By James R. Hubler, MD, JD, Department of Emergency Medicine, University of Illinois, Peoria, IL; Daniel Sullivan, MD, JD, FACEP, Chairman, Department of Emergency Medicine, Ingalls Memorial Hospital, Harvey, IL; Tim Erickson MD, FACEP, FACMT, Toxicologist, University of Illinois, Department of Emergency Medicine, Chicago, IL. Nursing is an important field in healthcare. 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 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. Assessment of Unconscious Clients For the care to be effective, a nurse should perform frequent, systematic and objective assessment on the comatose client. 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. Elevating the head end of the bed to degree prevents aspiration. Initial management. They are: This condition is caused by a generalised and progressive loss of cortical tissue in the brain. In the case of eye opening, the best response would score a 4, the best verbal response would score a 5 and the best motor responses would score a 6. It is dependent upon relatively intact functional areas within the cerebral hemispheres that interact with each other as well as with the RAS (Box 28.2). Lesions in this area can cause excessive sleepiness or even coma (Fitzgerald 1996). In cycle B, impulses are sent down the spinal cord to activate skeletal muscles. The patient has the ability to follow instructions, for example, ‘put out your tongue’, ‘lift up your arms’, ‘show me your thumb’. Nails; 4. Incomprehensible sounds = scores 2. Unconscious patients in areas such as critical care or emergency departments may also be accompanied by family and friends who are often extremely anxious. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. Score = 2. The responses described below are shown in Figure 28.6. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Anatomical and physiological basis for consciousness 737, The reticular activating system (RAS) 738, Chronic states of impaired consciousness 741, Emergency care of the unconscious patient 745, Nursing management of the unconscious patient 748, 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. The response is recorded as ‘localising to pain’ if the patient moves their arm across the midline, to the level of the chin, in an attempt to locate the source of the pain (Figure 28.6b). Gratitude in the workplace: How gratitude can improve your well-being and relationships This indicates more severe dysfunction of the brain and is a poor prognostic sign. 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, reduced or absent consciousness implies the presence of brain dysfunction and demands urgent medical attention. It's important to remember that you aren't trying to change your unconscious bias, but rather disengage it while caring for patients. Weaning oxygen. It is concerned with the arousal of the brain in sleep and wakefulness (Marieb 2004). This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care. Figure 28.7 Applying a central painful stimulus. Figure 28.2 illustrates a number of activating pathways passing from the mesencephalon upwards. The unconscious patient presents a special challenge to the nurse. The verbal response may also be compromised by the presence of an endotracheal or tracheostomy tube. Pre- hospital providers must maintain a low threshold for suspecting serious trauma in alcohol impaired patients. The differential diagnosis of altered mental status is huge and can be overwhelming in the face of an acutely ill, undifferentiated emergency department patient. Recognising the dying phase shifts focus of care from disease management to the patient’s priorities and symptoms #### Key points Every year, more than half a million people die in the United Kingdom, and over half of these deaths occur in hospital. To speech = scores 3. For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed. Critically ill patients present a challenge to the whole veterinary team because they require invasive diagnostic tests, advanced procedures and intensive nursing care. Management of the unconscious patient. High-quality nursing care is crucial if the patient is to relearn to perceive self and others, to communicate, to control their body and environment and to become independent. There are numerous pathways to both mesencephalic and thalamic areas, arising from the sensory, motor and cortical regions of the cerebral cortex, that deal with a range of emotions. 20, 1, 54-68. Nursing Standard. Score = 4. This protocol may be implemented without a physician’s order per policy Hypoglycemia: Adult Management Policy #: SYS-PC-DEG-001 The approach is based on the belief that after a history and a general physical and neurologic examination, the informed physician can, with reasonable confidence, place the patient into one of four major groups of illnesses that cause coma. In cycle A, the RAS excites the cerebral cortex and the cortex in turn re-excites the RAS. When applying a painful stimulus, it is important to explain to the patient and their relatives what you are about to do and why you are doing it, otherwise they may feel that unnecessary trauma is being inflicted. 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). After a prolonged period of wakefulness, the synapses in the feedback loops become increasingly fatigued, reducing the level of stimulation and activity directed to the reticular activating system and thereby inducing a state of lethargy, drowsiness and eventually sleep (Guyton & Hall 2000). Nurses have a pivotal role in pain management. Factors that impair consciousness may also cause respiratory changes. ... A brief summary of the nursing management of the unconscious patient … A definitive airway should be in place before traveling to radiology. It must be necessary to hold the patients jaw forward or place the patient in the lateral position to prevent the tongue obstructing airway by falling back. C. Flexing to pain. References Aim. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient … The patient opens their eyes when first approached, which implies that the arousal response is active. E. Extending to pain. Signs and symptoms may include: Reduction in awareness reflects generalised brain dysfunction, as seen in systemic and metabolic disorders (see Figure 28.3). Blog. Nurses have a difficult time because they approach the patient directly. Dr. RS Mehta, BPKIHS 2. What is visual communication and why it matters; Nov. 20, 2020. A nurse was knocked unconscious, was turning purple, had no pulse and had to be revived by a doctor in an assault reported by the nurses' union at Adelaide's Modbury Hospital. Medical management will vary according to the original cause of the patient’s condition, but nursing care will be constant. Figure 28.4 The neurological observation chart. This site needs JavaScript to work properly. The nurse needs to be aware if the patient has any hearing deficits because if their eyes are closed, this will affect the initial response. The damaged cortex is unable to interpret the incoming sensory impulses and therefore cannot transmit them to other areas for appropriate action. Consciousness results when the RAS, in turn, stimulates the cerebral cortex. Martin (1994) suggests that nurses who are expert in the care of head-injured patients can identify cues which indicate behavioural, cognitive, motor and sensory changes even in mild brain dysfunction. Skin; 3. Physiologically, the brain stem is functioning but the cerebral cortex is not, and patients can survive for several years requiring full-time nursing care. I will be using the Gibbs (1998) reflective cycle as a guide on this essay. The prehospital setting further complicates the management of this difficult group of patients. Nurse plays an important role in providing effective oral care and promoting oral hygiene of an unconscious patient. Lactate 3.8. Obeys commands. For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed. Figure 28.6 Motor responses. 11. Abnormal flexion. It is the field that maintains quality of life in a community. 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. In response to a painful stimulus, the patient bends their elbow with adduction of the upper arms and abnormal posturing of the wrist and fingers, otherwise known as decorticate posturing. This initiates a cycle that causes continued intense excitation of both regions. In order to function, the RAS must be stimulated by input signals from a wide range of sources. BE - -10. The mesencephalic area is composed of grey matter and lies in the upper pons and midbrain of the brain stem. General Care of the Unconscious Patient. Unconscious patients are extremely vulnerable. The best response for each of the three aspects is recorded as a numerical score. Deterioration or improvement will depend on a number of factors such as the mechanism, extent and site of injury, age, previous medical history and length of coma. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient … This assesses the integrity of the RAS in the brain stem and is observed and recorded using the following categories. A. Supraorbital ridge pressure. PC02 – 2.8. This is termed a ‘positive feedback response’. nursing assignment help nursing help nursing assignment. This is called the ‘arousal reaction’ and is the mechanism by which sensory stimuli wake us from deep sleep (Guyton & Hall 2000). 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