NURSING ASSIGNMENGT ON SENSORIUM

SENSORIUM (UNCONSCIOUSNESS): ASSESSMENT AND MANAGEMENT

DEFINITION: Sensorium is the totality of those parts of the brain that receive process and interpret
sensory stimuli . The sensorium is the supposed seat of sensation ,the place to which impressions from
the eternal world are conveyed and perceived.

ALTERED SENSORIUM: it describes limitations on or problems with the brain’s ability to receive, process
or interpret sensory information eg hallucinatory and confusional states, delirium, coma and sleep.

ASSESSMENT OF UNCONSCIOUS PATIENTS

Most common assessment used is the physical assessment and Glasgow coma scale

A.PHYSICAL ASSESSMENT: it is the systematic collection of object information that is directly observed
through examination, it has 5 techniques involved

I. INSPECTION OR OBSERVATION
 OVERALL APPESRANCE OF HEALTH ILLNESS
 SIGNS OF DISTRESS
 FACIAL EXPRESSIONS
 BODY SIZE
 GROOMING AND PERSONAL HYGIENE

II. PALPATION
 IT IS THE USE OF HANDS AND FIGURES TO GATHER INFORMATION
THROUGH TOUCHING IN WHICH WE CAN ASSESS
TEMPERTURE,TURGOR,TEXTURE,MOISTURE,VIBRATIONS,SIZE
MASSESAND FLUIDS
 IT HAS 3 METHODS NAMELY DORSUM,THE PALMA AND VIBRATIONS

III. PERCUSSION: It is the examination by tapping fingers on the body to determine

the condition of the internal organs by the sounds that are produced. It is done
by placing a finger of the left hand firmly against a part to be examined and
tapping with the finger tips of the right hand , produces sound waves by using
the fingers as a hammer
 IV. ASSCULTATION: It is the listening of sound within the body with the aid of a
stethoscope ,fetoscope or directly with the ear placed on the body.

B. GLASGOW COMA SCALE

 It is the neurological scale which leads to give a reliable and objective
way of recording the state of the patient’s consciousness.
 It has three ways of checking eye opening ,verbal response and motor
response

I. EYE OPENING
 OPEN SPONTANEOUS 4
 TO SPEECH 3
 TO PAIN 2
 NO EYE OPENING 1

II. VERBAL RESPONSE

 ORIENTED 5
 CONFUSED 4
 APPROPRIATE WORD 3
 INCOMPREHENSIVE SOUND 2
 NO RESPONSE 1

III. MOTOR RESPONSE

 OBEY COMMAND 6
 LOCALISE PAIN 5
 WITHDRAWS 4
 FLEXES 3
 EXTENDS 2
 NO RESPONSE 1

NURSING MANAGEMENT
1. Provide a bed and equipment needed, put patient in comfortable positions and cover with linen
2. Unconscious children should be observed constantly to detect any changes in vital signs and
avoid injuries by falling or any wrong movements.
3. Assess vital signs includes level of consciousness ,reflexes , responses, temperature, heart/ pulse
rate, respiration and blood pressure.
 4. Provide adequate respiration should be maintained by keeping the patent airway. The patient
should be placed in a semi prone position on one side
5. Prevent deformities ,proper body aliment with careful positioning to facilitate drainage or oral
secretion ,preventing pressure on the dependent extremities.
6. Patient should be protected from injuries of any sort.
7. Maintain patient’s personal hygiene by giving bed bath, perineal care, oral care etc
8. Prevent pressure sores by regular skin care and position changing
9. The bowels should be kept in regular movement to prevent constipation
10. Concial damage can be prevented by providing regular eye care cleaning the eye with normal
saline
11. Always have an organized nursing care plan

NURSING CARE PLAN

NAME: Mory STUDENT NURSE: Lumba Ng’uni

SEX:F AGE:18 DATE: 12/03/20

ASSESSMENT DIAGNOSI GOAL INTERVENTION RATIONAL EVALUATIO

S N
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