INTRODUCTION

CONSCIOUSNESS
Consciousness implies awareness the ability
to respond to sensory stimuli and have subjective experience.
The state of being aware of and responsive to one’s surroundings is known as consciousness.
There are two components of consciousness.
They are :
1. Alertness
An arousal, waking state, including the ability to respond the stimuli.
2. Cognitive power
Including the ability to process stimuli and produce verbal and motor responses.
COMA
Definition
The word coma is derived from the Greek word: Koma meaning deep sleep. The unarousable
sleep and disturbance of consciousness usually results from pathological status affecting
reticular formation of the brain stem, the hypothalamus or the cerebral hemisphere.
 Clinical Definition – an altered state of consciousness combined with the reduced capacity
for arousal and decreased responsiveness to visual, auditory & tactile stimulation.
 Coma is a state of unconsciousness in which a person cannot be awaked, fails to respond
normally to painful stimuli, light or sound, lacks a normal wake sleep cycle & does not
initiate voluntary actions.
 A person in a state of coma is described as being comatose.
Causes
With focal neurological sign:
Cerebrospinal fluid is normal

 Poisonings ,narcotic agent, toxins

 Metabolic disorder eg.hypoglycemia ,diabetes acidosis,uremia,hepatic encephalopathy
 Head injury.concusion
 Septicemia
 Postictal
 Hyperpyrexia, febrile encephalopathy
 Water intoxication
Cerebrospinal fluid is abnormal

 Meningitis
 Encephalitis
 Subarachnoid hemorrhage
  Cerebral vein thrombosis
 Midline cerebral trauma
Causes with focal neurological sign
 Demyelinating disorder
 Post ictal coma
 Intracerebral bleed, vascular malformation
 Infection, brain abscess subdural empyema ,encephalitis
 Head injury, intracranial hemorrhage
Miscallenous

 Systematic illnesses
 Hypertension
 Shock
Grades of coma
 Stage 1 or stupor
 Stage 2 of light coma
 Stage 3 or deep coma
 Stage 4 or brain death

Diagnostic test
 When an unconscious patient enters a hospital, the hospital utilizes a series of
diagnostic steps to identify the cause of unconsciousness. According to young, the following
steps should be taken when dealing with a patient possibly in a coma.
1. Perform a general examination & medical history check
2. Make sure the patient is in an actual comatose state & is not in locked in state (patient is
either able to voluntarily move their eyes blink or physical examination findings)
3. Find the site of the brain that may be causing coma (i.e., brain stem, back of brain…) and
assess the severity of coma with the Glasgow coma scale.
4. Take blood work to see if drugs were involved or if it was a result of hypoventilation /
hyperventilation.
5. Check for the level of “serum glucose, calcium, sodium, potassium, magnesium,
phosphate, urea and creatinine”.
6.Perform brain scan to observe any abnormal brain functioning using either CT or MRI
scans.
7.Continue to monitor brains waves and identify seizures of patient using EEGs.
 Physical examination is critical after stabilization. It should include vital signs, a general
portion dedicated to making observations about the patient’s respiration (breathing
pattern, body movement (if any, and of the patient body habitus).
 

Glasgow coma scale

 Developed as a internationally recognized tool to assist doctors and nurses to measure
level of unconsciousness.  
 It is used in many institutions as an assessment tool for evaluating head – injured patient
with disturbed consciousness. It allows for continuity of patient evaluation.
 It tests arousal and awareness.
Arousal
 ability of brain to “wake up” spontaneously or to stimulus
 Purely shows brainstem functionally. 

Awareness
 Tests the brains higher cognitive functioning of cerebral cortex language, thought motor
movement.
Three components with total of 15 points
1. Eye opening (arousal) – 4 points
2. Verbal (awareness) – 5 points
3. Motor (awareness) – 6 points
4. All combinations equal to 7 or less define coma. Approximately 50% of scores that equal
8 also define coma. Patients achieving a score of 9 or more are non comatose.

Treatment
The treatment should according to underlying cause
 for hypoglycemia: IV glucose
 for increase ICP : IV infusion of mannitol at a dose of 0.5g/kg every 6 to 8 hour for 6
doses
 for cases of hepatic coma: attempt is made to eliminate intestinal bacteria and their
product ammonia and false neurotransmitter like phenylethanolamine and octopomine.
 Parental systemic antibiotic, vitamin and non-absorbable synthetic disaccharide lactulose
is given (10 to 15 ml/day in divided dose) by nasogastric or per rectum.
 Hyperprothrombenimia is treated by injected vitamin k and blood transfusion.
 Corticosteroids for metabolic encephalitis but contraindicated in cerebral malaria.
 Exchange transfusion, plasmopheresis and peritoneal dialysis in specific situation.

The treatment hospitals use on comatose patients depends on both the severity & cause of the
comatose state. Although the best treatment for the comatose patients remains unknown
attention must first be directed to maintaining the patient’s respiration and circulation.
 The unconsciousness child requires nursing attendance, with observation, recording, and
evaluation of changes in objective signs. These observations provide valuable information
regarding the patient’s progress.
Nursing management
Nursing assessment:
 history taking: history of any medical illness,injury,infection. Severity of illness
 family history
 physical examination: vital sign, level of consciousness, hygiene level ,oxygen saturation,
grade of consciousness, airway ,breathing and circulation and intake output with
nutritious level
 Diagnostic investigation
 Assessment through Glasgow coma scale.
Nursing diagnosis
 Ineffective airway clearance related to altered loss of consciousness
 Risk of injury related to decrease loss of consciousness.
 Self-care deficit related to unresponsiveness
 Imbalance nutrition less than body requirement related to inability to feed
 Risk for impaired skin integrity related to prolonged bed rest and impaired mobility.
 Impaired urinary elimination related to impairment of neurological sensing and control.

Nursing intervention
Respiratory management
Respiratory effectiveness is the primary concern in the care of the
unconscious child, and establishment of an adequate air-way is always the first priority.
Carbon dioxide has a potent vasodilation effect and will increase cerebral blood flow (CBF)
and ICP. Cerebral hypoxia that lasts longer than 4 minutes nearly always causes irreversible
brain damage.

Children in lighter states of coma may be able to cough and swallow, but those in deeper
states are unable to handle secretions, which tend to pool in the throat and pharynx.
Dysfunction of cranial nerves IX and X places the child at risk for aspiration and cardiac
arrest; therefore the child is positioned to the likelihood of vomiting. An oral airway can be
used for the child who is suffering a temporary loss of consciousness, such as after the
contusion, seizure, or anesthesia. For children who remain unconscious for a longer time, a
nasotracheal or orotracheal tube is inserted to maintain the open airway and facilitate
removal of secretions. Suctioning is used only as needed to clear the airway, exerting care
to prevent increasing ICP. When the respiratory center is involved, mechanical ventilation is
usually indicated
 
Intracranial pressure monitoring
Management of the child with the increased ICP is possibly the most formidable task and
the most controversial subject in pediatric critical care. It appears that the outcome in
pediatric neurologic injury may reflect the initial cerebral damage more than the
subsequent intracranial hypertension.
 
Four major types of ICP monitors are
 Intraventricular catheter with fibroscopic sensors attached to a monitoring system.
 Subarachnoid bolt ( Richmond screw)
 Epidural sensor
 Anterior fontanel pressure monitor
 Nurses caring for patients with intracranial monitoring devices must be acquainted with
the system, assist with insertion, interpret the monitor readings, and be able to
distinguish between danger signals and mechanical dysfunction.
Suctioning
Suctioning and percussion are poorly tolerated and are therefore contraindicated unless
concurrent respiratory problem exist. Hypoxia and the Valsalva maneuver associated with
cough both acutely elevate ICP. Vibration, which does not increase ICP, accomplishes excellent
results and should be tried first if treatment is needed. If suctioning is necessary, it should be
brief and preceded by hyperventilation with 100% oxygen, which can be monitored during
suctioning with a pulse oxygen sensor reading to determine oxygen saturation.

Nutrition and hydration

Fluids and calories are supplied initially y the IV route. An IV infusion is started early, and the
type of fluid administered is determined by the patient’s general condition. Fluid therapy
requires careful monitoring and adjustment based on neurologic signs and electrolyte
determination. Often comatose children are unable to cope with the same amounts of fluid
they could tolerate at.

Thermoregulation
Hyperthermia often accompanies cerebral dysfunction; if it is present, measures are
implemented to reduce the temperature to prevent brain damage and to reduce metabolic
demands generated by the increased body temperature..
Times, and over hydration must be a Medically induced hypothermia assists in controlling ICP
and may result in an improved outcome ( Palmer 2000). Antipyretics are the method of choice
for fever reduction; cooling device are used to induce hypothermia. Laboratory test and other
methods are used in an attempt to determine the cause, if any, of the hypothermia voided to
prevent fatal cerebral edema
Elimination
A retention catheter is usually inserted in the acute phase, although diapers may be used and
weighed to record urinary output. The child who formerly had bowel and bladder control is
generally incontinent. If the child remains comatose for a long period, the indwelling catheter
may be removed and periodic bladder emptying accomplished by intermittent catheterization .
Stool softeners are usually sufficient to maintain bowel function, but suppositories or enemas
may be needed occasionally for adequate elimination and to prevent an impaction. The passage
of liquid stool after a period of no bowel activity is usually a sign of an impaction. To avoid the
preventable problem, daily recording of bowel activity is essential

Hygienic care
Routine measures for cleansing and maintaining skin integrity are an integral part of nursing
care of the unconscious child. Mouth care is performed at least twice daily, since the mouth
tends to become dry or coated with mucus. The teeth are carefully brushed with a soft
toothbrush or cleaned with gauge saturated with saline. Commercially prepared cleansing
devices, such as toothettes, are convenient for cleansing the mouth and the teeth. Lips are
coated with ointment or the other preparations to protect them from drying, cracking, or
blistering.
The deeply comatose child is also prone to eye irritation. The corneal reflexes are absent;
therefore the eyes are easily irritated or damaged by linen, dust, or other substances that may
come in contact with them. There is excessive dryness as a result of incomplete closure of the
eyes and/ or decreased secretion, especially if the child is undergoing osmothepary to reduce
or prevent brain edema.

Positioning and exercise

The unconsciousness child is positioned to prevent aspiration of saliva, nasogastric secretions,
and vomitus and to minimize ICP. The head of the bed is elevated, and the child is placed in a
side –lying or semi prone position. A small, firm pillow is placed under the head, and the
uppermost limbs are flexed and supported with the pillows. The weight of the body should not
rest on the dependent arm.  
In the semi prone position the child lies with the dependent arm at the side behind the body,
the opposite side supported on pillows, and the uppermost arm and leg flexed and resting on
the pillows. This position prevents undue pressure on the department extremities. The
dependent position of the face encourages drainage of secretions and prevents the flaccid
tongue from obstructing the airway.

Stimulation
 Sensory stimulation is important in the care of the unconscious child, just as it is in the care of
the alert child. For the temporarily unconscious or semiconscious child, sensory stimulation
helps arouse the child to the conscious state and orient the child in terms of time and place.
Auditory and tactile stimulation are especially valuable.
Tactile stimulation is not appropriate for the child in whom it may elicit an undesirable
response. However, for other children tactile contact often has a relaxing and calming effect.
When the child’s condition permits, holding or rocking has a The auditory sense is often present
in a state of coma. Hearing is the last sense to be lost and the first one to be regained;
therefore the child should be spoken to as any other child. Conversation around the child should
not include thoughtless or derogatory remarks. A radio playing soft music or a music box or CD
player is frequently used to provide auditory stimulation.

 . soothing effect provides the body contact needed by young children singing the child
favorite songs or reading a favorite story is a tactic used to maintain the child’s contact
with a familiar world. Playing songs or stories recorded in the parents’ voices can provide
a continuous source of familiar stimulation
Family support
 Helping parents of an unconsciousness child cope with the situation is especially
difficult. They may demonstrate all the guilt, fear, hospitality, and anxiety of any parent
of a seriously ill child. In addition, these parents are faced with the uncertain outcome of
the cerebral dysfunction.
 The fear of death, intellectual disability, or other permanent disability is present.
Nursing intervention with parents depends on the nature of the pathologic condition,
the parents personality, and the parent- child relationship before the injury or illness.
 If there is little or no residual effect, the child will be dismissed to home care fairly
soon. The parents need the most intensive nursing intervention during the period of
crisis and uncertainty. During the recovery phase they are given information,
information is clarified, and they are encouraged to become involved in the child’s care.
Often the child’s hospitalization is brief; however, some children require extended
hospitalization for intensive therapy and rehabilitation.