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Perhaps more than any other clients we encounter clients who are comatose or
confused need to care for in a holistic manner. All aspects of physiologic and
psychological function to need to addressed. Even if clients cannot interact with
their surroundings the nurse must care for them in respectful and dignified
manner. The brain requires a constant supply of oxygenated blood and glucose to
function. Interruption of this supply will cause loss of consciousness within a few
seconds and permanent brain damage in minutes.
Meaning of consciousness
It is a state of that has three important aspects-
Wakefulness is the ability to maintain an awake state or to be easily aroused
from sleep
2) Awareness of self;
It means the client can identify his or her present location.
3) Awareness of Environment and time;
It indicates that client knows the location, time, date

Review of anatomy:
The brain constitutes about one fiftieth of the body weight and lied within the
cranial cavity. The parts are
Mid brain
Medulla oblongata

This is the largest part of the brain and occupies the anterior and middle cranial divided by a deep cleft, the longitudinal cerebral fissure, into right and left
cerebral hemispheres, each containing one of the lateral ventricles. Deep within the
brain hemisphere are connected by a mass of white matter called corpus
callosum.The superficial part of the cerebrum is composed of nerve cells bodies or
grey matter, forming the cerebral cortex, and the deeper layer consist of nerve
fibers or white matter.
o Mental activities involved in memory, intelligence, thinking ,reasoning
o Sensory perception including the perception of pain, temperature, touch,
hearing, taste, and smell
o Initiation and control of skeletal muscle contraction(voluntary)

2. Diencephalon:
Deep within the cerebral hemisphere there are groups of cell bodies called nuclei
(previously called ganglia) which act as relay station where Impulses are passed
away from one neuron to the next in a chain. Important masses of grey matter
Basal nuclei
Functions of hypothalamus
1) The automatic nervous system
2) Appetite and satiety
3) Thirst and water balance
4) Body temperature
5) Emotional reactions
6) Sexual behavior
7) Biological clocks or circadian rhythms, e.g. sleeping and waking cycles and
secretion of hormones.
Brain stem:
The mid brain is the area of the brain situated around the cerebral aqueduct
between the cerebrum above and the pons below
The pons is situated in front 0f the cerebrum, below the mid brain and above the
medulla oblongata.
Medulla oblongata
The medulla oblongata extends from the pons above and continuous with the
spinal cord is about 2.5cm long and it lies just within the cranium above
the foramen magnum.
The vital centers, consisting of groups of cells associated with autonomic reflex
activity, lies in the deeper structure. These are the
Cardiac Centre
Respiratory Centre
Vasomotor Centre
Reflex centers of vomiting , coughing , sneezing and swallowing

The reticular formation is the a collection of neurons in the core of the brainstem,
surrounded by neural pathways which conduct ascending and descending nerve
impulses between the brain and the spinal has a vast number of synaptic
links with other parts of the brain and therefore constantly receiving information
being transmitted in ascending and descending tracts.
Changes of LOC are result of impaired cerebral brain function which deprives
the cells of the cerebral cortex and the reticular activating system of oxygen. The
RAS is located in the brain stem, with neural connection to many parts of the
nervous intact RAS can maintain a state of wakefulness even in the
absence of a functioning cerebral cortex interruptions of impulses from RAS or
alterations in functioning of cerebral hemisphere cause unconsciousness.

E.g..Spinothalamic. Auditory, visual etc.

Spinal reticular tract collateral fibers

Spinal cord
Reticular formation
Specialized sensory tract

Cerebral cortex Thalamus

Perception of

Unconsciousness implies that is a stage of depressed cerebral function that
result impairment in response to sensory stimuli; abnormal loss of awareness
of self & surroundings
Its onset is both sudden and gradual.
To produce unconsciousness a disorder must be
1. Disrupt the ascending reticular activating system ,which extends the
length of the brain stem and up to into the thalamus
2. Disrupt the function of both cerebral hemisphere
3. Metabolically depress over all brain function, as in a drug over dose.