Unconscious Clients (Patients) –
Assessment, Nursing Diagnosis –
A Simple Nursing Procedure
Consciousness:
It is a state of being wakeful and aware of self, environment and time.
Unconsciousness:
Unconsciousness can be brief, lasting for few seconds to an hour or so, or sustained, lasting for few hours or longer. Unconsciousness can be produced by a disorder that disrupts the ascending reticular activating system (RAS), both cerebral hemispheres and anything that metabolically depresses the overall brain function, e.g., drug overdose.
Coma is a state of sustained unconsciousness in which the client does not respond to verbal stimuli, does not move voluntarily, does not blink, may have altered respiratory patterns, altered papillary response to light and varying responses to painful stimuli.
Levels of consciousness
1. Alertness, oriented: open eyes spontaneously, responds to stimuli appropriately.
2. Lethargy, sleepy: slow to respond but appropriate response; opens eyes to stimuli; oriented.
3. Stupor: aroused by and opens eyes to painful stimuli; never fully awake; confused; unclear conversation.
4. Semi-coma stage: move in response to painful stimuli; no conversation; protective blinking/swallowing; pupillary reflex present.
5. Coma: unresponsive except to severe pain; no protective reflexes; fixed pupils; no voluntary movement.
Assessment of Unconscious Clients
For the care to be effective, a nurse should perform frequent, systematic and objective assessment on the comatose client. During the first few hours of coma, neurologic assessment is to be done as often as every 15 minutes.
Comatose clients are completely dependent on others because their consciousness and protective reflexes are impaired. Coma is often life-threatening and requires aggressive intervention. Nurses are responsible for meeting basic human needs and preventing the complications associated with coma.
History
Collect pertinent information regarding present illness, past illness/surgeries, personal history, nutritional history, socioeconomic and environmental status as these data help in determining the causes for coma.
Physical Assessment
Level of Consciousness
Glasgow coma scale is used to assess the level of consciousness.
1. Eye opening
Test and Score
Spontaneous – 4
To speech – 3
To pain – 2
No response – 1
2. Verbal response
Test and Score
Oriented – 5
Confused – 4
Inappropriate words – 3
Incomprehensible sound – 2
No response – 1
3. Motor response
Test and Score
Obeys commands – 6
Localizes – 5
Withdraws – 4
Flexes – 3
Extends – 2
No response – 1
Thus, the client’s response is rated on a scale from 3 to 15. A score of 3 indicates severe neurologic impairment. A score of 15 indicates that the client is fully responsive. A score less than 7 require frequent assessment.
Pattern of Respiration
Disturbances of respiratory center of brain may result in various respiratory patterns.
– Cheyne Stroke’s respiration: it suggests lesions deep in both the hemispheres, area of basal ganglia and upper brain stem.
– Hyperventilation: onset of metabolic problem or brain stem damage.
– Ataxic respiration with irregularity in depth and rate – damage to medullary center.
Eyes
Pupils (size, equality and reaction to light): Pupils Equal Round Reacting to Light and Accomodative (PERLA)
– Equal or unequal diameter – coma is toxic or metabolic in origin.
– Progressive dilation – increase in ILP
– Fixed dilated pupils – injury at the level of mid brain
Eye Movements – normally eyes move from side to side.
– Fixed dilated pupils – injury at the level of mid brain
– Eye movements absent in deep coma
– Abnormal in brain stem lesion
Corneal reflex – when touched with a wisp of clean cotton, blink response is normal. If abnormal, functions of 5th and 7th cranial nerve may have been affected. Unilateral lesion may be present, corneal reflex is absent in deep coma.
Facial Symmetry
Normally symmetric
Asymmetric – sagging or decrease in wrinkles – signs of paralysis.
Swallowing Reflex
Drolling versus spontaneous swallowing
Drooling is present in 10th and 12th cranial nerves, subarachnoid haemorrhage, meningitis, absent in deep coma.
Neck
Stiff neck – subrachnoid haemorrhage, meningitis
Absence of spontaneous neck movement – fracture or dislocation of cervical spine
Motor Response
Spontaneous purposeful movement – client fully awake
Movement only in response to noxious stimuli (pressure or pain) – in semi consciousness
Asymmetric response – in hemiplegia or paraplegia
Absent motor response – in deep coma
Flaccidity – cerebral hemispheres pathology and in metabolic depression of brain function; indicates severe neurologic impairment
Abnormal posturing
– Decorticate posturing (flexion and internal rotation of forearms and hands).
– Decerebrate posturing (extension and external rotation).
– Decerebrate posturing indicates deeper and more severe dysfunction than decorticate posturing; very poor prognostic sign.
Reflexes (Evaluate the specific sensory and motor pathways).
Superficial or cutaneous reflexes (abdominal, plantar, corneal, pharyngeal, cremasteric and anal) – absent in pyramidal tract disorders, e.g., absent on the affected side after CVA.
Deep tendon reflexes (muscle stretch or myotactic reflexes) (Biceps jerk, triceps jerk, ankle jerk, knee jerk)
– Asymmetric in paralysis
– Absent in deep coma
Pathologic reflexes
(Babinski’s reflexes, jaw, palm-chins (palmomental), clonus, snout, rooting, sucking reflex, glabellar, grasp reflex, chewing).
Pathologic reflexes indicate neurologic disorders often related to spinal cord or higher centers.
Body functions – circulation, respiration, elimination, fluid and electrolyte balance are examined in a systematic and ongoing manner.
Lab Tests and Procedures
Scanning, imaging, tomography – (CT, MRI, PET, EEG) – to
Identify the cause of unconsciousness
Lab tests include the analysis of blood glucose, electrolytes, serum ammonia, BUN levels, serum osmolality, Ca level, PTT, PT. other studies to evaluate serum ketones and alcohol, drug levels, arterial blood gas levels, etc. are also performed.
Nursing Diagnosis According to Priority
1. Ineffective airway clearance related to upper airway obstruction, by tongue and soft tissues, inability to clear respiratory secretions as evidenced by unclear lung sounds, unequal lung expansion, noisy respiration, presence of stridor, cyanosis or pallor.
2. Ineffective cerebral tissue perfusion related to effects of increased ICP as evidenced by papilledema. Cushing’s Triad, vomiting.
3. Risk of injury related to unconscious state.
4. Risk for fluid volume deficit related to inability to ingest fluids, dehydration from osmotic diuretics.
5. Ineffective thermoregulation related to damage to hypothalamic center as evidenced by persistent elevation of body temperature, warm and dry skin, flushed appearance of skin.
6. Risk for impaired tissue integrity – cornea, related to absence of corneal blink reflex, dryness of eyes.
7. Altered oral mucous membrane related to mouth breathing, absence of pharyngeal reflex, inability to ingest fluid as evidenced by dryness, inflammation, crusting and halitosis.
8. Imbalanced nutrition – less than body temperature, related to inability to eat and swallow as evidenced by weight and other nutritional parameters less than normal.
9. Self-care deficit-bathing, feeding, grooming, toileting related to unconscious state as evidenced by unkempt and poorly nourished look, bed soiling.
10. Risk for complications – pressure sore, contractures, DVT, hypostatic pneumonia, constipation – related to immobility.
Interrupted family process related to chronic illness of a family member as evidenced by anger, grief, non-participation in client care.