A terminally ill patients who is unconscious

Submitted to:
Mrs. Mamta Toppo
Associate professor,
College of nursing
RIMS, Ranchi
Submitted by:
Ambika Mehta
Roll no- 01
Basic B.sc Nursing 3rd
year
College of nursing
RIMS, Ranchi

Unconsciousness is a state which occurs when the
ability to maintain an awareness of self and
environment is lost. It involves a complete lack of
responsiveness to people and other environmental
stimuli.
Coma is a deepest state of unconsciousness .
Unconsciousness is a symptom rather than a
disease.

Consciousness
Consciousness is the
awareness of
environmental and
cognitive events such as
the sights and sounds of
the world as well as of
one’s memories, thoughts,
feelings and bodily
sensations.
Unconsciousness
Unconsciousness is a
state in which a patient is
totally unaware of both
self and external
surroundings, and
unable to respond
meaningfully to external
stimuli.

1. Alertness, oriented: Opens eyes spontaneously,
responds to stimuli appropriately.
2. Lethargy, Sleepy: Slow to respond but appropriate
response, opens eyes to stimuli
3. Stupor: Never fully awake, confused, unclear
conversations
4. Semi-coma stage: Moves in response to painful stimuli,
pupillary reflex present.
5. Coma: Unresponsive except to severe pain, no
protective reflexes, fixed pupils, no voluntary movement.

The person will be unresponsive ( does not respond to
activity, touch, sound or other stimulation)
Makes no purposeful movements
Drowsiness
Inability to speak or move parts of his or her body
Loss of bowel or bladder control
Respiratory changes ( cheyne stokes respiration, cluster
breathing, ataxic breathing, hyperventilation)
Abnormal pupil reactions

History ( Medical, Surgical)
Pattern of respiration
Pupil ( size, reaction)
Facial symmetry
Swallowing reflex
Limb movement and tendon reflex
Level of consciousness ( Glasgow coma scale)

Highest score is 15/15 – Good orientation
Lowest score is 3/15 - Deep coma. Considered brain dead if
client dependant on a ventilator.
GCS ≤ 8 – Severe brain injury
GCS – 9 to 12 – moderate brain injury
GCS ≥ 13 – Mild brain injury

ABCDE Management
A- Airway:
Assess patency of airway and imminent threats.
Check for upper airway obstruction.
Look for facial fractures and injuries to the neck.
Remove foreign body by direct vision and suction secretion.
An airway adjunct may be required to maintain patency.
Administer high concentrations of inspired oxygen.

B- Breathing:
Look for symmetrical expansion and respiratory rate.
Administer supplemental oxygen.
C-Circulation:
Identify pulses and assess rate, rhythum and check blood
pressure.
Intravenous access with administration IV crystalloid solution.

D-Disability:
Check the patients pupillary response.
Assess the posture
Assess the Glasgow coma scale
Check for any sign of raised intracranial pressure.
E- Exposure/Environmental control:
The aim is to expose the patient so that an adequate complete
examination can be performed.

Nursing Diagnosis:
1. Ineffective airway clearence related to upper airway
obstruction.
2. Ineffective cerebral tissue perfusion related to effects of
increased intracranial pressure.
3. Risk for impaired tissue integrity related to absence of
corneal blink reflex, dryness of eyes.
4. Risk for injury related to unconscious state.
5. Imbalanced nutrition less than body requirement related
to inability to eat and swallow.

1. Goal: Maintaining a patent airway.
Assess respiratory rate pattern, lung sound, lung
expansion, sign of tissue hypoxia, cyanosis.
Elevate head of bed to 30° or place client in lateral
position.
Suction the mouth, pharynx and trachea as often as
necessary to prevent aspiration of secretions.
Administer humidified oxygen.

2. Goal: Maintains optimum Cerebral perfusion
Assess sign of increased intracranial pressure,
cerebral edema.
Monitor ABG values
Administer osmotic diuretics e.g mannitol
Maintain Paco2 through hyperventilation.
Administer stool softness as prescribed.

3. Goal : Maintains intact corneal tissue integrity.
Assess signs of impaired corneal integrity look for
presence of corneal blink response.
Protect eyes with an eye shield.
Inspect the condition of eyes with a flash light at regular
intervals.
Instill artificial tears as prescribed.
Apply eye patches when indicated.

4. Goal: prevent from injury
Assess risk factors for injury.
Keep side rails up and bed in lowest position
whenever the client is not recieving direct care.
Administer prescribed Antiseizure drugs.
Give adequate support to the limbs and head when
moving or turning the unconscious client.

5. Goal: Maintains optimum nutrition.
Always observe the patient carefully when administering
anything by gavage.
Do not leave the patient carefully when administering
anything by gavage.
Keep accurate records of all intake.
Fluids are maintainef by IV therapy.
Keep accurate records of IV intake and urine output.
Observd the patient for sign of dehydration or fluid
overload.

Pressure sore
Hypostatic pneumonia, pulmonary embolism
Deep vein thrombosis, postural hypotension, thrombo
embolism
Paralytic ilius, constipation
Urinary tract infection
Contracture, osteoporosis, dystrophy
Foot drop
Anxiety, depression

Unconsciousness is an abnormal state resulting from disturbance
of sensory perception to the extent that the patient is not aware of
what is happening around him.
Unconsciousness may occur as the result of traumatic brain injury,
brain hypoxia, severe poisoning with drug that depress the activity
of the central nervous system, severe fatigue, anaesthesia and
other causes.
Nurse play and important role in the care of unconscious patient to
prevent potential complications respiratory ,distress, pneumonia,
aspiration, pressure ulcer, this is achived by: Maintaining patent
airway,protecting the client,maintaining fluid balance and managing
nutritional needs etc.

 Is coma is a last stage of unconsciousness?
 What is the initial step in evaluation of an unconscious patient?
 Is nystagmus is commonly seen in unconscious patient ?
 Is communication is important in care of unconscious patient?
 Is catatonia can cause unconsciousness?
 Is trauma is only cause of unconsciousness?
 What is the emergency nursing care of unconscious patient?
 How to assess the unconscious patient?
 Enlist the levels of unconsciousness?
 Discuss the pathophysiology of unconsciousness?

A terminally ill patients who is unconscious

A terminally ill patients who is unconscious

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