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UNCONSCIOUNESS
INTRODUCTION OF HUMAN BRAIN:

The human brain is made up of three basic parts: the cerebrum, the cerebellum, and the
brainstem. The cerebrum is the largest part of the brain and makes up about 85% of the
brain's total weight. It's divided into two hemispheres, the cerebral hemispheres, one on each
side of the head. The cerebrum is where all of the body's most complicated mental and
sensory functions are controlled—intelligence, reasoning, memory, emotions, vision, the
ability to feel, etc.

The cerebellum is a smaller part of the brain that lies behind the cerebrum. It plays an
essential role in coordination, posture and balance. The brainstem is the stemlike part of the
brain that connects the cerebral hemispheres to the spinal cord and is responsible for
controlling many basic bodily functions, such as breathing, blood pressure, and being awake
and alert.

CONSCIOUSNESS:

It is an alert cognitive state in which you are aware of self and environment, with
appropriate responsiveness to stimuli. As with most mental processes that occur in the brain,
the biology of consciousness—also called arousal—is very complicated and not well
understood. The full consciouness depends upon interaction between the cerebral cortex and
the central reticular formation (reticular activating system), is a subcortical mass of relatively
undifferentiated neurons located throughout the central portion of the brain stem. Impulses
are transmitted from the central retricular formation to the cortex and thus producing a state
of alertness.

One of the important physiological processes that keeps a person

conscious is the transfer, or neurotransmission, of chemical signals from the brainstem to the
cerebral hemispheres of the brain. This continuous neurotransmission needs to be happening
in order for a person to be aware of their environment. Abnormalities that interrupt it can lead
to coma or other states of unconsciousness.

An altered level of consciousness (LOC) is apparent in the patient who is not

oriented, does not follow commands, or needs persistent stimuli to achieve a state of
alertness. Level of consciousness is gauged on a continuum with a normal state of alertness
and full cognition (consciousness) on one end and coma on the other end. Coma is a clinical
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state of unconsciousness in which the patient is unaware of self or the environment for
prolonged periods (days to months even years).

CONTINUM OF CONSCIOUSNESS:

Consciousness

Confused

lethargic

Obtunded

Stuporous

Camotose

TERMINOLOGY OF LEVELS OF CONSCIOUSNESS:

1. Alert/Consciousness: attends to the environment; responds appropriately to

commands and questions with minimal stimulation.
2. Confused: disoriented to surroundings; may have impared judgement, may need cues
to respond to commands.
3. Lethargic: drowsy, needs gental verbal or touch stimulation to initiate a response.
4. Obtunded: responds slowly to external stimulation; needs repeated stimulation to
maintain attention and response to the environment.
5. Stuporous: responds only minimally with vigorous stimulation; may only mutter as a
verbal response.
6. Comatose: no observable response to any external stimuli.
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INTRODUCTION OF UNCONSCIOUSNESS:

Interruption of impulses from the reticular activating system, or failure of the cerebral cortical
neurons to respond to incoming impulses, deprivation of oxygen to neurons for even few
seconds decreases neuronal metabolism, produces a loss of consciousness.

Unconsciousness is a term used widely to denote a state of unresponsiveness of an individual

to an externalstimuli. It can be a transient feature or it can be with no observable response to
even a deepstimuli which is called coma.

DEFINITION OF UNCONSCIOUSNESS:

 Unconsciousness can be defined as a state in which the cerebral functions are

decreased, the individual is unresponsive to sensory stimuli.
 The part of mind not readily accessible to conscious awareness but whose existence
may be manifested in symptom formation, in dreams or under the infulence of drugs.

CAUSES:

 Structural causes:
1. Trauma
2. Brain stem tumor
3. Vascular disease
4. Infections
5. Neoplasms

 Metabolic causes:
1. Systemic metabolic derangements (hypoglycaemia, hyponatremia)
2. Hypoxic encephalopathies (severe congestive heart failure, pronglonged
hypertension, COPD)
3. Toxicity (heavy metals, carbon monoxide and alchol)
4. Extremes of body temperature (heatstroke, hypothermia)
5. Deficiency states
6. Seizures

PATHOPHYSIOLOGY:
 Normally, consciousness is controlled by RAS & its integrated components

RAS begins in medulla as Reticular Formation

RF converts to RAS which is located in mid brain

Connects to hypothalamus

Connects to thalamus

Connects to cortex
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 To produce coma, a disorder must affect both the cerebral hemispheres and the
brain stem itself.
 Disorders affect these areas in one of the three ways:
1) Direct compression or destruction of structures responsible for
Consciousness .e.g. tumor in brain stem.
2) Decrease in the availability of oxygen or glucose. e.g. hypoxia &
ischemia.
3) Toxic effects of substances on structures of RAS. e.g. toxic waste from
liver or kidney disease, bacterial invasion from meningitis

Due to etiological factors (brain tumour)

Disturbance in Cerebrospinal fluid

No space in skull for expansion of brain

Increased pressure on brain

Disturbed cerebral function

Alteration in the level of consciousness

Vital functions of the body get disturbed

Patient goes in coma

CLINICAL MANIFESTATIONS:
1. Decreased wakefulness
2. Decreased attention to surrounding environment
3. Confusion
4. Disorientation
5. Agitation
6. Poor memory
7. Decreased ability to carry out activities of daily living
8. Decreased mobility
9. Incontinence
10. Irritability
11. Unwillingness to cooperate
12. Headche
13. Disturbed vital functions

 Sensory –perceptual alterations

1. Hallucination
2. Delusions
3. Illusions
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DIAGNOSTIC EVALUATION:
 History: Investigations looking for any infection, like: diabetes, over dosage of
drugs, toxicity.
 Structural test:
1. Skull X-ray films
2. Electroencephalogram
3. Computerized tomography of the head
4. Cerebral angiography
5. Magnetic resonance imaging
6. Transcrainal doppler studies
7. Lumber puncture

 Metabolic test:
1. Complete blood count
2. Blood glucose
3. Serum electrolytes
4. Sreum creatinine and blood urea nitrogen(BUN)
5. Liver function studies
6. Cardiac enzymes
7. Arterial blood gases

COMPLICATIONS:
1. Respiratory distress or failure
2. Pneumonia
3. Pressure ulcer
4. Aspiration
5. Deep vein thrombosis
6. Contractures
7. Urinary retention or incontinence
8. Musculoskeletal deterioration

MEDICAL MANAGEMENT:
The goal of medical management is
 To preserve the brain functions.
 To maintain the patent airway

1. The patient may be orally or nasally intubated or tracheostomy may be performed.

2. Mechanical ventilator is used to maintain adequate oxygenation.
3. Intravenous catheter is inserted to provide fluids and intravenous medications.
4. Circulatory status is monitored to ensure the adequate perfusion to the body and brain.
5. Nutritional support is provided through tube feeding or gastrostomy.
6. Antibiotics should be given if infection is suspected.
7. Fluid and electrolyte balance should be maintained.

NURSING MANAGEMENT:

ASSESSMENT OF UNCONSCIOUS PATIENT:

Assessment of the patient with an altered level of consciousness depends upon each patient
circumstances.
 Assess level of responsiveness using the Glasgow Coma Scale.
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Glasgow coma scale is an assessment tool designed to note trends in a clients

response to stimuli in terms of eye opening, verbal response and motor response. GCS
scores range from 3(deep coma) to 15(normal).
Eye opening response spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response oriented 5
Confused 4
Inappropriate words 3
Incomprehensive sounds 2
None 1
Best motor response obeys commands 6
Localizes pain 5
Withdraws 4
Flexion 3
Extension 2
None 1
Total 3 to 15

 Assess facial symmetry and swallowing reflexes, and elicit deep tendon reflexes.
 Assess for decorticate posturing, involving adduction and flexion of upper
extremities, internal rotation of lower extremities and plantar flexion of the feet (arms
flexed, adducted, and internally rotated, and legs in extension).
 Decerebrate posturing , involving extension and outward rotation of upper extremities
and plantar flexion of the feet (extremities extended and reflexes exaggerated)
 Rule out paralysis or stroke as cause of flaccidity.
 Examine respiratory status (cheyne-stroke respiration, hyperventilation), eye
signs(Doll’s eye movement, pupils size, equality, reactions to light) ,
Corneal reflexes
 Assess for neck stiffness, absence of spontaneous neck movement.
 Suspect a toxic or metabolic disorder if patient is comatose

NURSING DIAGNOSIS:
Based on the assessment data, the major nursing diagnosis may include the following:
1. Ineffective cerebral perfusion related altered level of consciouness as manifested by
confusion and disorientation
2. Ineffective airway clearance related to inability to clear respiratory secreations as
evidenced by unconsciousness
3. Risk of injury related to decreased level of consciousness as manifested by cogitative
impairment
4. Deficient fluid volume related to unconsciousness as manifested by inability to take in
fluids by mouth
5. Impaired oral mucous membrane related to unconsciousness as manifested by mouth-
breathing, absences of pharyngeal reflex, and inability to ingest fluids
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6. Risk of impaired skin integrity related to altered level of consciousness as manifested

by immobility or restlessness
7. Impaired tissue integrity of cornea related to diminished or absent corneal reflex
8. Ineffective thermoregulation related to damaged to hypothalamic centre
9. Impaired urinary elimination related to impairment in neurologic sensing and control

GOALS AND OBJECTIVES:

1. Optimizing cerebral tissue perfusion
2. Maintaining the airway
3. Protecting the patient
4. Maintaining the fluid balance and managing the nutritional needs
5. Providing mouth care
6. Maintaining the skin and joint integrity
7. Preserving the corneal integrity
8. Achieving thermoregulation
9. Preventing urinary retention

NURSING INTERVENTIONS:
 Optimizing cerebral tissue perfusion
1. The patient is closely monitored for neurologic deterioration.
2. Blood pressure, pulse, level of responsiveness, pupillary responses and motor
functions are checked.
3. Respiratory status is monitored.
4. Any changes are reported.

 Maintaining the airway

1. Establish an adequate airway, and ensure ventilation.
2. Position patient in a lateral or semi-prone position; do not allow patient to remain on
back
3. Remove the secretions to reduce the danger of aspiration.
4. Elevate head of bed to a 30-degree angle to prevent aspiration.
5. Provide frequent suctioning and oral hygiene.
6. Ascultate chest every 8 hours for crackles wheezes, or absence of breath sounds.
7. Promote pulmonary hygiene with chest physiotherapy and postural drainage.

 Protecting the patient

1. Provide padded side rails for protection and raised all the time.
2. Care should be taken to prevent injury from invasive lines and equipments.
3. Protect the patient’s dignity and privacy
4. Avoid unnecessary restraining the patient.
5. Not speaking negative about the patient’s condition or prognosis.

 Maintaining the fluid balance and managing the nutritional needs

1. Assess for hydration status; examine mucous membrane; assess for skin tissue
turgor.
2. Meet fluid needs by giving required intravenous fluids and then nasogastric or
gastrostmy feeding.
3. Give intravenous fluids and blood transfusions slowly if patient has intracraial
condition.
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4. Never give oral fluids to the patient who cannot swallow; insert feeding tube for
adminstration of enteral feedings.

 Providing mouth care

1. Inspect mouth for dryness, inflammation, and crusting.
2. Cleanse and rinse carefully to remove secreations and cursts and keep mucous
membrane moist.
3. A thin coating of petrolatum to lips prevents drying, cracking.
4. Assess sides of mouth and lips for ulceration if patient has an endotracheal tube.
Move tube to opposite side of mouth daily.

 Maintaining the skin and joint integrity

1. Follow a regular schedule of turning and repositioning to prevent ischemic
necrosis over pressure area, and to provide kinesthetic, proprioceptive, and
vestublar stimulation.
2. Give passive exercise of extremities to prevent contractures.
3. Use splint or foam boots to prevent footdrop and eliminate pressure on toes.
4. Keep hip joints and legs in proper alignment with supporting trochanter rolls
5. Position arms in abduction, fingers lightly flexed, and hands in slight supination.

 Preserving corneal integrity

1. Cleanse eye with cotton balls moistened with sterile normal saline to remove
debris and discharge.
2. Instill artificial tears every 2 hours, as prescribed.
3. Use cold compresses as prescribed for periocular edema after cranial surgrey.
4. Use eye patches cautiously because of potential for further abrasions.

 Achieving thermoregulation
1. Adjust environment to promote normal body temperature.
2. Use prescribed measurement to treat hyperthermia: remove bedding, except light
sheet
3. Administering repeated doses of acetaminophen as prescribed.
4. The room temperature may be cooled to 18.3° C (65°F) but avoid shivering.

 Preventing urinary retention

1. Palpate or scan bladder at intervals to detect urinary retention.
2. Insert indewlling catheter if there are signs of urinary retension.
3. Use external catheter for male patients and absorbent pads for female patients if
they can urinate spontaneously.
4. Monitor frequently for skin irritation and breakdown and implement appropriate
skin care
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BIBLIOGRAPHY

‘Phipps’, ‘Medical Surgical Nursing Health & Illness Prespectives’, Mosby

publishers, Edition 7th , page no. 1317-1328
‘Suddarth’s and Brunner’, ‘Textbook of Medical-Surgical Nursing’, Published
Lippincot Villians & Wilkins, Edition 10th , Page no. 1850-1856
‘Williams S. Linda & Hooper D. Paula’, ‘Understanding Medical Surgical Nursing’,
Edition 2th , Published by FA Davis Company, Page no. 814-815
‘Watson’, Medical Surgical Nursing and Related Physiology’, Edition 2th, Published
by WB Saunder Company, page no. 156-163.
‘Graicy KF & Prema TP’, ‘Essentials of Neurological and Neurosurgical
Nursing’,Published by Jaypee Brothers, edition 2nd (2006), Page no.67-70.
http://www.neurologychannel.com/coma/brain-anatomy.shtml
hptt://wwwreceus.com/unconciousness
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