1. Unconsciousness can be brief, lasting for a few seconds to hours or so, sustained, lasting for a few hours or longer. Coma is state of sustained unconsciousness in which the patient: -Does not respond to verbal stimuli. -Does not move voluntarily. -May have altered respiratory patterns. -Does not blink. -Joyce M Black

2. An altered level of consciousness is apparent in the patient who is not oriented, does not follow commands or needs persistent stimuli to achieve a state of alertness. Coma a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods[days to months of even years] -Smeltzer Suzanne. C. 3. Akinetic mutism Altered level of consciousness Brain death Coma Decerebration Dcortication Epilepsy Peristent vegetative state 4. Altertness Drowsiness Stupor Somnolence Sopor Coma Semicoma 5. Hypoxia a)Respiratory insufficiency b)Shock Metabolic [chemical brain depressants]: a) Extrinsic: b) Intrinsic c) Hypoxic encephalopathys d) Extremes of body temperature e) Deficiency states 6. Brain pathologic conditions: a) Trauma b) Seizures c) Tumors d) Infections 7. EYE MANIFESTATION AND RESPIRATORY PATTERNS: 8. Physical examination: -Vital signs: Temperature, pulse, respiration. -Height and weight[approximate]. -Integumentary system. (1)Observe for skin. (2)Observe for nails. (3)Head. (4)Eyes and vision. (5)Ears and hearing. (6)Nose and sinuses. (7)Mouth. 9. (8)Neck. (9)Breast. (10)Thorax and lungs. (11)Cardio vascular. (12)G. I. system. (13)Genitor urinary system. (14)Genitor reproductive. (15)Musculo skeletal system. (16)Nervous system. (17)Hematologic. 10. Examinaton of neck and cervical spine Examination of cranial nerves Reflexes-superficial reflex,deep reflex Discrimination- stercognosis,graphesthesia Motor function test - muscle tone,muscle strengh grading,rapid alternating movement, PIN POINT TEST, ROMBERG TEST 11. CT ,MRI Lumbar puncture Electroencephalography Laboratory test Tests for abnormal ocular reflexes: -Oculocephalic response -Oculovestibular response 12. Skull x-ray film Cerebral angiogram Evoked potentials 13. -Metabolic test: -Complete blood count -Urinalysis -Electrolytes[includes glucose, blood urea nitrogen, creatinine] -Liver function studies -Cardiac enzymes -Serum osmolarity -Arterial blood gas -Toxicology screens for drugs of abuse 14. Goals: to preserve brain function and to prevent additional brain injury. Determine level of involvement: once airway, breathing, and circulation are established, initial assessment of the comatose patient includes evaluation of the following factors: -Level of consciousness, though observation of response to stimuli. -Presence or absence of localizing neurologic manifestation. -Pupils size and reactivity to light. 15. Reverse common causes of coma: -After a blood specimen is drawn for testing, intravenous glucose is given to reverse potential insulin reaction. -Who appear malnourished, wernickes[alcohol abuse], can be given thiamine For prevention. -Repetitive seizures: iv diazepam or lorazepam to stop the seizures. -Coma from drug overdose: opioid overdose may be reversed with naloxone. 16. -The patients altered level of conscious is a space-occupying lesion, surgical removal of the mass may improve the patients condition. -Burr holes may be created to drain a subdural hematoma. -A craniotomy may be performed to remove a tumor, abscess, or intracerebral hematoma. -A ventricular catheter or shunt may be place to relive hydrocephalus. 17. -Assessment: -History collection, -Physical examination -Neurological examination -Alertness is measured by the patients ability to open the eye spontaneously or to a stimuli -Motor response includes spontaneous, purposeful movement 18. -Determining the patients orientation to time, person, and place assess verbal response. -Verbal response cannot be evaluated when the patient is intubated or has a tracheotomy, and this should be clearly documented. -Alertness is measured by the patients ability to open the eyes spontaneously or to a stimulus. -Patients with severe neurologic dysfunction cannot do this. -Posturing may be decorticate or decelerate -The most severe neurologic impairment results in flaccidity. 19. RESPIRATORY FAILURE PNEUMONIA PRESSURE ULCER. ASPIRATION - 20. 1,Black Joyce. M., Hawks Jane Hokanson, Medical surgical Nursing, Clinical Management for positive outcomes, 2007, 7th ed, Saunders, St. Louis, Pp: 2051-2071 2,Kinney Marguerite Roders, et. Al., AACN, Clinical Reference for Critical Care Nursing, 1998, 4th ed, mosby, St. Louis, Pp: 672-675. 3,Bradley Walter. G., et. Al., Neurology in 21. 4,Kandel ekric. R, et. al., Principles of Neural Science, 2000, 4th ed, Mc Graw-Hill, New York, Pp: 901-908 5,Lewis Sharon. I., et.al., Medical Surgical Nursing, Assessment and Management of clinical Problems, 2007, 7th ed,Elsevier, ST. Louis, Pp:1470-1471, 1478- 1480. 6, Lippincott, Manual of Nursing practice, 2006, 8th ed, Lippincott, Philadelphia, Pp: 475-478 7,Smeltzer Suzanne. C., Bare Brenda, Burnner and Suddarths , Text book of Medical Surgical Nursing, 2004, 10th ed, Lippincott, Philadelphia, Pp: 1850- 22. Based on the assessment data, the major nursing diagnoses may include the following: (1)Ineffective airway clearance related to altered level of consciousness -Outcome identification: patient maintains the clear airway Assess the general condition of the patient. Assess for the airway clearance for the patient. 23. (2)Risk of injury related to decreased level of consciousness -Outcome identification: patient will be prevented from injuries Assess the general condition of the patient Assess the patient for the risk for the injury (3)Deficient fluid volume related to inability to take in fluids by mouth -Outcome identification: Patient maintains adequate fluid status Assess for the general condition of patient Check for the hydration status 24. (4)Self care deficit [complete]related to decreased level of conscious. (5)Impaired oral mucous membranes related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake. (6)Risk for impaired skin integrity related to immobilization (7)Impaired tissue integrity of cornea related to diminished absent corneal reflex. (8)Ineffective thermoregulation related to damage to hypothalamic center. 25. (9)Impaired verbal communication related to altered level of conscious. (10)Impaired urinary elimination related to impaired in neurologic sensing and control. (11)Bowel incontinence related to impairment in neurological sensing and control also related to transitions in nutritional delivery methods. (12)Disturbed sensory perception related to neurological impairment. 26. (13)Interrupted family process related to health crisis. -Outcome identification: Patient relatives is able cope up with the patient long term duration in the hospitals -Collaborative problems: -Respiratory distress or failure -Pneumonia -Aspiration -Pressure ulcer -Deep vein thrombosis 27. Most of the time, a wait-and-see approach was taken. Today the family and the health care team should have some idea of the probable eventual outcome for the patient. Coma after injury has a statistically better outcome than coma associated with medical illness. About 50% of patients in coma from head injury die, many instantly. 28. The central nervous system contains a vast network of neuron controlling the bodys vital functions. Yet this system is vulnerable, and its optimal function depends on several key factors. The neurologic system relies on its own structural integrity for support and homeostasis. As the brain tissue expands in the inflexible cranium, ICP rises and cerebral perfusion is impaired. Further expansion places pressure on viral centers, which can cause permanent neurologic deficits or lead to brain death. 29. 8,William Linda. S, Hopper Paula. D., Understanding Medical Surgical Nursing, 2008, 3rd, Jaypee Brothers, New Delhi, Pp: 282-284 9,Long Barbara. C., et. al., Medical Surgical Nursing, A Nursing Process Approach, 1993, 3rd ed, Mosby St. Louis, Pp: 1220-1227, 1541. 10,Phipps Wilma. P., et, al., Medical Surgical Nursing, Health and Illness Perspective, 2003, 7th ed, Mosby, St. Louis, Pp: 1317-1325 11,Morhr. J. P., and Gautier. J.C., Guide to Clinical Neurology, 1995, 1st ed, Churchill Living stone, New York, Pp: 221-235 30. Kristen Mc Donald, AJN, The singing the Broke the Coma, 2007, April, 107, 4, Pg: 72 31. http://www.redorbit.com http://www.lifeissues.net http://dhealth solution.blogspot.com http://www.ncl.ac.uk/nsa/coma.html http://faculty.ksu.edu 32. THE END