Care of comatosed client Prepared by Dr. Hanan Said Ali

Learning objectives Define of coma. Describe the pathophysiology. Enumerate the clinical manifestations. List the complications. Explain the medical management. Describe the nursing care for comatose patient.

Care of comatosed client Definition of coma Is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli. The duration of coma is usually limited to 2 to 4 weeks.

Care of comatose client Pathophysiology The underlying causes of neurologic dysfunction are disruption in the cells of the nervous system, neurotransmitters, or brain anatomy. A disruption in the basic functional units (neurons) or neurotransmitters results in faulty impulse transmission, impeding communication within the brain or from the brain to other parts of the body.

Clinical Manifestations As the patient’s state of alertness and consciousness decreases, there will be changes in the pupillary response, eye opening response, verbal response, and motor response. Initial changes may be reflected by slight behavioural changes such as restlessness or increased anxiety.

Clinical Manifestations Cont. As the patient becomes comatose, the pupils become fixed (no response to light). The patient in a coma does not open the eyes, respond verbally, or move the extremities in response to a request to do so.

Diagnostic Findings Procedures used to identify the cause of unconsciousness include:- scanning, imaging, tomography (eg, computed tomography, magnetic resonance imaging, and electroencephalography. Laboratory tests include analysis of: blood glucose, electrolytes, serum ammonia, and blood urea nitrogen, calcium level, and partial thromboplastin and prothrombin time

Diagnostic Findings Cont.  Other studies may be used to evaluate serum ketones and alcohol, drug levels, and arterial blood gas levels.

Complications  respiratory failure, pneumonia, pressure ulcers, and aspiration. The patient with altered LOC is subject to all the complications associated with immobility, such as:- pressure ulcers, venous stasis, musculoskeletal deterioration, and disturbed gastrointestinal functioning.

Complications Cont. Pressure ulcers may become infected and act as a source of sepsis. Aspiration of gastric contents or feedings may occur, precipitating the development of pneumonia or airway occlusion.

Medical Management The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. a mechanical ventilator is used to maintain adequate oxygenation. The circulatory status (blood pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain.

Medical Management Cont. Nutritional support, using either a feeding tube or a gastrostomy tube, is initiated as soon as possible. other medical interventions are aimed at pharmacologic management of complications and strategies to prevent complications.

Assessment of Patient Assessing the verbal response. Determining the patient’s orientation to time, person, and place assesses verbal response. Alertness is measured by the patient’s ability to open the eyes spontaneously or to a stimulus. Motor response includes spontaneous movement (eg, the awake patient can move all four extremities with equal strength), movement only in response to noxious stimuli.

Assessment of Patient Cont. Posturing may be decorticate or decerebrate (A) Decorticate posturing, involving adduction and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. (B) Decerebrate posturing, involving extension and outward rotation of upper extremities and plantar flexion of the feet.

Assessment of Patient Cont. the nurse monitors parameters such as respiratory status, eye signs, and reflexes.

Nursing Care MAINTAINING THE AIRWAY secretions must be removed to eliminate the danger of aspiration. Elevating the head of the bed to 30 degrees helps prevent aspiration. Positioning the patient in a lateral or semiprone position will also help as it permits the jaw and tongue to fall forward, thus promoting drainage of secretions.

MAINTAINING THE AIRWAY Cont. The patient may require suctioning and oral hygiene. Chest physiotherapy and postural drainage may be initiated to promote pulmonary hygiene. The chest should be auscultated at least every 8 hours to detect adventitious breath sounds or absence of breath sounds. Nursing actions for the mechanically ventilated

PROTECTING THE PATIENT Padded side rails are provided and raised at all times. Care should be taken to prevent injury from invasive lines and equipment, and other potential sources of injury should be identified (eg, restraints, tight dressings, environmental irritants,, tubes and drains).

MAINTAINING FLUID BALANCE AND MANAGING NUTRITIONAL NEEDS Hydration status is assessed by examining tissue turgor and mucous membranes, assessing intake and output trends, and analyzing laboratory data. The quantity of fluids administered may be restricted to minimize the possibility of producing cerebral oedema. A feeding tube will be inserted for the administration of fluids and enteral feedings.

PROVIDING MOUTH CARE The mouth is inspected for dryness, inflammation, and crusting. The mouth is cleansed and rinsed carefully to remove secretions and crusts and to keep the mucous membranes moist. A thin coating of petrolatum on the lips prevents drying, cracking. If the patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips.

MAINTAINING SKIN AND JOINT INTEGRITY A regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin. Dragging the patient up in bed must be avoided, because this creates a shearing force and friction on the skin surface. Maintaining correct body position. A passive exercise of the extremities to prevent contractures.

MAINTAINING SKIN AND JOINT INTEGRITY The use of splints or foam boots aids in the prevention of footdrop and eliminates the pressure of bedding on the toes. The arms should be in abduction, the fingers lightly flexed, and the hands in slight supination. The heels of the feet should be assessed for pressure areas

PRESERVING CORNEAL INTEGRITY The cornea is likely to become irritated or scratched, leading to corneal ulcers. (inadequate or absent corneal reflexes) The eyes may be cleansed with cotton balls moistened with sterile normal saline to remove debris and discharge. If artificial tears are prescribed, they may be instilled every 2 hours.

MAINTAINING BODY TEMPRATURE High fever in the unconscious patient may be caused by infection of the respiratory or urinary tract, drug reactions, or damage to the hypothalamic temperature-regulating centre. A slight elevation of temperature may be caused by dehydration.

MAINTAINING BODY TEMPRATURE Strategies for reducing fever include: Removing all bedding over the patient (with the possible exception of a light sheet or small drape) Administering repeated doses of acetaminophen as prescribed. Giving a cool sponge bath and allowing an electric fan to blow over the patient to increase surface cooling. Frequent temperature monitoring is indicated.

PREVENTING URINARY RETENTION The bladder is palpated or scanned at intervals to determine whether urinary retention is present. If the patient is not voiding, an indwelling urinary catheter is inserted and connected to a closed drainage system. the patient is observed for fever and cloudy urine. The area around the urethral orifice is inspected for drainage

PREVENTING URINARY RETENTION An external catheter (condom catheter) for the male patient and absorbent pads for the female patient can be used for the unconscious patient who can urinate spontaneously. As soon as consciousness is regained, a bladder- training program is initiated. The incontinent patient is monitored frequently for skin irritation and skin breakdown

PROMOTING BOWEL FUNCTION  The abdomen is assessed for distension by listening for bowel sounds and measuring the girth of the abdomen with a tape measure. Commercial fecal collection bags are available for patients with fecal incontinence.

PROMOTING BOWEL FUNCTION Immobility and lack of dietary fibber may cause constipation. The nurse monitors the number and consistency of bowel movements and performs a rectal examination for signs of fecal impaction Stool softeners may be prescribed and can be administered with tube feedings. To facilitate bowel emptying, a glycerine suppository may be indicated. The patient may require an enema every other day to empty the lower colon.

PROVIDING SENSORY STIMULATION The nurse touches and talks to the patient and encourages family members and friends to do so. Avoid making any negative comments about the patient’s status or prognosis in the patient’s presence The nurse orients the patient to time and place at least once every 8 hours. Sounds from the patient’s home and workplace may be introduced using a tape recorder.

PROVIDING SENSORY STIMULATION Family members can read to the patient from a favourite book and may suggest radio and television programs that the patient previously enjoyed. When arousing from coma, many patients experience a period of agitation(anxiety), indicating that they are becoming more aware of their surroundings but still cannot react or communicate in an appropriate fashion.

PROVIDING SENSORY STIMULATION At this time: minimize the stimulation to the patient by: limiting background noises. Having only one person speak to the patient at a time. Giving the patient a longer period of time to respond. Allowing for frequent rest or quiet times.

MEETING FAMILIES’ NEEDS Reinforce and clarify information about the patient’s condition, permit the family to be involved in care. Listen to and encourage ventilation of feelings and concerns

MONITORING AND MANAGING POTENTIAL COMPLICATIONS Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. Total blood count and arterial blood gas measurements are assessed to determine whether there are adequate red blood cells to carry oxygen and whether ventilation is effective.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS Chest physiotherapy and suctioning are initiated to prevent respiratory complications such as pneumonia. The patient should also be monitored for signs and symptoms of deep vein thrombosis.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS Prophylaxis such as subcutaneous heparin should be prescribed. Thigh-high elastic compression stockings or pneumatic compression stockings. should also be prescribed to reduce the risk for clot formation

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