NSC 207 UNCONSCIOUSNESS

AGBONJINMI LAWRENCE
ADEWALE
OBJECTIVES
• Identify the potential causes of unconsciousness in patients,
including traumatic and non-traumatic etiologies, through a
comprehensive assessment.
• Implement evidence-based interventions promptly based on the
etiology of unconsciousness, ensuring proper airway management,
blood glucose control, and other specific treatments.
• Apply neuroimaging knowledge, such as CT or MRI scans, to aid
in diagnosing the underlying intracranial causes of
unconsciousness and guide treatment decisions.
• Collaborate with an inter-professional healthcare team, including
specialists from various medical fields, to address complex cases of
unconsciousness and improve patient outcomes.
INTRODUCTION
Unconsciousness means:
• Lack of orientation
• Lost or lack of consciousness
• Alteration of mental state
• Complete or near compete of responsiveness to people
and other environmental stimulus
• Comatose state is an illustration of unconsciousness
INTRODUCTION CONTD
• Unconscious patients experience diminished alertness,
decreased self-awareness, and impaired responsiveness
to external stimuli. Unconsciousness damages the
ascending reticular activating system, cerebral
hemispheres, or various toxic, metabolic, or infectious.
It is caused by Trauma, cerebrovascular disease,
seizures, intoxication, and infection all these result in
emergency admission.
INTRODUCTION CONTD
• Some patients naturally recover fully without medical
intervention, whereas others require intensive care and
detailed diagnostic evaluations. This topic will discuss
the etiologies and physiological aspects of reducing
unconsciousness, highlighting the vital role of the
inter-professional healthcare team in assessing and
managing this condition to improve patient outcomes
and minimize complications among affected patient
 Definition of Unconsciousness
• Unconsciousness is inability of a patient to respond to
people and activities. Medically, this is often referred
to as state of coma or comatose state. But when other
changes in awareness exit without becoming
unconscious, they are referred to as altered mental
status or changed mental status.
• Unconsciousness is an abnormal state which occur as
if the patient is sleeping, but he is not alert and not
fully responsive anything in his surroundings. Levels
of unconsciousness range from drowsiness to collapse
 Definition of Unconsciousness contd
• Unconscious: is an abnormal state, when the patient is un-
arousable and unresponsive and has been regarded as
symptom but not a disease condition.
Its degree vary in length and severity as follows:
• Brief: fainting
• Prolong: deep coma.
• Coma: is deepest state of unconsciousness, arousal and
awareness are lacking.
It is important to note that state of unconsciousness or any
other sudden mental status changes must be treated as
emergency.
.
Definition of Unconsciousness contd
• Unconsciousness is a state of depressed cerebral
function and altered level of consciousness(LOC)
present when patient is not oriented, does not
follow commands, or needs persistent stimuli to
achieve a state of alertness.
• LOC is gauged on a continuum, with a normal
state of alertness and full cognition
(consciousness) on one end and coma on the other
end.
Definition of Unconsciousness contd
Alert/Oriented: Patient is fully conscious and able to identify
place, person and time.
• Coma (comatose): Patient is in a prolonged state of
unconsciousness and no responsive to internal or external
stimuli
• State in which patient is unable to respond to people and
activities
• Lack of awareness and capacity for sensory perception
• Temporarily lacking consciousness
• Without conscious volition
 Definition of Unconsciousness contd
• An ordinary deep sleep can make a patient
unconscious(sleepwalking and sleeptalking) but
when it is due to a fall or that the patient fainted
it remains a medical condition. Unconscious
patient aren't aware of what's going on, and they
can't talk or do things. Sometimes an individual
might experience in ability to know what is going
on in his mind, this is also regarded as
unconscious thoughts and desires
Definition of Unconsciousness contd
• Any unconscious patient have passed out or asleep.
And he is not aware of anything going on in his
environment is said to be unconscious.
• Unconsciousness is when a patient is not conscious;
lack awareness and hasn’t the capacity for sensory
perception.
• Sigmund Freud established the unconscious mind as
the store of feelings, urges, memories, and thoughts,
outside a person's conscious realization
Definition of Unconsciousness contd
•

• comatose is being in a coma, unconscious and unable to

communicate, often for long periods of time as a result of bad
illness or unexpected accident or injury, especially to the head
• Comatose comes from the Greek kōma, that is, patient is in a
"deep sleep." The patient body is “still” and unable to respond
to things around her. Being comatose means being in that
sleepy, unresponsive state and not being able to get out of it.
• Semicomatose means the patient is in a state of partial coma
• Subconscious means the patient is just below the level of
consciousness
 Definition of Unconsciousness contd
• Unconsciousness is when patient is unable to respond to
things in his surrounding or participate in any activity. This is
often term coma or being in a comatose state. When other
changes in awareness occur without becoming unconscious
these are called altered mental status or changed mental status
• unconscious is the vast sum of operations of the mind that
take place below the level of conscious awareness. The
conscious mind contains all the thoughts, feelings, cognitions,
and memories we acknowledge, while the unconscious
consists of deeper mental processes not readily available to the
conscious mind
Definition of Unconsciousness contd
• Unconsciousness is a state in which a living individual exhibits a
complete, or near-complete, inability to maintain an awareness of
self and environment or to respond to any human or
environmental stimulus.
• Unconsciousness can result from various underlying causes,
like damage to brain structures due to stroke, hemorrhage,
tumors, or head injuries. Additional potential factors
encompass seizures, low blood sugar, electrolyte
imbalances, and drug overdoses.
Definition of Unconsciousness contd
• Unconsciousness is a state of exhibiting a complete, or
near-complete, inability to maintain an awareness of self
and environment or to respond to any human or
environmental stimulus.
• Unconsciousness may occur as the result of traumatic
brain injury, brain hypoxia (inadequate oxygen, possibly
due to a brain infarction or cardiac arrest), severe
intoxication with drugs that depress the activity of the
central nervous system (e.g., alcohol and
other hypnotic or sedative drugs),
severe fatigue, pain, anaesthesia, and other causes.
Definition of Unconsciousness contd
• Loss of consciousness should not be confused
with the notion of the psychoanalytic
unconscious,, cognitive processes that take place
outside awareness (e.g. implicit cognition ), and
with altered state of consciousness such as sleep,
delirium, hypnosis, and other altered states in
which the patient responds to stimuli, including
trance and psychedelic experience.
CHARACTERISTICS OF UNCONSCIOUSNESS
• Unconsciousness can be brief, last for
second, hours or longer but the longer it
is, its irreversible due to permanent
disorder in the brain structure and the
higher the mortality rate and poorer the
neurologic outcome
Epidemiology
• The prevalence and causes of altered consciousness levels differ among
institutions and patient populations. For instance, high-volume trauma
centers typically encounter many unconscious patients with TBIs.
Among the most frequent non-traumatic causes, hemorrhagic strokes
comprise 6% to 54%, anoxic brain injuries 3% to 42%, poisonings 1%
to 39%, and metabolic conditions 3% to 42%.
• While strokes are the most common cause of non-traumatic coma in
general, non-structural causes, with a prevalence ranging from 37% to
75%, slightly exceed the prevalence of structural causes, which falls
within the range of 28% to 64%.
• The overall mortality rate varies from 25% to 87%. Strokes and anoxic
coma exhibit the highest mortality rates, ranging from 60% to 95% and
54% to 89%, respectively. On the contrary, epilepsy and poisoning
have the lowest mortality rates, with less than 10%. Geraghty M(2005)
 Pathophysiology of Unconsciousness.

• Pathophysiology: Consciousness involves arousal,

or wakefulness, and awareness. Neither of these
functions is present in the patient in coma.
Ascending fibers of the reticular activating system
(ARAS) in the pons, hypothalamus, and thalamus
maintain arousal as an autonomic function. Neurons
in the cerebral cortex are responsible for awareness.
Diffuse dysfunction of both cerebral hemispheres
and diffuse or focal dysfunction of the reticular
activating system can produce coma
Pathophysiology of Unconsciousness contd
• Structural causes usually produce compression or
dysfunction in the area of the ARAS, whereas
most medical causes lead to general dysfunction
of both cerebral hemispheres. Trauma,
hemorrhage, and tumor can damage the ARAS,
leading to coma. Destruction of large regions of
bilateral cerebral hemispheres can be the result
of seizures or viral agents. Toxic drugs, toxins, or
metabolic abnormalities can suppress cerebral
function
Pathophysiology of Unconsciousness contd
• Pathophysiology(SUMMARY)
• Consciousness is complex function controlled by
RAS(reticular activating system) responsible for
awareness located in the midbrain, connects to the
hypothalamus and Thalamus.
• Integrated pathway connects to the limbic system
via hypothalamus.

• reticular activating system

Pathophysiology of Unconsciousness contd
Pathophysiology(SUMMARY)

• Reticular formation produces wakefulness

where as RAS are responsible for awareness
of self and environment
• Disorder that affect any part of RAS can
produce coma.
• To produce coma a disorder must affect
both cerebral hemisphere and the brain stem
Assessment of unconscious patient
• Assessment of unconscious patient:
Assessment of the critically ill patient with
neurologic dysfunction includes a review of
the patient’s health history, a thorough
physical examination, and an analysis of the
patient’s laboratory data. Numerous invasive
and noninvasive diagnostic procedures may
also be performed to assist in the
identification of the patient’s disorder.
Assessment of unconscious patient
• History: Common to all neurologic
assessments is the need to obtain a
comprehensive history of events
preceding hospitalization. An adequate
neurologic history includes information
about clinical manifestations, associated
complaints, precipitating factors,
progression, and familial occurrences.
Assessment of unconscious patient
2. Physical Examination: Five major components
make up the neurologic evaluation of the critically ill
patient:
• A. Level of consciousness.
• B. Motor function.
• C. Pupillary function.
• D. Respiratory function.
• E. Vital signs. A complete neurologic examination
requires assessment of all five components
Assessment of unconscious patient
• Medical history: This is divided into past and present history,
though it takes time but it is very important that the nurse
should take a comprehensive history
• The primary goal of obtaining a medical history from the
patient is to understand the patient's state of health and
determine whether the history is related. The secondary goal is
to gather information to prevent potential harm to the patient
during treatment.
• A patient's health history is a key factor in timely and accurate
diagnosis of acute illness and leads to improved outcomes. A
thorough social and environmental health history can be just as
informative as the physical examination and clinical diagnostics
in the diagnosis and prompt treatment of illness.
 Assessment of unconscious patient Contd
• A personal medical history may include information
about allergies, illnesses, surgeries, immunizations,
and results of physical exams and tests. It may also
include information about medicines taken and health
habits, such as diet and exercise.
• The patient history provides an idea of which
pathogen may cause infection and allows the
microbiologist to optimize culture and identification
methods, as well as interpret results from more
advanced tests
Assessment of unconscious patient Contd
• The Nurse must instruct the patient to follow a simple
command such as stick your tongue out or lift up your
right arm. This would score 6. Asking the patient to
squeeze your hands should be avoided as this might elicit
a reflex squeezing rather than the obeying of a command
• Glasgow Coma Scale (GCS) – Up-To-Date. The GCS is
scored between 3 and 15, 3 being the worst and 15 the
best. It is composed of three parameters: best eye
response (E), best verbal response (V), and best motor
response (M).
Glasgow Coma Scale (GCS)
Response to verbal command 3
Response to pain 2
No eye opening 1

Best verbal response

Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Glasgow Coma Scale (GCS)
Best motor response
Obeys commands 6
Localizing response to pain 5
Withdrawal response to pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1
Total
 Glasgow Coma Scale (GCS)
• The GCS is scored between 3 and 15, 3 being the worst and 15 the best.
It is composed of three parameters: best eye response (E), best verbal
response (V), and best motor response (M). The components of the
GCS should be recorded individually; for example, E2V3M4 results in
a GCS score of 9.
• In the setting of head trauma, a GCS score of 8 or less measured on
admission represents severe traumatic brain injury (TBI).
• Traditionally, a GCS score of 9 through 12 has represented moderate
TBI, and a GCS score of 13 through 15 mild TBI. However, the
recognition that more than one-third of patients with TBI and a GCS
score of 13 have potentially life-threatening intracranial lesions has led
to a reevaluation of this classification. While a revised classification
has not been widely adopted, a GCS score of 9 through 13 likely best
represents the TBI population at moderate risk for death or long-term
disability.
Assessment of unconscious patient Contd
• Abnormal Motor Responses:
• -Abnormal flexion also known as decorticate posturing
. In response to painful stimuli, the upper extremities
exhibit flexion of the arm, wrist, and fingers, with
adduction of the limb. The lower extremity exhibits
extension, internal rotation, and plantar flexion.
Abnormal flexion occurs with lesions above the
midbrain, located in the region of the thalamus or
cerebral hemispheres.
Assessment of unconscious patient Contd
• - Abnormal extension also known as decelerate rigidity or
posturing occur when the patient is stimulated, teeth clench,
arms are stiffly extended, adducted, and hyperpronated. The
legs are stiffly extended, but with plantar flexion of the feet.
• · Evaluation of Reflexes :Deep tendon reflexes (DTRs) are
usually evaluated by a physician when a complete
neurologic evaluation is performed. The four reflexes tested
are: a) the Achilles (ankle jerk), b) the quadriceps (knee
jerk), c) the biceps, and d) the triceps
Assessment of unconscious patient Contd
Assessment of vital signs focuses on two areas: a)
evaluation of blood pressure and b) observation of
heart rate and rhythm. As a result of the brain and
brainstem influences on cardiac, respiratory, and
body temperature functions, Changes in vital signs
should be regarded as signs of deterioration in
neurologic status.
Assessment of unconscious patient Contd
• Single-Positive Emission Tomography
• Hoton Emission Computed Tomography
• Electroencephalography
• Intracranial Pressure Monitoring
• Cerebrospinal Fluid Analysis
• Transcranial Doppler Studies
• Laboratory tests include analysis of blood glucose, electrolytes,
serum ammonia, and liver function tests; blood urea nitrogen
(BUN) levels; serum osmolality; calcium level; and partial
thromboplastin and prothrombin times
Assessment of unconscious patient Contd
Diagnostic Procedures that should also be
carried out includes:
• · Computed Tomography
• · Magnetic Resonance Imaging
• · Cerebral Angiography
• · Myelography
• · Digital subtraction angiography
• · Lumbar puncture
Other Diagnostic Procedures
• Laboratory Test
• EEG
• Test for Abnormal reflex
• Oculocephalic response (Doll’s eye reflex:
movement of eyes opposite direction that the
head move
• Oculovestibular: Perform cranial nerve test: iii,
iv, vi, viii, Nystagmus
Stages of unconsciousness
• Stages of unconsciousness
• full consciousness with some impairment.
• a minimally conscious state.
• a confusional state.
• a vegetative state.
• a coma.
Stages of a Coma
Stages of a Coma
• Stage 1: Unresponsiveness. During the
unresponsive stage, a patient typically does not
respond consistently. ...
• Stage 2: Early Responsiveness. During this stage,
the patient will begin to respond to stimuli. ...
• Stage 3: Agitation and Confusion. ...
• Stage 4: Higher Level of Responsiveness.
Recovery through phases of unconsciousness
Recovery through phases of unconsciousness are:.
• Coma.
• Vegetative State.
• Minimally Conscious State.
• Confusional State.
• Full Consciousness (often with specific impairments)
• Recovery of these phases can be slow or static
Levels of consciousness
• The 4 levels of consciousness are lethargy,
stupor, and coma. Additional terms for altered
consciousness are also used
• For example, the early stages of brain edema
or organ failure can cause confusion but then
advance rapidly through lethargy, stupor, and
coma
• There are two components to level of
consciousness: arousal and awareness
TYPES OF UNCONSCIOUSNESS
Three types of the unconscious.
• 1 – The pre-reflective unconsciousness
• 2 – Dynamic unconsciousness
• 3- The unvalidated unconsciousness
CAUSES OF UNCONSCIOUSNESS
There are two major causes. They are:
A. STRUCTURAL OR SURGICAL UNCONSCIOUSNESS
• Trauma
• Epidural / Subdural hematoma
• Brain contusion
• Hydrocephalus
• Stroke
• Tumor
CAUSES OF UNCONSCIOUSNESS CONTD
B.METABOLIC OR MEDICAL UNCONSCIOUSNESS
• Infection
• Meningitis
• Encephalitis
• Hypo/hyperglycemia
• Hepatic encephalopathy
• Hyponatremia
• Drug /alcohol overdose
• Poisoning /intoxication
CAUSES OF UNCONSCIOUSNESS CONTD
• C. General causes
• Unconsciousness can be caused by nearly any major illness or
injury. It can also be caused by substance (drug) and alcohol use.
Choking on an object can result in unconsciousness as well.
• Brief unconsciousness (or fainting) is often a result from
dehydration, low blood sugar, or temporary low blood pressure. It
can also be caused by serious heart or nervous system problems. A
doctor will determine if the affected person needs tests to
diagnose their fainting.
• Other causes of fainting include straining during a bowel
movement or urination, very hard cough, very fast breathing
(hyperventilating), or vasovagal syncope.
SIGNS AND SYMPTOMS(CLINICAL MANIFESTATION)
• The person will be unresponsive (does not respond to activity,
touch, sound, or other stimulation)
• Makes no purposeful movements
• Abnormal pupil reactions
• Does not respond to questions or to touch
• Drowsiness
• Inability to speak or move parts of his or her body
• Loss of bowel or bladder control (incontinence)
• Stupor
• Respiratory changes (Cheyne Stokes Respirations,
hyperventilation)
 SIGNS AND SYMPTOMS(CLINICAL MANIFESTATION)CONTD
Symptoms that may indicate that unconsciousness is
about to occur include:
• sudden inability to respond.
• slurred speech.
• a rapid heart rate.
• confusion.
• dizziness or lightheadedness.
SIGNS AND SYMPTOMS(CLINICAL MANIFESTATION) CONTD
• Symptoms
• The person will be unresponsive (does not respond to activity, touch, sound,
or other stimulation).
• The following symptoms may occur after a person has been unconscious:
• Amnesia for (not remembering) events before, during, and even after the
period of unconsciousness
• Confusion
• Drowsiness
• Headache
• Inability to speak or move parts of the body (stroke symptoms)
• Lightheadedness
SIGNS AND SYMPTOMS(CLINICAL MANIFESTATION) CONTD
• Loss of bowel or bladder control (incontinence)
• Rapid heartbeat (palpitations)
• Slow heartbeat
• Stupor (severe confusion and weakness)
• If the person is unconscious from choking, symptoms may include:
• Inability to speak
• Difficulty breathing
• Noisy breathing or high-pitched sounds while inhaling
• Weak, ineffective coughing
• Bluish skin color
• Being asleep is not the same as being unconscious. A sleeping person will respond
to loud noises or gentle shaking. An unconscious person will not .
Four broad causes of unconsciousness
• The causes of unconsciousness can be
classified into four broad groups: low
brain oxygen levels heart and
circulation problems (e.g. fainting,
abnormal heart rhythms) metabolic
problems (e.g. overdose, intoxication,
low blood sugar) brain problems (e.g.
head injury, stroke, tumour, epilepsy).
FIRST AID MANAGEMENT

When a patient notices any of the signs and

symptoms of unconsciousness. He should be
advised to:
• lie down racing his legs in the air.
• lie down, sit down and put his head between
your knees
FIRST AID MANAGEMENT CONTD
• Position the person on the back
• .Prop up the patient's legs or raise the foot of the
bed- about 12 inches (30 centimeters). Loosen
belts, collars or other tight clothing. To reduce the
chance of fainting again, don't get the person up
too fast. If the person doesn't regain consciousness
within one minute, call 911 or your local
emergency number.
FIRST AID MANAGEMENT CONTD
• Ensure patient airway is Clear
• Note any alteration in the state of unconsciousness
either improving or deteriorating.
• Note if patient unresponsive to breathing or gasping
• Activate emergency response and get defibrillator
• Check Vital signs
• Start CPR
MEDICAL-SURGICAL MANAGEMENT
• Goal: Preserve brain function, prevent additional
brain injury, maintain supply of Oxygen and glucose
to brain, maintain patient airway way and enhance
breathing
• SURGICAL
• maintain airway, put patient in dorsal position, Give
analgesic for pain, do V/S, provide for administration
of i/v fluid, pass cathether, Anticonvulsant therapy
MEDICAL MANAGEMENT
• 1. Obtain and maintain a patent airway.
• 2. Orally or nasally intubated, or a tracheostomy may
be performed.
• 3. a mechanical ventilator is used to maintain
adequate oxygenation and ventilation.
• 4. The circulatory status (blood pressure, heart rate)
is monitored to ensure adequate perfusion to the body
and brain.
Medical management Contd
• 5. An intravenous (IV) catheter is inserted to provide
access for IV fluids and medications.
• 6. Neurologic care focuses on the specific neurologic
pathology, if known.
• 7. Nutritional support, via a feeding tube or a
gastrostomy tube.
• 8. Other medical interventions are aimed at
pharmacologic management and prevention of
complications.
• 9.Surgery Craniotomy • Cranioplasty • Burr-hole
if necessary
NURSING MANAGEMENT
• Nursing Assessment
• Nurses frequently need to monitor the conscious level as
impairments may complicate the existing condition and may
cause complications and further deterioration.
• GLASGOW COMA SCALE.
• The Glasgow Coma Scale (GCS) A neurological scale – Gives a
reliable, objective record of the level of consciousness (LOC) of
a person, for initial as well as continuing assessment. The nurse
observes and describes three aspects of the patients behavior:
• Eye opening response
• Verbal response
• Motor response
NURSING MANAGEMENT CONTD
• Physical Assessment
• Voluntary movement – Strength and asymmetry in the
upper extremities
• Deep tendon Reflexes – biceps, triceps and patella
• Posture – Decerebrating and Decorticating
• Pupillary light reflex (pupil size)
• Corneal blink reflex
• Gag swallowing reflex
NURSING DIAGNOSIS
• Nursing Diagnosis
• Ineffective airway clearance
• Ineffective cerebral tissue perfusion
• Risk for increased ICP
• Imbalanced fluid volume
• Impaired skin integrity
• Self care deficit
• Imbalanced nutrition
• Incontinence : bowel and /or bladder
• Risk for aspiration
• Risk for contractures
• Altered family process
NURSING CARE
• Maintaining a patent airway
• The breath sounds must be assessed every 2 hourly.
• ABG results must be interpreted to determine the degree of
oxygenation provided by the ventilators or oxygen.
• Assess for cough and swallow reflexes
• Use an oral artificial airway to maintain patency,
Tracheostomy or endotracheal intubation and mechanical
ventilation maybe necessary
NURSING CARE
• Preventing Airway Obstruction:
• Position on alternate sides 2-4 hrs to prevent secretions accumulating in the airways on
one side.
• Maintain the neck in a neutral position
• Oro-nasopharyngeal suction equipment may be necessary to aspirate secretions.
• If facial palsy or hemiparalysis is present the affected side must be kept the uppermost.
• Chest percussion and postural drainage may be prescribed to assist in the removal of
tenacious sections.
• Dentures are removed
• Nasal and oral care is provided to keep the upper airway free of accumulated
secretions debris
• Monitoring neurological signs at intervals determined by their condition
• Document these results and compare with previous assessments
NURSING CARE
• Ineffective cerebral tissue perfussion
• Assess the GCS, SPO2 level and ABG of the patient.
• Monitor the vital signs of the patients (increased temperature)
• Head elevation of 30 degrees maintained to facilitate venous drainage. •
Reduce agitation .(Sedation.)
• Reduce cerebral edema (Corticosteroids, osmotic or loop diuretics.) Generally
peaks within 72 hrs after trauma and subsides gradually.
• Schedule care so that harsh activity [suctioning bathing, turning] are not
grouped together, with breaks between care for recovery.
• Administer laxatives, antitussives and antiemetics as ordered
• Manage temperature with antipyretics and cooling measures. Prevent seizure
with ordered dilantin.
• Administer mannitol 25-50 g IV bolus if ICP >20, as prescribed
NURSING CARE
• Risk for increased ICP.
• Assess the GCS score, assess signs of increased
ICP(intracranial pressure) .
• Head elevation of 30 degrees to facilitate venous drainage
and prevent aspiration.
• Pre-oxygenation before suctioning should be mandatory ,
and each pass of the catheter limited to 10 seconds, with
appropriate sedation to limit the rise in ICP.
• Insertion of an oral airway to suction the secretions
NURSING CARE
• Risk for increased ICP.
• As fluid intake is restricted and glucose is avoided to control cerebral edema.
• Signs of increased ICP :
• Restlessness
• headache
• pupillary changes: ASSESS every hourly
• respiratory irregularity
• widening pulse pressure, hypertension and bradycardia. (CUSHING’S
TRIAD)
• NORMAL ICP : 5 TO 15 mm of Hg
NURSING CARE
• Imbalanced fluid and electrolyte
• Intake-Output chart should be meticulously maintained.
• Daily weight should be taken.
• Assess and document symptoms that may indicate fluid
volume overload or deficit.
• Diuretics may be prescribed to correct fluid overload and
reduce oedema.
• Overhydration and intravenous fluids with glucose are
always avoided in comatose patients as cerebral oedema
may follow.
NURSING CARE
Impaired skin integrity
• The nurse should provide intervention for all self-care needs including bathing, hair
care, skin and nail care.
• Frequent back care should be given.
• Comfort devices should be used.
• Positions should be changed.
• Special mattresses or airbeds to be used.
• Adequate nutritional and hydration status should be maintained.
• Patient’s nails should be kept trimmed.
• Keep the lips coated with a water-soluble lubricant to prevent encrustation, drying,
cracking. Inspect the paralyzed cheek.
• Nasal passages may get occluded so they may be cleaned with a cotton tipped
applicator.
 NURSING CARE
• Proper positioning
• Lateral position on a pillow to maintain head in a neutral position
• Upper arm positioned on a pillow to maintain shoulder alignment
• Upper leg supported on a pillow to maintain alignment of the hip
• Change position to lie on alternate sides every 2-4hrs
• For hemiplegia – position on the affected side for brief periods,
taking care to prevent injury to soft tissue and nerves, oedema or
disruption of the blood supply
• Maintaining correct positioning enables secretions to drain from
the client’s mouth, the tongue does not obstruct the airway and
postural deformities are prevented.
NURSING CARE
• Self care deficit
• Attending to the hygiene needs of the unconscious patient
should never become ritualistic, and despite the patient's
perceived lack of awareness, dignity should not be compromised.
• Involving the family in self care needs.
• Incontinence, perspiration, poor nutrition, obesity and old age
also contribute to the formation of pressure ulcers.
• Care should be taken to examine the skin properly, noting any
areas which are red, dry or broken.
• Fingernails and toenails also need to be assessed Chronic
illnesses, such as diabetes needs more attention
NURSING CARE
• Bathing:
• Minimum two nurses should bathe an unconscious patient as turning the patient
may block the airway.
• Proper assessment of the condition of the skin must be done when giving a bed bath.
• Hair care should not be neglected.
Oral Hygiene:
• A chlorhexidine based solution is used.
• Airway should be removed when providing oral care. It should be cleaned and then
reinserted.
• If the patient has an endotracheal tube the tube should be fixed alternately on each
side.
• Minimum of four-hourly oral care to reduce the potential of infection from micro-
organisms.
• Also not to damage the gingiva by using excessive force
NURSING CARE
Eye Care:
• In assessing the eyes, observe for signs of irritation, corneal drying,
abrasions and edema.
• Gentle cleaning with gauze and 0.9% sodium chloride should be
sufficient to prevent infection.
• Artificial tears can also be applied as drops to help moisten the eyes.
Corneal damage can result if the eyes remain open for a longer time.
• Tape can be used to close the eyes.
• Nasal Care: -Cleaning of the nasal mucosa with gauze and water -
Nasogastric tube placement damage to the nasal mucosa
Ear Care: -Clean around the aural canal, although care must be
taken not to push anything inside the ear.
NURSING CARE
• Imbalanced nutrition
• Diet prescribed nutrition based on individuals requirements specifically to
meet energy needs, tissue repair, replace fluid loss to maintain basic life
functions
• METHODS • TPN (Total parenteral nutrition)
• Enteral feeding via Nasogastric, nasojejunal OR PEG tube
• Intravenous fluids are administered for comatose patients.
• As fluid intake is restricted and glucose is avoided to control cerebral oedema
and intravenous infusion cannot be considered as a nutritional support.
• Total parentral nutrition, i.e. TPN is considered for prolonged
unconsciousness.
• Naso-gastric feedings are given
NURSING CARE
• Impaired bowel/ bladder functions
• Assess for constipation and bladder distention.
• Auscultate bowel sounds.
• Stool softeners or laxatives may be given.
• Bladder catheterization may be done.
• Meticulous catheter care must be provided under aseptic techniques.
• Monitor the urine output and color.
• Initiate bladder training as soon as consciousness has regained
NURSING CARE
Sensory stimulation
• Brain needs sensory input
• Widely believed that hearing is the last sense to go
• Talk, explain to the patient what is going on
• Upon waking many clients remember….. and will accurately recall
events and processes that happened while they were “sleeping”.
(unconscious)
• Some have reported they longed for someone to talk to them and not
about them.
• Encourage stimulation by: • Massage • Combing/washing hair •
Playing music/radio/CD/TV • Reading a book • Bring in perfumed
flowers • Update them with family news Altered family process •
Include the family members in patient’s car
NURSING CARE
Altered family process
• Include the family members in patient’s care.
• Communicate frequently with the family members.
• The family members should be allowed to stay with the patient
when and where it is possible.
• Use external support systems like professional counsellors,
religious clergy etc.
• Clarifications and questions should be encouraged.
PREVENTION OF UNCONSCIOUSNESS
• Avoid situations where the blood sugar level gets too low.
• Avoid standing in one place too long without moving, especially if patient is prone to
fainting.
• Get enough fluid, particularly in warm weather.
• If patient feel like he is about to faint, he should lie down or sit with his head bent forward
between his knees.
• If patient is having a medical condition, such as diabetes, he should always wear a medical
alert necklace or bracelet.
• Patient should be discouraged of spending too much time in hot places
• For people feeling lightheaded, nauseous, or overly sweaty, they recommend lying down
and elevating the legs.
• Generally, it is also helpful if patient stay hydrated and consume more salt.
• Some people need medication or a pacemaker to prevent a loss of consciousness.
• Preventing a loss of consciousness can also involve getting a diagnosis and treatment for an
underlying issue.
• Generally, having a healthy diet, getting enough exercise, attending screenings and
scheduled visits, and receiving prompt medical treatment for any health concerns can help
people prevent causes of unconsciousness.
COMPLICATION OF UNCONSCIOUSNESS
• Patients lose their protective reflexes and sensory
responses
• Vulnerable to aspiration
• Anoxic brain injuries
• Airway obstruction
• Skin ulcerations
DO NOT DO THESE TO UNCONSCIOUS PATIENT

• DO NOT give an unconscious patient any food or

drink.
• DO NOT leave the patient alone, else, restrain the
patient
• DO NOT place a pillow under the head of an
unconscious patient.
• DO NOT slap an unconscious patient 's face or splash
water on their face to try to revive them.
References
• American Red Cross. First Aid/CPR/AED Participant's Manual. 2nd ed. Dallas, TX: American
Red Cross; 2016. www.pdfdrive.com/american-red-cross-first-aidcpraed-d128296673.html.
Accessed February 20, 2023.
• Kleinman ME, Goldberger ZD, Rea T, et al. 2017 American Heart Association focused update on
adult basic life support and cardiopulmonary resuscitation quality: an update to the American
Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation. 2018;137(1):e7-e13. PMID: 29114008 pubmed.ncbi.nlm.nih.gov/29114008/.
• Lei C, Smith C. Depressed consciousness and coma. In: Walls RM, ed. Rosen's Emergency
Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 12.
• Papa L, Meurer WJ. Stroke. In: Walls RM, ed. Rosen's Emergency Medicine: Concepts and
Clinical Practice. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 87.
• Probst M. Syncope. In: Walls RM, ed. Rosen's Emergency
• Geraghty M. Nursing the unconscious patient. Nurs Stand. 2005 Sep 14-20;20(1):54-64; quiz 66.