Moderator: Dr.

Rachel Andrews
Presenter: Mr. Mahesh Kumar Sharma
M.Sc.(Neurosciences Nsg.) 1st yr.
 Consciousness
It is defined as a state of awareness of
oneself and of one’s environment , as well
as a state of responsiveness to that
environment or adaptation to the external
milieu.
Components of consciousness
It comprises of two components :
Arousal
Awareness
 Unconsciousness
A state of complete or
partial unawareness
or lack of response to
sensory stimuli.
Various degrees of
unconsciousness are
there: e.g. confusion,
stupor etc.
Any abnormality of the following areas can
cause unconsciousness:

Bilateral hemispheric abnormality

Brainstem abnormality
Thalamic abnormality
ABNORMALITIES

Structural brain lesions:

Supratentorial lesions
Infratentorial lesions
Metabolic causes
Psychogenic causes
 Supratentorial lesions
Destructive lesions :
result indirectly from interruption of the blood
supply, leading to infarction, or from direct
injury to the brain.
Compressive lesions:
can compress or distort brain tissue and
arteries, resulting in shifting or herniation of
brain tissue from one compartment to
another.
Supratentorial lesions
Supratentorial lesions:
Large cerebral infarct with edema
Intracerebral , subdural , extradural,
Subarachnoid hemorrhage
Cerebral tumor
Cerebral abscess
Cerebral edema
 Contd ….
Infratentorial lesions :
Brainstem infarcts or hemorrhage
Brain stem tumor
Brainstem trauma
Cerebellar abscess
Cerebellar hemorrhage
Cavernoma of brain stem
 Metabolic /diffuse causes
 Diseases of neurons
 Metabolic encephalopathy
 Diseases of other organs e.g. liver, lungs etc.
 poisons, alcohol and drugs
 Fluid and electrolyte imbalance
 Concussion and Postictal states
 Infections
 Nutritional deficiency
 Hypoglycemia
 Anoxia or ischemia
 Common fainting
 Temperature regulation disorders
 Psychogenic causes

Hysteria

Catatonia
Continuum of unconsciousness
disoriented
shortened attention
span
memory deficits
difficulty in following
commands
alteration in
perception of stimuli.
Disoriented to time,
place and person
Increased motor
activities.
Illusion, hallucinations
Reduced ability to be aroused & limited
response to environment.
Sleeps unless stimulated with speech or
touch
Verbally a grunt or nod
Deep sleep or
unresponsiveness
Can be aroused only
with painful stimuli
Responds by
withdrawing or
grabbing at the
source of pain
 Coma
State in which a patient is totally
unaware of both self and external
surroundings, and unable to respond
meaningfully to external stimuli.
 Contd…..
Totally unconscious, unresponsive, unaware, and
unarousable.

Do not respond to external stimuli, such as pain or

light

Do not have sleep-wake cycles.

Coma usually lasts a few days to a few weeks.

After this time, some patients gradually come out of

the coma, some progress to a vegetative state, and
some die.
 Related terms
Vegetative state
Persistent vegetative states
Locked in syndrome
Akinetic mutism
Brain death
 Vegetative state
Opens eyes spontaneously
Does not follow commands
No intentional movements
Show spontaneous roving eyes
Sleep awake cycles
can result from diffuse injury to
the cerebral hemispheres of the
brain without damage to the
cerebellum and brainstem
Persistent vegetative state
Many patients
emerge from a
vegetative state within
a few weeks, but
those who do not
recover within 30
days are said to be in
a persistent
vegetative state
(PVS).
Locked in syndrome
Caused by damage to
specific portions of the
lower brain and brainstem
with no damage to the
upper brain.
Eye opening is well
sustained
Basic cognitive abilities are
evident on examination
Mode of communication is
eye movements or clinking
of the upper eyelid
Akinetic mutism
Patients are immobile
and usually lie with their
eyes closed.
Sleep wake cycles exists.
There is little or no
vocalization.
Motor response to
noxious stimuli is absent
or minimal
Command following or
verbalization can be
elicited but occur
infrequently
 Brain death
Irreversible damage of the brain, including
the brainstem and cerebellum, and
cessation of functions. Pulmonary and
cardiac functions can be maintained by
artificial means.

Untreated coma causes it.

 Diagnostic criteria of brain death
THE HARVARD CRITERIA

Criteria Confirmation Duration

Absence of Unresposive Isoelectric 24 hours
hypothermia coma electroencephalo
and drug Apnea gram
intoxication Absent reflexes
THE MINNESOTA CRITERIA
Criteria confirmation Duration

Irrepairable -No spontaneous -Conventional 12 hours

intracranial movements angiography
lesion -Apnea when off with no filling of
respirator for 4 min. intracranial
-Absent brainstem vessels
reflexes -Cerebral blood
-Dilated and fixed flow studies
pupils demonstrates
no cerebral
-Absence of corneal, blood flow
ciliospinal, vestubular,
tonic neck and doll’s
eye
 Stringent criteria
A pupillary light response
B testing the corneal
response
C injection of ice-cold
water to test the
vestibulo-ocular reflex
D stimulating the glabella
with the knuckle
E stimulating the trachea
with a suction catheter
 Confirmatory tests
Conventional angiography
EEG
Transcranial doppler
Nuclear brain scan
Single photon emission computed
tomography
Somatosensory evoked potential
 Syncope/blackouts
Temporary loss of consciousness and
posture, described as "fainting" or
"passing out."
 Causes of syncope
Diminished venous return to the heart
Disorders of the pump ( decreased
cardiac output )
Disorders of pathways
Disorders of blood
 when it is important?
Some forms of syncope suggest a serious
disorder:
those occurring with exercise
those associated with palpitations or
irregularities of the heart
those associated with family history of
recurrent syncope or sudden death
Do’ s for syncope
Catch the person before falls.

Have the person lie down with

the head below the level of the
heart.

Raise the legs 8 to 12 inches.

If a victim knows who is about

to faint can lie down right
away, he or she may not lose
consciousness.
 Do’s
Turn the victim's head to
the side so the tongue
doesn't fall back into the
throat.

Loosen any tight clothing.

Apply moist towels to the

person's face and neck.

Keep the victim warm

 Don’ts for syncope
Don't slap or shake anyone who's just fainted.

Don't try to give the person anything to eat or

drink, not even water, until they are fully
conscious.

Don't allow the person who's fainted to get up

until the sense of physical weakness passes.
watch for a few minutes to be sure he or she
doesn't faint again.
 Examination of an unconscious
patient
History
Level of consciousness: assessed with the
help of glass gow coma scale.

EYE OPENING RESPONSE (E)

- Spontaneous eye opening - 4
- Opens to voice - 3
- Opens to painful stimuli - 2
- No response - 1
VERBAL RESPONSE (V)
- Oriented, normal conversation -5
- Confused, disoriented -4
- Inappropriate words -3
- Incomprehensible sounds -2
- No response -1
BEST MOTOR RESPONSE (M)
- Obeys command -6
- Localizes pain -5
- Withdraws to pain -4
- Abnormal flexion -3

- Abnormal extension -2

- No response -1
 Research input : Variability in agreement between
physicians and nurses when measuring the Glasgow
Coma Scale in the emergency department limits its
clinical usefulness.
Holdgate A, Ching N, Angonese L.
Department of Emergency Medicine, Emergency
Medicine Research Unit, Liverpool Hospital,
Liverpool BC, NSW, Australia.
. A senior ED doctor (emergency physicians and trainees)
and registered nurse each independently scored the
patient's GCS in blinded fashion within 15 min of each
other
, a significant proportion of patients had GCS scores which
differed by two or more points. This degree of
disagreement indicates that clinical assessment with
GCS should not be considered as the only mean of
deciding treatment.
 Respiration
Cheyene stoke respiration
 Contd……..
Neurogenic respiration :

Apneustic breathing:
 Contd..

Biot’s respiration( cluster respiration)

Ataxic respiration:
Pupils examination
 Eye examination
Extraocular movements
 Brain stem reflexes
Doll’s eye reflex:
Doll’s eye reflex
 Oculovestibular test
40 to 60 mL of ice
water is used to
irrigate the ear. If the
brainstem is intact,
the eyes deviate to
the side of the cold
water.
1)Corneal reflex:
Blinking indicates 5 th
and 7 th cranial nerve
functioning.

2)Gag reflex
 Motor response

DECORTICATE / DECEREBRATE POSTURING

Myoclonic jerks
 Diagnostic tests
ELECTROLYTES : BUN, creatinine, liver
enzymes, CBC, PT, PTT

ABG analysis
URINE SCREEN for alcohol and drug levels
ARTERIAL AMMONIA LEVELS
THYROID STUDIES
 Contd…..
CT/MRI: scan for history of head trauma
Lumbar puncture:

EEG
CARDIAC STUDY: 12-lead study
TRANSCRANIAL DOPPLER: to rule out
vasospasm.
PET : if available
 Differential diagnosis b/w different
causes of coma
FOCAL LESIONS:
1) Motor signs unilateral & asymmetrical
2) Signs of dysfunction progress rostral to caudal
3) Comma follows motor abnormalities
4) Pupils unilaterally non reactive; later B/L non
reactive
5) Sudden onset
 Metabolic coma
1)Confusion and stupor commonly precede motor
signs
2)Motor signs usually are symmetric
3)Pupillary reactions are preserved in most cases
4)Asterixis, Myoclonic, tremor, and seizure are
common
5)Acid-base imbalances are common
 Psychiatric causes
1)EEG is normal
2)No pathologic reflexes
3)Eupnea or hyperventilation is usual
4)Motor tone is inconsistent or normal
5)Pupils reactive or dilated
6)Lids close actively
Syncope :
Vasovagal syncope
 Lower head end at onset
Postural hypotension
Hyperventilation
 Reassurance & exercises to control breathing
Cardiac arrhythmias
 Pharmacological or implanted pacemaker control
of cardiac rhythm.
 Contd …
Hypoglycemia
 Attention to drug regime in diabetes
 Removal of insulinoma of pancreas
Vertebro basilar TIAs
 Treat source for emboli—Aspirin
Epilepsy
 Anticonvulsant drugs
Hysterical attacks
 Try to establish the reason for this behaviour
 Careful explanation to the patient
Initial management for coma
ABC:
A achieve optimal oxygen and glucose
transport to the brain
B minimize the adverse effects of metabolic and
structural disturbances, with particular reference to
raised intracranial pressure (ICP)
 Contd…….
Hyperventilation
Helps to reduce raised ICP by removing extra
CO2 and causing vasoconstriction ,thus
decreasing raised ICP.

Pharmacological treatment
Mannitol : 0.5 mg/kg over 15 min and repeat
after 4 hrs.
Steroids : Dexamethasone
Loop diuretics : inj. Lasix 40 mg stat
Antihypertensives

Surgical interventions: ventriculostomy for

draining CSF.
Treatment of underlying causes
Hypoglycemia : 50 ml of 50% D IV push
wernicke’s encephalopathy :thiamine
Drug overdose :naloxone
Seizures : antiepileptic
Infection :antibiotics
Hyperglycemia: insulin
Poison ingestion: gastric lavage
Monitoring : ongoing for vital signs and
neurological examination.
 Nursing Assessment
 LOC
 RR, rhythm
 Pupils
 Cornea
 Eye movements
 Doll’s eye reflex
 Vitals
 Skin
 Bladder function
 Intake and output
 Pulmonary functions
 Nsg .problems
high risk for Airway obstruction r/t loss of
swallowing, gag and coughing reflexes.
 Clear the airways of any foreign body and loosen
any tight clothing
 If suspecting spinal injury, do not move the patient
without neck collar.
 Use jaw thrust method to resuscitate the patient .
 Place the patient in lateral or semi prone position.
 Intubation may be required to maintain the airways
High risk for aspiration r/t ineffective airway
clearance and absent gag reflex.

 place in lateral position to allow the drainage of

secretions
 assess for breath sounds every 2-4 hourly
 do trachoebronchial suctioning
 while giving mouth care, place the patient with the
head turned to one side.
 Monitor ABG and other parameters.
high risk for altered cerebral tissue perfusion
r/t increased ICP.

 assess LOC including alertness and orientation 2-4

h.
 assess pupillary size, position, response to light
and consensual response
 assess EOM 1-4 h
 cognitive function may be impaired by edema and
inadequate blood flow
 note verbalization and response to verbal
commands by checking hand grip and release, leg
movements dorsiflexion and plantar flexion 1-4 h
 in unconscious client note spontaneous
movements, withdrawal to pain 1-4hs
 report if any deterioration occurs
 monitor temperature 2 h and give hydrotherapy if it
is more than 38.5c
 monitor cardiovascular and pulmonary status, vital
signs
 elevate the head end of the bed by 30 degrees
 monitor intake and output 4h
 avoid extreme hip flexion
 monitor Hb and Hct
 assess for sign of bleeding
 check for hematuria
 administer blood and blood products
research input : The relationship of selected nursing
activities to ICP.
Rising CJ.
Dakota Hospital, Fargo, North Dakota 58103-6014.
Selected nursing measures--turning, suctioning and
bathing--were recorded on the data collection tool as
they occurred. Suctioning and turning were noted to be
associated with an increase in ICP; however, a
sustained increase in ICP was not observed.
These findings further support the need for nurses to be
aware of the patient's ICP prior to turning and suctioning.
high risk for injury r/t unconscious state

 provide padded side rails

 prevent injury due to invasive lines a nd
equipments
 any kind of restrain is likely to be countered by the
patient with resistance, leading to self injury or to a
dangerous increase in ICP
 give adequate support to the limbs when moving
an unconscious patient
 protect them from external source of heat
 protect during seizures or periods of agitation
high risk for altered oral and nasal mucous
membrane r/t NPO status, inability to swallow
and unconsciousness

 inspect the pt.’s mouth

 keep the lips coated with water soluble lubricant
 give oral hygiene 8 h
 avoid agents with lemon and alcohol as they cause
dryness
 suction the secretions
 clear the nostrils with swab
high risk for impaired skin integrity r/t
immobility and loss of protective reflexes

 -check for any signs of redness and excoriations at

the pressure points
 -Turn the patient from side to side every 2 h
 -unconscious women need perineal care
 -apply protective eye coverings with adhesive tape
 -use water mattresses and water filled bags to
protect form pressure sores
High risk for contractures r/t immobility

 maintain the extremities in functional position by

providing support
 hand rolls prevent flexion contractures of the
fingers
 Cock up arm splints prevent wrist drop
 Splints, casts or high topped tennis shoes help
properly supprt feet
 Remove these support devices 4 h for skin care
and passive exercises.
 Altered nutrition ;less than body requirement r/t
inability to eat secondary to unconsciousnes

 IV fluids are given initially

 Nutritional and fluid needs are met through NG feed but only
when:
 Patient does not have paralytic ileus or delayed gastric
emptying
 Bowel sounds are audible
 Gastric residual volume is less than 100 ml/hr
 Nursing responsibilities in tube feeding are critical as the
patient:
– Cannot communicate
– May have lost protective cough and gag reflexes
 As consciousness returns test the client’s ability to suck and
swallow
 Once a client can safely swallow, begin small oral liquid
feedings
High risk for fluid volume deficit r/t inability to
drink and respond to normal thirst mechanism

 monitor intake and output every 4 h

 assess and document any sweating, diarrhea,
polyuria and vomiting
 assess blood urea, creatinine, sodium and
potassium
 Over hydration and intravenous fluids with glucose
are always avoided because cerebral edema may
follow
high risk for bowel incontinence r/t
unconsciousness
 examine the patient for abdomen distension
 small and frequent stool may indicate fecal
impaction
 maintain a regular schedule of stool softners,
suppositories and digital removal
 begin a programme of bowel training
altered elimination r/t
unconscious state
 there can be urinary retention
or incontinence
 if any sign of retention then
place an indwelling catheter
 palpate the bladder for
distension
 an external drainage for the
male patient and absorbent
pad for female can be used
 as soon as patient regain
consciousness, start bladder
training
altered communication r/t unconsciousness

explain all the procedures before carrying out them.

Do not whisper at the bed side.
Never shout or blame the patient
Don’t discuss about the patient’s condition with the
relative at the bed side
locked in syndrome patients communicate via blinking so
respond to them appropriately
be calm , gentle and patient
help the family members to communicate with the patient
and encourage them to talk effectively.
Communication with critically ill patients.
Alasad J, Ahmad M.
Department of Clinical Nursing, University of Jordan, Amman,
Jordan. jalasad@ju.edu.jo
a study that investigated the experiences of a group of critical
care Jordanian nurses concerning verbal communication with
critically ill patients.
: Communication with sedated or unconscious
patients in intensive care units should not be viewed
as only an interactive process. Rather, it should be
perceived as the means to give the information and
support that such patients need.
 altered family process r/t
family member in coma

 explain about the condition

of the patient
 encourage them to clear
their doubts and involve
them in patient care
 when a patient is not
expected to survive then
explain the family members
about prognosis
COMA STIMULATION PLAN
TACTILE stimulation
KINESTHETIC stimulation
OLFACTORY stimulation
ORAL stimulation
AUDITORY stimulation
VISUAL stimulation
Research input :
The effect of familiar and unfamiliar voice treatments on
intracranial pressure in head-injured patients.
Treloar DM, Nalli BJ, Guin P, Gary R.
University of Florida, College of Nursing, Gainesville 32610.
to investigate effects of verbal stimulation on ICP in head-injured
patients.
The familiar voice message was played to each subject.
After a rest period, the unfamiliar voice message was
played. ICP was recorded before, during and after
playing both taped messages.
suggest families of head-injured patients with
normal ICP can verbally interact with the
patients for short periods without significant
increases in ICP.
 Organ donation
Organ donation : is the removal of the
tissues of the human body from a person
who has recently died, or from a living
donor, for the purpose of transplanting or
grafting them into other persons.
 Types of donations
Brain death donations
Non heart beating donations (cardiac
death)
 Three most common causes for
this non donation or mismatch are

family refusal
non recognition or delayed determination
of brain death
loss of donors due to profound
cardiopulmonary and metabolic instability
 Nurses role in organ donation:
to identify potential donors and contact the
appropriate source to verify if the patient is
eligible for tissue or organ donation.

A thorough assessment to be done by

taking history and doing physical
examination, to confirm with the diagnosis.
 Contd….
A nurse must be familiar with types of
donation and donation criteria .
offer the family the option for donation,
and provide bereavement support .
become familiar with different religious
positions regarding tissue and organ
donation
Organ and tissue donation: a trustwide perspective
or critical care concern?
Elding C, Scholes J.
Brighton and Sussex University Hospitals Trust, Royal
Sussex County Hospital, Eastern Road, Brighton, UK.
christine.elding@bsuh.nhs.uk
to assess the current level of knowledge, confidence and
value system staff have, working in all areas of the
hospital setting in relation to organ and tissue donation
. Education strategies that adopt an experiential
approach should be developed in order to create
confidence in healthcare
 Conclusion
Altered level of consciousness place a
client at the risk of injury.
Nurse play a very important role in caring
for an unconscious patient, helping the
patient in carrying out ADL.
Proper assessment and prompt
intervention can improve the prognosis.
 References
Luck Mann’ s “medical and surgical
nursing” 4th edition, Saunders's
publications .page no.673-670.
Barker’s “neuro sciences nursing” 2nd
edition, mosby publications. Page no.698-
712.
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