1. Management of unconscious patients
Dr. Maha Subih

2. Altered LOC
Altered LOC is not a disorder itself; rather, it is a result of multiple pathophysiologic phenomena. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or renal failure, DKA).
cause of neurologic dysfunction is disruption in the cells of the nervous system, neurotransmitters, or brain anatomy
Disruptions result from cellular edema or other mechanisms, such as disruption of chemical transmission at receptor sites by antibodies.

3. Important Concepts Coma is a state of unarousable unresponsiveness
Akinetic mutism is a state of unresponsiveness to the environment no voluntary movement.
Persistent vegetative state: the unresponsive patient resumes sleep–wake cycles after coma but lack cognitive or affective mental function.
Locked-in syndrome: paralysis and the inability to speak, but eye movements and lid elevation remain intact (fullyconscious)

4. Clinical Manifestations
Alterations in LOC occur along a continuum, and the C/M depend on where the patient is on this continuum.
Alertness ________________________ Coma
As the patient’s state of alertness and consciousness decreases, changes occur in the pupillary responses and GCS.
initial alterations in LOC may be reflected by subtle behavioral changes, such as restlessness or increased anxiety.
The pupils become sluggish (response is slower); 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.

5. Assessment and Diagnostic Findings
neurologic examination
It includes an evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function.
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale
A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive

6. If the patient is comatose and has localized signs such as abnormal pupillary and motor responses, it is assumed that neurologic disease is present until proven otherwise. If the patient is comatose but pupillary light reflexes are preserved, a toxic or metabolic disorder is suspected

7. Medical Management
first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway.
May intubated, or a tracheostomy may be performed mechanical ventilator is used to maintain adequate oxygenation and ventilation.
The circulatory status (BP-HR) is monitored to ensure adequate perfusion to the body and brain.
IV fluids and medications.
Nutritional support, via a feeding tube or a gastrostomy tube.
measures designed to determine and treat the underlying causes of altered LOC, other medical interventions are aimed at pharmacologic management
and prevention of complications.

8. Nursing Diagnosis Ineffective airway clearance related to altered LOC
Risk of injury related to decreased LOC
Deficient fluid volume related to inability to take fluids by mouth
Impaired oral mucosa related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake
Risk for impaired skin integrity related to prolonged immobility
impaired tissue integrity (cornea) related to diminished or absent corneal reflex
Ineffective thermoregulation related to damage to hypothalamic center
Impaired urinary elimination and bowel incontinence related to impairment in neurologic sensing and control
Disturbed sensory perception related to neurologic impairment
Interrupted family processes related to health crisis

9. Potential Complications
Respiratory distress or failure
Pneumonia
Aspiration
Pressure ulcer
Deep vein thrombosis (DVT)
Contractures

10. Decorticate Posturing
Decerebrate Posturing

11. Nursing Interventions
Maintaining an airway
Frequent monitoring of respiratory status including auscultation of lung sounds
Positioning to promote accumulation of secretions and prevent obstruction of upper airway—HOB elevated 30°, lateral or semiprone position
Suctioning, oral hygiene, and CPT
Obstruction of the airway is a risk because the epiglottis and tongue may relax, occluding the oropharynx, or the patient may aspirate vomitus or nasopharyngeal secretions

12. Nursing Interventions
Protecting the patient
side rails are padded.
prevent injury from invasive lines and equipment, and others…
Avoid restrains, tight dressings, environmental irritants, wet bedding or dressings, and tubes and drains.
Ensuring the patient’s dignity---- providing privacy and speaking to the patient during nursing care

13. Nursing Interventions
Maintaining Fluid Balance & Nutritional Needs
Assess hydration status -- tissue turgor, intake and output, and laboratory data.
Initially administer required IV fluids for patients with increased ICP must be slowly.
The quantity of fluids restricted to prevent cerebral edema.
feeding or gastrostomy tube will be inserted

14. Nursing Interventions
Providing Mouth Care
Inspect the mouth for dryness, inflammation, and crusting.
oral care to remove secretions and crusts and to keep the mucous membranes moist.
A thin coating of petrolatum on the lips prevents drying, cracking, and encrustations.
If an endotracheal tube: tube moved to the opposite side of the mouth daily to prevent ulceration
Toothbrushing every 8 hours to decrease ventilator-associated pneumonia

15. Nursing Interventions
Maintain tissue integrity
Assess skin frequently
Frequent turning; use turning schedule
Avoid dragging or pulling the patient up in bed
Passive ROM
Use of splints, foam boots, trochanter rolls to support the hip joints
keeps the legs in proper alignment.
keeps the legs in proper alignment. The arms are in abduction, the fingers lightly flexed, and the hands in slight supination.

16. Maintain tissue integrity
Assess the heels of the feet for pressure areas. Specialty beds, such as fluidized or low-air-loss beds, -- to decrease pressure on bony prominences
Turning also provides kinesthetic (sensation of movement), proprioceptive (awareness of position), and vestibular (equilibrium) stimulation.
Dragging or pulling the patient up in bed must be avoided, because this creates friction on the skin surface.
Maintaining correct body position is important; equally important is passive exercise of the extremities to prevent contractures.

17. Nursing Interventions
Preserving Corneal Integrity
Some unconscious patients have their eyes open and have inadequate or absent corneal reflexes The cornea become irritated, dried out, or scratched, leading to ulceration.
clean with cotton balls moistened with sterile normal saline
Artificial tears instilled every 2 hours.
Periorbital edema: often occurs after cranial surgery. If cold compresses are prescribed, care must be exerted to avoid contact with the cornea.
Eye patches should be used cautiously because of the potential for corneal abrasion from contact with the patch.

18. Nursing Interventions
Maintaining body temperature
fever R/T infection of the respiratory or urinary tract, drug reactions, or damage of hypothalamic temperature-regulating center.
A slight elevation R/T dehydration.
Persistent hyperthermia indicate brain stem damage and a poor prognosis
Adjust environment temperature(room temp.18.3C)
If elderly: warmer environment

19. Maintaining body temperature
Such temperature elevations must be controlled, because the increased metabolic demands of the brain can exceed cerebral circulation and oxygen delivery, potentially resulting in cerebral deterioration
Strategies for reducing fever include:
Remove all bedding over the patient (except of a light sheet, towel, or small drape)
Administer acetaminophen as prescribed
Give cool sponge baths + electric fan
Use a hypothermia blanket
Frequent temperature monitoring

20. Preventing Urinary Retention
Palpate bladder or ultrasound
an indwelling urinary catheter is inserted .
observe for fever and cloudy urine and inspect the area around the urethral orifice for drainage.
intermittent catheterization program is initiated
An external catheter (condom catheter) for the male
skin care and monitor skin for irritation and breakdown.

21. Promoting Bowel Function
Assess Distention
Diarrhea from infection, antibiotics, and hyperosmolar fluids.
Fecal impaction-Constipation R/T Immobility and lack of dietary fiber
Monitor number and consistency of bowel movements and observe for signs of fecal impaction.
Stool softeners may be prescribed and administered with tube feedings.
a glycerin suppository or enema every other day
Use Commercial fecal collection bags

22. Providing Sensory Stimulation
using auditory, visual, olfactory, gustatory, tactile, and kinesthetic activities
maintain usual day and night patterns for activity and sleep.
touch and talk to the patient and encourages family members and friends to do so.
Avoid negative comments about the patient’s status
Orient the patient to time and place at least every 8 hours.
Introduce sounds from the patient’s usual environment
Family members can read a favorite book
radio and television programs

23. Providing Sensory Stimulation
When arousing from coma: patients experience a period of agitation-- aware of the surroundings but still cannot react or communicate effectively
minimize stimulation (limit noises, one person speak a time, give patient time to respond, and allow rest).

24. Meeting the Family’s Needs
go through the process of severe anxiety, denial, anger, and grief.
unprepared for the changes in the cognitive and physical status Require time, assistance, and support
Clarify information
Permit the family to be involved in the care
Encourage ventilation of feelings
support groups
End-of-life care