dryness, cracks, encrustation, inflammation Give oral care every 2 – 4 hrs Avoid lemon or alcohol containing agents for cleaning Apply a thin coat of emollient cream on lip after oral care Move the ET tube to the opposite side of the mouth, if present Keep nostrils free of crusts 39 9. Imbalanced nutrition- less than body requirement, R/T inability to eat and swallow: 9. Imbalanced nutrition- less than body requirement, R/T inability to eat and swallow Fluid diet with ryles tube (RT) – Juice, shake, milk, thin porridge IV fluids as advised, and careful monitoring of i/o Initiate TPN – if RT feed not tolerated (excessive vomiting, regurgitation, decreased peristalsis, absent bowel movement) Assess wt, general appearance and other signs of malnutrition at frequent intervals 40 10. Self care deficit – bathing, feeding, grooming, toileting) owing to unconscious state: 10. Self care deficit – bathing, feeding, grooming, toileting) owing to unconscious state Assess self care needs Daily bed bath and change of clothes as required Oral hygiene x 4 hrly Perineal care x BD Hair wash twice a week or as needed Cut nails short Care of urinary bladder –use of absorbent pads /condom drainage / intermittent catheterization as indicated Watch out for signs of UTI (increased body temp., cloudy urine, hematuria , bad odor) 41 11. Risk for complications due to prolonged recumbence (immobility): 11. Risk for complications due to prolonged recumbence (immobility) ( i ) Integumentary system - Pressure sore, perineal excoriation Examine skin for redness on pressure prone areas Keep skin dry and soft, free of pressure Use air cushion, air/ water mattress, pillows, foam pads Change of position x 2 hrly Care of pressure points x 4 hrly . Avoid vigorous massage over bony prominences Avoid dragging/ pulling in bed High calorie & high protein, vitamin rich diet Plenty of fluids Gentle perineal care, after bowel evacuation 42 11. Risk for complications due to prolonged recumbence (immobility): 11. Risk for complications due to prolonged recumbence (immobility) (ii) Musculoskeletal system – contractures and joint deformity, muscle wasting, foot drop Examine for stiff joints Maintain anatomical position with comfort devices (foot rest, trochanter rolls, sand bags, water filled gloves, rolled cloth) Protein rich diet ROM exercises x 4 hrly Use of foot board 43 11. Risk for complications due to prolonged recumbence (immobility): 11. Risk for complications due to prolonged recumbence (immobility) ( iii) Circulatory system - Deep vein thrombosis (DVT) Monitor for signs of DVT - Compare the circumference of both legs Look for Homans sign Look for redness, swelling and > ed temperature of legs Intermittent elevation of legs above heart level for 20 mins Passive ROM exercises x 4 hrly Anti emboli (elastic) stockings x sos Anticoagulants as advised 44 11. Risk for complications due to prolonged recumbence (immobility): 11. Risk for complications due to prolonged recumbence (immobility) (iv) GIT – Stress ulcer (of stomach), Constipation, fecal impaction, diarrhea, perineal excoriation Regular RT feeds, antacids, H 2 receptor antagonists as advised Watch out for regular bowel evacuation Adequate fluids as required Stool softeners and enema as indicated Change of position x 2 hrly Cotton padding under lower back Gentle perineal care Observe perineum for redness or skin breakdown 45 11. Risk for complications due to prolonged recumbence (immobility): 11. Risk for complications due to prolonged recumbence (immobility) (v) Genito -urinary system – UTI Assisted drainage – condom/ catheterization Catheter care Plenty of fluids Strict intake output chart Report low urinary output Watch out signs of urinary infection 46 11. Risk for complications due to prolonged recumbence (immobility): 11. Risk for complications due to prolonged recumbence (immobility) (vi) Sensory overload and under load Maintain therapeutic levels of noise – 30 dB or less (whisper). Do not shout/ talk loudly. Have soft music at low volume Have rubber door stoppers and door frames Do not pull/ drag furniture and other equipments Talk soothingly with the client Orient to the happenings around - person, place, time Read a favorite book Encourage loved ones to visit and spend time with the client Play recorded messages of loved ones Handle gently- Touching, turning, cleaning, changing dresses, feeding etc 47 Nursing Considerations: Nursing Considerations (1) Always assume that the patient can hear, even though he makes no response. (2) Always address the patient by name and tell him what you are going to do. (3) Refrain from any conversation about the patient's condition while in the patient's presence. 12. Interrupted family process related to chronic illness of the client: 12. Interrupted family process related to chronic illness of the client Assess family response toward client’s illness – Anxiety, denial, anger, remorse, grief, reconciliation Use of coping mechanisms Role of client in the family Communication pattern & IPR between family members Social support available Financial status Develop a trusting & supportive relationship with family & significant others Provide information & frequent updates on client’s condition and progress Involve family in routine care & teach procedures 49 PowerPoint Presentation: Demonstrate and teach methods of sensory stimulation – Use of physical touch & reassuring voice Talk in a meaningful way despite no response from client Orient periodically to person, place and time Recognizing and reporting unusual restlessness of client Enlist help of social worker, home health agency or other resources Assist with financial concerns, need for medical equipment and other care issues 50 Thank you…: Thank you… 51

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