UNCONCIOUS AND COMA CNH

Objectives  Describe the patophysiology of altered LOC  Describe the clinical manifestation of altered LOC  Identify assessment & diagnostic finding

 Identify complications of altered LOC  Identify medical management for client with altered LOC  Identify nursing interventions for client with altered LOC

Altered Cerebral Function  Altered Cerebral Function occurs with illness and injury  Brain Function Deterioration

Altered Level of Consciousness (LOC)  Consciousness Condition in which person is aware of self and environment and able to respond to stimuli appropriately  Requires  Arousal: alertness; dependent upon reticular activating system (RAS); system of neurons in thalamus and upper brain stem  Cognition: complex process involving all mental activities; controlled by cerebral hemispheres

Terms used to describe LOC TermCharacteristics of client Full consciousness  Alert  Orientated to person, place, time  Comprehends spoken and written words Confusion  Unable to think rapidly and clearly  Easily bewildered with poor memory, short attention span  Judgment impaired

Disorientation  Not aware or orientated to people, place and time Obtundation  Lethargic  Responsive to verbal stimuli or tactile but quickly draft back to sleep Stupor  Generally unresponsive  May be briefly aroused by vigorous, repeated or painful stimuli  May shrink away from or grab at the source of stimuli

Semicomatose  Does not move spontaneously  Unresponsive to stimuli although by vigorous or painful stimuli  May result in stirring, moaning or withdrawal from the stimuli, without actual arousal Coma  Unarousable, will not stir or moan in response to any stimulus  May exhibit nonpurposeful response (slight movement) of area stimulated but makes no attempt to withdraw

Deep coma  Completely unarousable and unresponsive to any kind of stimulus including pain  Absense of corneal, pupillary, pharyngeal, tendon and plantal reflexes

Pathophysiology  Lesions or injuries affecting cerebral hemisphere directly or that compress or destroy neurons in RAS  Metabolic disorders

 Arousal affected by:  Destruction of RAS:  stroke, demyelinating diseases  Compression of brain stem producing edema and ischemia:  tumors, increased intracranial pressure, hematomas or hemorrhage, aneurysm

 Cerebral hemisphere function depends on continuous supply or oxygen and glucose  Most common impairment caused by global ischemia, hypoglycemia

 Processes within brain that destroy or compress structures affect LOC:  Increased intracranial pressure  Stroke, hematoma, intracranial hemorrhage  Tumors  Infections  Demyelinating disorders

 Systemic conditions affecting brain function a.Hypoglycemia b.Fluid and electrolyte imbalances 1.Hyponatremia 2.Accumulated waste products from liver or renal failure 3.Drugs affecting CNS: alcohol, analgesics, anesthetics  Seizure activity: exhausts energy metabolites

Client assessment results with decreasing LOC  Increased stimulation required to elicit response from client  More difficult to rouse; client agitated and confused when awakened  Orientation changes: loses orientation to time first; then place; finally person  Continuous stimulation required to maintain wakefulness  Client has no response, even to painful stimuli

Patterns of breathing  As respiratory center are affected: predictable changes in breathing patterns  Types of respirations and brain involvement  Diencephalon: Cheyne-Stokes respirations

 Midbrain: neurogenic hyperventilation; may exceed 40/minute; due to uninhibited stimulation of respiratory centers  Pons: apneustic respirations: sighing on mid inspiration or prolonged inhalation and exhalation; excessive stimulation of respiratory centers  Medulla:ataxic/apneic respirations (totally uncoordinated and irregular); loss of response to CO2

Pupillary and oculomotor responses  Predictable progression  Localized lesion effects ipsilateral pupil (same side as lesion)  Generalized or systemic processes pupils affected equally

 Compression of cranial nerve III at midbrain, pupils become oval or eccentric (off center); progress to pupils become fixed (no response to light); progress to dilation  With deteriorating LOC, spontaneous eye movement is lost

Motor Function  Predictable progression  Assessment of level of brain dysfunction and side of brain affected a.Client follows verbal commands b.Pushes away purposely from stimulus c.Movements are more generalized and less purposeful (withdrawal, grimacing) d.Flaccid with little or no motor response

Coma States  Possible outcome of altered LOC:  Comas range from full recovery, without any residual effects, to persistent vegetative state (cerebral death) or brain death

Stages  Irreversible coma (vegetative state)  Permanent condition of complete unawareness of self and environment; death of cerebral hemispheres with continued function of brain stem and cerebellum  Client does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow, and cough

 Eyes may wander but cannot track object  Minimally conscious state: client aware of environment, can follow simple commands, indicate yes/no responses; make meaningful movements (blink, smile)  Often results from severe head injury or global anoxia

Locked-in syndrome  Client is alert and fully aware of environment; intact cognitive abilities but unable to communicate through speech or movement because of blocked efferent pathways from brain  Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking  Occurs with hemorrhage or infarction of pons; disorders of lower motor neurons or muscles

Brain death  Cessation and irreversibility of all brain functions  General criteria a.Absent motor and reflex movements b.Apnea c.Fixed and dilated pupils d.No ocular responses to head turning e.Flat EEG

Prognosis 1.Outcome varies according to underlying cause and pathologic process 2.Young adults can recover from deep coma 3.Recovery within 2 weeks associated with favorable outcome 4.Prognosis is poor – lack pupilary reaction or reflex eye movement 6hr after the onset of coma

Collaborative Care 1.Management includes identifying cause, preserve function and prevent deterioration 2.Involves total system maintenance in many cases

Diagnostic Tests 1. Blood glucose: cerebral function declines rapidly 2. Serum electrolytes: hyponatremia: coma and convulsions when Na < 115 mEq/L 3.ABG: hypoxemia frequent cause of altered LOC;

4.BUN and creatinine: renal function 5.Liver function tests: tests determine liver function; high ammonia levels interfere with cerebral metabolism 6.Toxicology screening of blood and urine (acute drug or alcohol) 7.CBC: anemia or infectious cause of coma

8.CT, MRI: identification of neurologic damage 9.EEG: evaluate electrical activity of brain, unrecognized seizure activity 10.Cerebral angiography: visualization of cerebral vascular system including aneurysms, occluded vessels, tumors 11.Transcranial Doppler: assess cerebral blood flow 12.Lumbar puncture: CSF to assess infection, possible meningitis

Medications 1. IV fluids normal saline, lactated Ringer’s 2.Specific medications to address specific problems a.50% glucose: hypoglycemia b.Naloxone for narcotic overdose c.Regulation of osmolality with diuretics d.Antibiotics: infections

Surgery  May be indicated if cause of coma is tumor, hemorrhage, hematoma  Other Measures (as indicated) 1.Airway support and mechanical ventilation if indicated 2.Maintenance of nutritional status with enteral feedings

Nursing Diagnoses 1. Ineffective Airway Clearance:  Assess ability to clear secretion  Limit suctioning to < 10 – 15 seconds;  Hyperoxygenate before  Turn from side to side every 2 hr

2. Risk for Aspiration  Assess swallowing and gag reflexes every shift as appropriate to the client’s level of consciousness  Monitor and report manifestation of aspiration  Maintain NPO  Place in the side lying position  Provide oral care and suctioning as needed

3.Risk for Impaired Skin Integrity:  preventative measures  continual inspection 4.Impaired Physical Mobility:  maintain functionality of joints  physical therapy

5.Anxiety (of family) a.Extremely stressful time b.Reinforce information from physician c.Encourage to speak with client who is in coma