Out line:

1. Introduction
2. Define (sleep-consciousness- loss of consciousness- coma-
unconsciousness)
3. Characteristic of coma.
4. Pathophysiology of coma.
5. Level of unconsciousness.
6. Causes of coma.
7. Signs and symptoms of coma.
8. Diagnosis and findings.
9. Treatment and recovery
10. Nursing management and care plan for comatose patient.

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INTRODUCTION
Managing of the critically ill/ unconsciouspatient can be a challenging experience
andit requires a collaborative approach. Howeverone of the key members of the team
is thecritical care nurse because the patient needs the services of the nurse at all
times.

 Unconscious patients have no control overthemselves or their environment and

thus are dependent on the nurse
 Therefore a nurse in critical care unit/Intensive care unit needs to be abreast with
appropriate knowledge and right attitude on how to care for the unconscious
patient.

DEFINITION OF TERMS:
Sleep
Sleep is the state of altered consciousness or partial unconsciousness from which
anindividual can be aroused
Coma:
A coma is a profound or deep state of unconsciousness . People in a state of
coma are alive but unable to move or respond to their environment. Coma may

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 occur as a complication of an underlying illness or as a result of an injury, like a
brain injury.

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.
Characteristics of coma include:

1. No eye-opening
2. Unable to follow instructions
3. No speech or other forms of communication
4. No purposeful movement
Pathophysiology of Coma :
For a patient to maintain consciousness, two important neurological
components must function -:
1. 1st is the cerebral cortex which is the gray matter covering the outer layer of the
brain .
2. Reticular Activating System (RAS), which is located in the brainstemInjury to
either or both of these components coma.

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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 judgment
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:
 Characterized 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
 Cannot be roused and does not wake up with vigorous stimulation

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What is a persistent vegetative state?

A person in a coma may experience some improvement and transition into what is
termed a “vegetative state.” The difference between a coma and a vegetative state
is that a person in a deep coma usually requires hospital care, while a person in a
vegetative state may be released to the family for home care. The individual in
the vegetative state has a lot more lower-brain function (automatic functions like
breathing, heart-rate regulation, and sleep), and a bit more upper brain-stem
function (like eye opening or making sounds) than a person in deep coma.

Causes of Coma:

Comas are caused by an injury to the brain. Brain injury can be due to increased
pressure, bleeding, loss of oxygen, or buildup of toxins. The injury can be temporary
and reversible. It also can be permanent.
More than 50% of comas are related to head trauma or disturbances in the brain's
circulatory system. Problems that can lead to coma include:
Trauma:
Head injuries can cause the brain to swell and/or bleed. When the brain swells as
a result of trauma, the fluid pushes up against the skull. The swelling may
eventually cause the brain to push down on the brain stem, which can damage the

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 RAS (Reticular ActivatingSystem) -- a part of the brain that's responsible for
arousal and awareness.

Swelling:
Swelling of brain tissue can occur even without distress. Sometimes a lack of
oxygen, electrolyte imbalance, or hormones can cause swelling.
Bleeding:
Bleeding in the layers of the brain may cause coma due to swelling and
compression on the injured side of the brain. This compression causes the brain to
shift, causing damage to the brainstem and the RAS (mentioned above). High
blood pressure, cerebral aneurysms, and tumors are non-traumatic causes of
bleeding in the brain.
Stroke:
When there is no blood flow to a major part of the brain stem or loss of blood
accompanied with swelling, coma can occur.

Blood sugar:
In people with diabetes, coma can occur when blood sugar levels stay very high.
That's a condition known as hyperglycemia. Hypoglycemia, or blood sugar that's
too low, can also lead to a coma. This type of coma is usually reversible once the
blood sugar is corrected.
Oxygen deprivation:
Oxygen is essential for brain function. Cardiac arrest causes a sudden cutoff of
blood flow and oxygen to the brain, called hypoxia or anoxia. After
cardiopulmonary resuscitation (CPR), survivors of cardiac arrest are often in
comas. Oxygen deprivation can also occur with drowning or choking.
Infection:
Infections of the central nervous system, such as meningitis or encephalitis, can
also cause coma.
Toxins:
Substances that are normally found in the body can accumulate to toxic levels if
the body fails to dispose of them correctly. As an example, ammonia due to liver
disease, carbon dioxide from a severe asthma attack, or urea from kidney failure
can accumulate to toxic levels in the body. Drugs and alcohol in large quantities
can also disrupt neuron functioning in the brain.
Seizures:
A single seizure rarely produces coma. But continuous seizures -- called status
epilepticus -- can. Repeated seizures can prevent the brain from recovering in
between seizures. This will cause prolonged unconsciousness and coma.

 40% of comatose states result from drug poisoning.

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  25% of comatose patients, occurs from cardiac arrest.
 20% of comatose states result from the side effects of a stroke.
 The remaining 15% of comatose cases result from trauma, bleeding, malnutrition,
hypothermia or hyperthermia, abnormal glucose levels, and many other disorders.
Signs and symptoms:

Generally:-
 Patient is unable to voluntarily open the eyes,
 Does not have a sleep-wake cycle.
 Unresponsive in spite of strong tactile (painful), or verbal stimuli and who
 Generally scores between 3 to 8 on the Glasgow Coma Scale is considered to be
in coma.
Onset of Coma:-
Is either acute or gradual onset:-
_The severity and mode of onset of coma depends on the underlying cause. E.g.,
severe hypoglycemia (low blood sugar) or hypercapnia (increased carbon dioxide
levels in the blood) initially cause mild agitation and confusion, but progress to
obtundation, stupor and finally complete unconsciousness (coma).
_ However, coma resulting from a severe traumatic brain injury or subarachnoid
hemorrhage can be instantaneous. The mode of onset may therefore be indicative
of the underlying cause.

Diagnoses and findings :

Diagnosis of coma is simple; however, the underlying cause is challenging.
The first priority in treatment is stabilization following the basic ABCs.
Investigations are performed to assess the underlying cause. Investigative
methods are divided into physical examination & imaging (as CAT scan, MRI,
etc.) & special studies (EEG, etc….)
Diagnostic steps :
The following steps should be taken when dealing with a patient in
a coma:

1. Perform a general examination & medical history check!! (from the

attendants)

2. Make sure patient is in an actual comatose state and is not mistaken for
locked-in state (patient will either be able to voluntarily move his eyes or
blink) or psychogenic unresponsiveness (caloric stimulation of the vestibular
apparatus will result in slow deviation of eyes towards the stimulation
followed by rapid correction to mid-line; this response can't be voluntarily
suppressed: therefore, if the patient doesn't have this response, then
psychogenic coma can be ruled out as a differential)
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 3. Find the site of the brain that may be causing coma (i.e. brain stem, C.C.…).

4. Assess the severity with the GCS.

5. Take blood work to see if drugs were involved.

6. ABG, to see if it was a result of hypoventilation /hyperventilation

7. Check for levels of “serum glucose, calcium, sodium, potassium, magnesium,

phosphate, urea, and Cr.”.

8. Perform brain scans (either CT or MRI scans)

9. Continue to monitor brain waves and identify seizures of patient using EEGs.
Treatment and Recovery
Medical treatment:-

1. Treatment depends on both severity and cause of coma (e.g. hypoglycemia, brain
edema, induce hypothermia).
2. ICU admission.
3. Attention to ABC and other supportive measures or care.
4. Prevent infections, bedsores and provide balanced nutrition.
5. The nursing staff will move the patient every 2–3 hours from side to side. Aim is
to avoid bedsores, atelectasis & pneumonia.
6. Pneumonia can occur from the person’s inability to swallow leading to aspiration,
lack of gag reflex or from feeding tube, (aspiration pneumonia).
7. Physical therapy to prevent contractures and orthopedic deformities.
8. Sedation for agitated restless comatose patient’s (wrist restraints as well as side
rails may be used)
9. Emotional challenges:-
10.Coma has a wide variety of emotional reactions from the family members of the
comatose patient, as well as the primary care givers taking care of the patients.
Common reactions, such as desperation, anger, frustration, and denial are
possible. The focus of the patient care should be on creating a friendly
relationship with the family members as well as creating a rapport with the
medical staff.
11.Society and Culture’s Debate:-
12.Society places a lot of importance on the idea of “brain death” because most
“industrialized countries have equated this with death of the individual”.
However, “human death is a singular phenomenon characterized by irreversible
cessation of all vital functions (circulation, respiration, and consciousness)”. This
means that death may be consisted of much more than just the brain’s inability to
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 function. For example, although a patient may be “brain dead”, they may still be
considered alive because they can still grow and even reproduce.

Nursing care for comtoise patient :

Assessment of unconscious patients:

1. History

History is obtained by family, friends or EMS 

 The Glasgow C.S. is a helpful to examine and determine the depth of coma, track
patient’s progress and predict outcome as best as possible.
2. Physical assessment

Physical examination is critical after stabilization :

1. Vital signs. (To gain understanding of patient's fluid status, heart function,
vascular integrity, and tissue oxygenation).
2. Assessment of the brainstem and cortical function through special reflex tests
e.g. the oculocephalic reflex test (doll's eyes test), oculovestibular reflex test
(cold caloric test), nasal tickle, corneal reflex, and the gag reflex .
3. Respiratory pattern (breathing rhythm) is significant. Certain stereotypical
patterns of breathing have been identified e.g -:
a. Cheyne-Stokes breathing in which there is alternating episodes of
hyperventilation & apnea, seen in pending herniation, extensive
cortical, or brainstem damage .
b. Apneustic breathing which is characterized by sudden pauses of
inspiration and is due to a lesion of the pons .
c. Ataxic breathing is irregular and is due to a lesion (damage) of the
medulla .

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Special Tests :
1 .Oculocephalic reflex:
o Also known as the doll's eye .
o Performed to assess the integrity of the brainstem .
o Patient's eyelids are gently elevated and the cornea is visualized. The patient's
head is then moved to the patient's left side, to observe if the eyes stay or deviate
toward the patient's right; same maneuver is attempted on the opposite side. If the
patient's eyes move in a direction opposite to the direction of the rotation of the
head, then the patient is said to have an intact brainstem. Yet, failure of both eyes
to move to one side, can indicate damage or destruction of the affected side. In
special cases, where only one eye deviates and the other does not, this often
indicates a lesion (or damage) of the medial longitudinal fasciculus (MLF) which
is a brainstem nerve tract .

3. Caloric reflex test :

 Evaluates both cortical and brainstem function ;
 Cold water is injected into one ear and the patient is observed for eye
movement; if the patient's eyes slowly deviate toward the ear where the water
was injected, then the brainstem is intact, however failure to deviate toward
the injected ear indicates damage of the brainstem on that side .
4. Cortex:
is responsible for a rapid nystagmus away from this deviated position and is often
seen in patients who are conscious or merely lethargic .
5 .Cranial nerves.
•Due to the unconscious, only a limited number of the nerves can be assessed. These
include the cranial nerves number 2 (CN II), number 3 (CN III), number 5 (CN V),
number 7 (CN VII), and cranial nerves 9 and 10 (CN IX, CN X .)
•Gag reflex helps assess cranial nerves 9 and 10 .
•Pupil reaction to light is important because it shows an intact retina, and cranial
nerve number 2 (CN II); if pupils are reactive to light, then that also indicates that
the cranial nerve number 3 (CN III) (or at least its parasympathetic fibers) are intact .
•Corneal reflex assess the integrity of cranial nerve number 7 (CN VII), and cranial
nerve number 5 (CN V). Cranial nerve number 5 (CN V), and its ophthalmic branch
(V1) are responsible for the afferent arm of the reflex, and the cranial nerve number
7 (CN VII) also known a facial nerve, is responsible
for the efferent arm, causing contraction of the muscle orbicularis oculi resulting in
closing of the eyes

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3.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 commandes -6
 Localises -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.
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 •Glasgow coma scale.
Nursing Diagnoses :
•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.

Nursing Management for unconcsious patient :

1. Loosen Clothing at Neck, Chest and Waist.

2. If the weather is cold wrap the blankets around the patient body.
3. If breathing has stopped or about to stop, turns casual in to the required posture
and start CPR (artificial respiration).
4. Breathing may noisy or quiet, if not noisy, let the casualty lie on his back. Raise
the shoulders slightly by a pad and turn the head to one side.
5. Watch for some time. If breathing becomes difficult, or gets obstructed, change
the posture to easy breathing.
6. If breathing is noisy (i.e. the lungs are filled with secretions and the air passing
through makes a bubbling noise) turn casualty to three-quarter-prone position and
support in this position with pads, (in a stretcher case, raise the foot of stretcher
so that lung secreting drains easily.
7. See that there is a free supply of fresh air and that the air passages are free.
8. Take the casualty away from harm full gases, if any; if inside a room, open doors
and windows.
9. Remove false teeth.
10.Apply specific treatment for the cause of unconsciousness.
11.Watch continuously for any changes in the condition, do not leave the casualty
until he passed on to medical hands
12.No form of drinks should be given in this condition.
13.It is best to send the casualty a healthier place on a stretcher.
14.On return to consciousness, wet the lips with water
15.If there are no thoracic or abdominal injury sips of water also can be given.

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Nursing care include :
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.

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7.Hygiene:-It includes,
 Oral care
 Bed bath
 Skin care
 Protect from flies and mosquitoes
8.Care of pressure sore:-
 The bed linen must keep clean and dry.
 Use safety devices like water bed, air bed, pillows, side rails.
9.Nutrition:-
 Maintain electrolyte balance and water balance.
 Give parenteral line fluids and nutrition e.g: TPN (Total parentraeral
nutrition), Or
Naso gastric tube feeding e.g: high protein liquid diet, fruit juices, water.
10.Elimination:-
 Monitor Foley’s catheter e.g.urine color and 24 hours volume.
 Check for abdominal distension.
 Check for urinary retention.
 If the patient Is constipated a glycine suppository may be ordered by the
physician.
11.Note:-
 Don not live unconsciousness patient.
 Do not give food and drinks.
 Assess for Glasgow coma scale to Patient Know the Conscious Level.
12. Family needs
•Family support.
•Educate the needs of client.
•Care to be provided.
13. Potential complications
•Respiratory distress
•Pneumonia
•Aspiration
•Pressure ulcer
REFERENCES
 S.L . Lewis et al, Medical Surgical Nursing: Assessment
and management of clinical problems,8th edition,2011
 G. A .Hacknes and J. Dincher, Medical Surgical
Nursing: Total Patient Care, 10th edition,1999
 Mosby`s Medical Dictionary 7th edition
 P. A. Potter and A. G. Perry, Fundamentals of
Nursing,7th edition,2009
 V. Kumar et al,Robbin`s basic pathology,8th edition,2007
ISBN:978 0 8089 2366 4
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