Care of Unconsciousness Patient

CARE OF UNCONSCIOUSNESS PATIENT

Loss of Consciousness is apparent in patient who is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. A person who is unconscious and unable to respond to the spoken words can often hear what is spoken.

Consciousness is a state of being wakeful and aware of self, environment and time

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.

Levels of Unconsciousness

1. Alert :

- Normal consciousness

2. Automatism :

• Aware of surroundings  
• May be unable to remember actions later
• Possible abnormal mood, may show defects of memory and judgement

3. Confusion :

• Loss of ability to speak and think in a logical coherent fashion
• Responds to simple orders
• May be disorientated for time and space

4. Delirium/Acute confusion with agitation :

• Characterised by restlessness and possible violence
• Not capable to rational thought
• May be troublesome and not comply with simple orders

5. Stupor :

• Quite and uncommunicative
• Remains conscious but sits or lies with a glazed expression
• Does not respond to orders
• Bladder and rectal incontinence occur
• More serious than the previous wild stage

6. Semi-coma :

• A twilight stage
• Patients often pass fitfully into unconsciousness
• May be aroused to the stuporosed state by vigorous stimulation

7. Coma :

• Patient deeply unconscious 
• Can not be roused and does not wake up with vigorous stimulation

Causes of Unconsciousness :

• Head Injury
• Skull Fracture
• Asphyxia
• Fainting 
• Extremes of Body Temperature
• Cardiac Arrest
• Blood Loss
• Cerebro vascular Accident
• Epilepsy
• Infantile Convulsions
• Hypoglycemia
• Hyperglycemia
• Drug Overdose
• Hypothermia
• Poisonous Substances and Fumes

Assessment of unconscious patients:

History

Physical assessment

Glasgow coma scale

        Eye opening

                     spontaneous  -4

                     to speech       -3

                     to pain           -2

                     no response   -1

        Verbal response

                      oriented    -5

                      confused   -4

                      inappropriate words  -3

                      incomprehensible sounds-2

                      no response      -1

        Motor response

                      Obeys commands  -6

                      Localizes  -5

                      Withdraws  -4

                      Flexes  -3

                      Extends  -2

                      No response  -1

  TOTAL  SCORE:  3-15

Assessment of LOC

• Evaluation of mental status.
• Cranial nerve functioning.
• Reflexes.
• Motor and sensory functioning.
• Scanning, imaging, tomography, EEG.
• Glasgow coma scale.

Nursing Diagnosis

• Ineffective airway clearance related to altered level of consciousness
• Risk for injury related to decreased level of consciousness.
• Risk for impaired skin integrity related to immobility
• Impaired urinary elimination related to impairment in sensing and control.
• Disturbed sensory perception related to neurologic impairment.
• Interrupted family process related to health crisis.
• Risk for impaired nutritional status.

Management

1. Maintaining patent airway

• Elevating the head end of the bed to 30 degree prevents aspiration.
• Positioning the patient in lateral or semi prone position.
• Suctioning.
• Chest physiotherapy.
• Auscultate in every 8 hours.
• Endo tracheal tube or tracheostomy.

2. Protecting the client

• Padded side rails
• Restrains.
• Take care to avoid any injury.
• Talk with the client in-between the procedures.
• Speak positively to enhance the self esteem and confidence of the patient. 

3.Maintaining fluid balance and managing nutritional needs

• Assess the hydration status.
• More amount of liquid.
• Start IV line.
• Liquid diet.
• NG tube.

4.Maintaining skin integrity

• Regular changing in position. 
• Passive exercises. 
• Back massage.
• Use splints or foam boots to prevent foot drop. 
• Special beds to prevent pressure on bony prominences.

5.Preventing urinary retention

• Palpate for a full bladder. 
• Insert an indwelling catheter.
• Condom catheter for male and absorbent pads for females in case of incontinence. 
• Inducing stimulation to urinate.

6. Providing sensory stimulation

• Provided at proper time to avoid sensory deprivation.
• Effort are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep.
• Maintain the same schedule each day.
• Orient the client to the day, date, and time accordingly.
• Touch and talk.
• Proper communication.
• Always address the client by name, and explain the procedure each time.

7. Family needs

• Family support.
• Educate the needs of client.
• Care to be provided.

8. Potential complications

• Respiratory distress
• Pneumonia
• Aspiration
• Pressure ulcer

Nursing Care of Physically Challenged

NURSING CARE OF PHYSICALLY CHALLENGED

FRACTURES

A fracture is a discontinuity or break in a bone. The five major fracture classifications as follow:

1.      Incomplete: Fracture involves only a portion of the cross-section of the bone. One side breaks; the other usually just bends (greenstick).

2.      Complete: Fracture line involves entire cross-section of the bone, and bone fragments are usually displaced.

3.      Closed: The fracture does not extend through the skin.

4.      Open: Bone fragments extend through the muscle and skin, which is potentially infected.

5.      Pathological: Fracture occurs in diseased bone (such as cancer, osteoporosis), with no or only minimal trauma.

Stable fractures are usually treated with casting. Unstable fractures that are unlikely to reduce may require surgical fixation.

NURSING CARE OF THE PATIENT WITH A PLASTER CAST

Although a patient with an arm or leg cast is much more self-reliant than a patient in a body or spice cast, it is a nursing responsibility to monitor all patients and assist as needed. Nursing management includes the following actions to assess the effectiveness of the cast.

• Check the edges of the cast and all skin areas where the cast edges may cause pressure. If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately.
• Slip your fingers under the cast edges to detect any plaster crumbs or other foreign material.
• Move the skin back and forth gently to stimulate circulation
• Lean down and smell the cast to detect odors indicating tissue damage. A musty or moldy odor at the surface of the cast may be the first indication that necrosis from pressure has developed underneath.
• Check the integrity of the cast by looking for cracks, breaks, and soft spots.
• The casted body part must be examined and assessed frequently in order to prevent complications.
• Assess the casted part by checking the following.
•  Assess circulation by performing the blanching test and comparing the skin temperature and blanching reaction of the affected limb to that of the unaffected limb.
• Assess the presence of sensation in the affected limb by touching exposed areas of skin and instructing the patient to describe what he felt.
• Assess the motor ability of the affected limb by having the patient wiggle his fingers or toes.
• Patient education will do much to prevent complications. Instruct the patient to do the following.
• Avoid resting cast on hard surfaces or sharp edges that may dent the cast and cause pressure areas.
• Never use a pen or other foreign object to "scratch" inside the cast. This may cause skin damage and infection.
• Report any danger signs like pale, cold fingers or toes, tingling, numbness, increased pain, pressure spots, odor, or feeling that the cast has become too tight to the nursing staff immediately
• Report any damage to the cast such as cracks, breaks, or soft spots.
• Never attempt to remove or alter the cast.
• After a leg cast is applied, prevent or alleviate swelling by elevating the extremity above the level of the heart.
• If the patient has an arm cast, instruct him to make and release a tight fist.
• Encourage the patient to wiggle his fingers and toes frequently

NURSING CARE OF PATIENT ON TRACTION

Traction permits pull on the long axis of the fractured bone and overcomes muscle tension/shortening to facilitate alignment and union.

• Maintain position/integrity of traction (e.g., Buck, Russell)
• Ascertain that all clamps are functional.
• Lubricate pulleys and check ropes for fraying. Secure and wrap knots with
  adhesive tape.
• Keep ropes unobstructed with weights hanging free; avoid lifting/releasing weights.
• Position patient so that appropriate pull is maintained on the long axis of the bone.
• Review restrictions imposed by therapy, e.g., not bending at waist/sitting up with Buck traction or not turning below the waist with Russell traction.
• Review follow-up/serial x-rays.
• Administer analgesics as per physician orders.

Pain Management

Pain is a normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus associated with surgery, trauma, and acute illness. It is generally time-limited and is responsive to Opioid therapy, among other therapies.

Definition

The international association for the study of pain (IASP) defined pain as an unpleasant  sensory and emotional experience associated with actual or potential tissue damage or it is described in terms of such damage.

Nature of pain

• Clinical pain is subjective and no objective measures of it exists, the only people who can accurately define their own pain are experiencing that pain.
• Pain is a protective physiological mechanism. E.g.: a person with a sprained ankle avoids bearing full weight on the foot to prevent further injury.
• Pain is a warning that tissue damage has occurred.
• Pain is a leading cause of disability.

Types of pain

There are different ways to define types of pain, which include according to onset, duration, severity, modes of transmission, location, causation and causative forces.

• Onset or time of occurrence. e.g.: postoperative pain.
• Duration. e.g.: chronic pain or acute pain
• Severity or intensity. E.g.: severe, mild or scored (0 to 10 a scale )
• Location or source. e.g.: superficial, deep or central pain
• Causation. E.g.: pain due to receptor stimulation or nerve damage or psychophysiologic pain
• Causative force or agent. E.g.: spontaneous, self inflicted or other pain.

Acute pain

• Recent onset and is most commonly associated with a specific injury.
• It is time limited and has a defined cause and purpose.
• It may be mild, moderate or severe in nature and sudden in onset.
• It occurs after an injury or disease, persists until healing occurs.

Chronic pain

• Is a complex physiological and psychological phenomenon that causes varying degrees of disability in a larger portion.
• It is constant or intermittent in nature that persist over a period of time.
• It is often can not be attributed to a specific cause or injury.
• It may lasts for six months or larger.
• Classified as malignant or non malignant.

Superficial pain

• It occurs when receptors in surface tissues are stimulated.
• Classified into 2 types
• Pain with an abrupt onset and a sharp or stinging quality.
• Pain with a slower onset and burning quality.
• It may be delineated by having the client point to the painful area.
• It is relatively uncomplicated because it is readily localized , that is, which client can indicate exactly where it hurts.

Deep pain

• Deep pain arises from deep tissues.
• It is divided automatically into splanchnic which refers to pain in the viscera and deep somatic referring to pain in deep structures  other than the viscera such as muscle, tendons, joints and periosteum.

Splanchnic pain:

• Viscera pain tends to be diffuse, poorly localized, vague, dull pain.
• Autonomic manifestations such as diarrhea, cramps, sweating, hypertension frequently accompany viscera pain.
• It includes acute appendicitis, cholecystities, inflammation of the biliary and pancreatic tract, gastro duodenal disease, cardiovascular disease, renal and ureteral colic.

Deep somatic pain:

• It is generally diffuse, less localizable than cutaneous pain. somatic structures vary in their sensitivity to pain.
• Highly sensitive structure include tendons, deep fascia, ligaments, joints, bone periosteum, blood vessels and nerve.
• Skeletal muscle is sensitive only in stretching and ischemia.

Localized pain

• It arises directly from the site of the disturbance.

Referred pain

• It is one which is felt in a part of the body which is remote from the actual point of stimulation.
• The impulses usually arise in an organ, but the pain is projected to a surface area of the body.
• E.g.: angina pectoris, the pain originates in the heart muscles, but it may be experienced in the mid-sternal region, the base of the neck and down to the left arm.

Intractable pain

• Persistent, severe pain that cannot be effectively controlled by the usual medication.
• It producing prolonged and intense bombardment of the central nervous system, are very difficult to bear.

Psychogenic pain

• It is experienced when there is no detectable organic lesion.
• It refers to pain that believed primarily due to emotional factors rather than physiologic dysfunction.
• Clients experiencing psychogenic pain have a real pain expereince.

Factors influencing pain

• Situation:
• The situation associated with the pain influence the person’s response to it.
• A person’s responses to pain experienced in a formal crowed situations may differ greatly from the responses were he or she alone or in a hospital.
• Culture:
• It influences how people learn to react to expressing pain.
• People responds to pain in different ways.
• A young girl may be allowed to cry because of pain whereas boys are not allowed to cry in some culture.
• Age:
• It is an important variable that influences pain particularly in children and older adults.
• Young children have difficulty in understanding pain.
• Older people may assign different meanings to that pain, it thought by the elderly as natural manifestation of aging.
• Sex:
• In most cultures boys are expected to show less expression of pain than girls.
• As they grow older men are also expected to express less pain than women.
• Meaning of pain:
• The meaning of a person’s pain is a factor that influence his or her responses to pain.
• For e.g.: pain caused by childbirth may be responded differently from pain caused by surgery.
• A client copes differently with pain depending on its meaning.
• Anxiety:
• When anxiety is high pain is felt greater.
• Emotionally healthy persons are usually able to tolerate moderate or even severe pain than those whole emotions are less stable.
• Fatigue:
• It heightens perceptions of pain.
• This intensifies pain and decreases coping abilities.
• Pain is often experienced less after a restful sleep than at the end of a long day.
• Attention:
• The degree at which a client focuses on pain can influence pain perception.
• Increased attention has been associated with increased pain, whereas distraction has been associated with a diminished pain response.
• Previous experience:
• Each person learns from painful experiences.
• Patient had repeated experience of pain may be better prepared to tolerate or take necessary actions to relieve pain to some extent.
• Coping style
• Family and social support

Assessment of Pain

• Pain assessment is one of the most common and difficult activities a nurse performs.
• Highly subjective.
• Need a good rapport with the person in pain.

Factors to consider in a complete pain assessment are

• The intensity.
• Timing.
• Location.
• Quality.
• Personal meaning.
• Aggravating and alleviating factors.
• Pain behaviors.

Pain Assessment Scales

• Visual Analogue Scale (VAS).
• Faces pain scale

Pain Management Strategies

• Pharmacological
• Non pharmacological measures

Pharmacological Methods

• Main drug forms are
• Balanced anesthesia/analgesia.
• Analgesics.
• Patient controlled analgesia.
• Local anesthetic agents.
• Opioid analgesic agents.

• Most effective when a multi modal approach is used.
• It refers to the use of more than one form of analgesia concurrently.
• Three general categories of analgesia are
• NSAID(non steroidal anti-inflammatory drugs)
• Opioids
• Local anesthetics
• PCA allows the self administration of drugs for chronic pain.
• Mainly used in cancer and POP cases.
• This approach can be used with oral analgesic agents  as well as continuous infusion of opioid drugs.
• Local anesthetics work by blocking nerve conduction when applied directly to the fibers.
• Topical application
• Intraspinal administration

Non Pharmacological Methods

• Cutaneous stimulation and massage.
• Cold and heat therapies.
• Trans Cutaneous Nerve Stimulation (TENS): It is a battery operated device with electrodes, applied to the skin to produce a tingling, vibrating or buzzing sensation in the area of pain. It decreases the pain by stimulating the non pain receptors of the site
• Distraction
• Relaxation techniques
• Guided imagery
• Hypnosis

Pender's Health Promotion Model

The health promotion model (HPM) proposed by Nola J Pender (1982) was designed to be a “complementary counterpart to models of health protection.”

• It defines health as a positive dynamic state not merely the absence of disease. Health promotion is directed at increasing a client’s level of well being.
• The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health.

The model focuses on following three areas:

·         · Individual characteristics and experiences

·         · Behavior-specific cognitions and affect

·         · Behavioral outcomes

The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral specific knowledge and affect have important motivational significance. These variables can be modified through nursing actions. Health promoting behavior is the desired behavioral outcome and is the end point in the HPM. Health promoting behaviors should result in improved health, enhanced functional ability and better quality of life at all stages of development. The final behavioral demand is also influenced by the immediate competing demand and preferences, which can derail an intended health promoting actions.

ASSUMPTIONS

The HPM is based on the following assumptions, which reflect both nursing and behavioral science perspectives:

1.       Individuals seek to actively regulate their own behavior.

2.       Individuals in all their biopsychosocial complexity interact with the environment, progressively transforming the environment and being transformed over time.

3.       Health professionals constitute a part of the interpersonal environment, which exerts influence on persons throughout their life span.

4.       Self-initiated reconfiguration of person-environment interactive patterns is essential for behavior change