UNCOUNCIOUSNESS

JAMES
Definition
This is a state of altered consciousness in which there are
degrees described as
Sleep – patient is easily aroused
Stupor – patient is aroused with difficulty
Coma – patient cannot be aroused
There is loss of voluntary function and protective
responses. The patient is kept alive by the involuntary
mechanisms of respiration and heart action. Bowel and
bladder actions are irregular and uncontrolled. Behavioral
responses are lost.

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Causes
These can be established from
History –
head injury, diabetes, hypertension, acute vascular
conditions (CVA), renal disease, alcoholism
Appearance –
paralysis
Examination –
e.g. smell of breath - in diabetes, alcohol

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Causes Cont…
Interpretation of results -
 blood sugar etc
Tests –
 neurological examination
Infections –
 e.g. Malaria
Poisons –
e.g. ingested poisons

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Causes Cont…
The following MNEMONIC (memory aid) using vowels and doctors
(MDs) was established to help remember:
A –Alcohol, Apoplexy (CVA, Stroke)
E – Epilepsy
I – Injury
O – Opium
U – Uremia
M – Meningitis
D – Diabetes
M – Malaria
D – Drugs
AEIOUMDMD mnemonic
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Signs and symptoms
No reaction to stimulus
Cyanosis
Cheyne – Stokes breathing due to impaired respiratory
centre, especially in coma
Smell of breath – alcohol, acetone
Cervical spine rigidity – in meningitis, intracranial injury
Visible injury over skull
Pupils that do not react to light
Paralysis (in CVA /Stroke)

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Observations
Observations
Neurological observations 4 hourly (using Glasgow Coma
Scale)
Vital signs

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 1 2 3 4 5 6
Eye No Eye Eye Eye Eyes N/A N/A
opening opening opening opening opening
Response in to speech spontaneo
response usly
to pain
stimuli

Verbal No Incompr Inappropr Confused Oriented N/A

Response Verbal ehensible iate words
Respons sounds
e
Motor No Extensio Flexion to Withdraw Localizes to Obeys
Response Motor n to pain pain al from pain comma
Respons pain nds
e

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Interpretation
Severe- GCS < 8
Moderate- GCS 9–12
Minor-GCS ≥ 13.

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Care of an unconscious Patient
Aim: To supply physiological needs and to prevent
complications
Clear the airway of vomit, tongue, teeth, blood, secretions
and maintain the airway
Place patient in the semi-prone position
Support head with a small pillow to maintain body
alignment
Relief of obstruction by e.g. tracheostomy or endotracheal
intubation (by doctor if indicated) and tracheotomy care
Administration of oxygen

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Care Cont…
Total Nursing Care
Change of position 2 hourly and before feeding
Pressure area care to prevent bedsores
Hourly passive exercises (by nurse)
Covering of eyes to prevent dryness and infection
Physiotherapy
Nutrition – swallowing reflex is lost – Intravenous fluids ->
nasal-gastric tube with nutritious fluid diet with extra
vitamins - > normal diet

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Care Cont…
Elimination – In urinary incontinence, ensure there is no
retention which may cause restlessness.

Males: a urinal may be placed to collect urine,

emptied frequently and ensuring it does not cause
pressure; or a condom catheter with a urine bag; or a self
retaining catheter.
Females: a self retaining catheter is inserted and released,
initially hourly then 2 hourly. Bowel movement: The
patient is kept clean and linen changed.

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Care Cont…
Investigations: prepare and assist as requested for:
Radiological examination
e.g. skull x-ray, CT scan
Lab tests e.g. blood urea, sugar
Administer medication as prescribed, depending on cause
e.g. insulin / glucose in diabetes; antibiotics if infection etc.
(see MNEMONIC)
Reassure relatives

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Neurological Examination
This is an examination performed to test nerve reflexes and sensory
perception of a patient suffering from disease or injury of the central
nervous system.

Requirements – on a Trolley
Patella / tendon hammer – to test reflexes
Substances for testing sense of taste – sugar and salt in small
unlabelled containers; a spoon and saucer
Substances for testing sense of smell – oil of peppermint or cloves in
small unlabelled containers
Two metal rods – one in a jug of hot water, the other in cold water to
test temperature sensation
Cotton wool swab – to test the sense of touch

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Requirements Cont…
A tape measure – to measure length or circumference of a limb
and wasting of muscles
A key or coin – to test the sense of fine touch
The sense of grip is tested by grasping the examiner`s hands
/fingers
 Tuning fork - to test hearing
An auriscope - to examine ears
A torch – to test the reaction of the pupil to light
An ophthalmoscope – to examine the retina of the eyes
A sphygmomanometer and stethoscope for blood pressure /
auscultation
Patient`s notes and X –rays
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Procedure
Procedure
Ensure patient has empty bladder
Explain the procedure to the patient
Screen the bed and close nearby windows
Ensure the room is warm and quiet and the bed stripped with patient
covered with sheet or blanket
If necessary, undress the patient and leave him in pants in a supine position
The doctor will instruct the patient to move to any other position, stand or
walk (if conscious) to observe the gait and posture
When assistance is required, the nurse remains with him BUT stays at the
bedside throughout the procedure when the patient is a girl or a woman
After the procedure, the patient is dressed and made comfortable, and
offered a hot drink.

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Indications For Neurological Exam
Head injuries
Electric (high voltage) shock
Hydrocephalus
Infections e.g. meningitis
Cerebral abscess / tumor
Poliomyelitis
Epilepsy
Parkinson`s disease
Multiple sclerosis
trigeminal neuralgia (intense pain on the side of the head
due to inflammation of the 5th cranial nerve)
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