ADVANCED NURSING PRACTICE

A SEMINAR ON
UNCONSCIOUSNESS

INTRODUCTION

The brain serves many functions in the body. Unlike other body systems that monitor and
regulate a group of functions, such as gastro intestinal tract regulates digestion, the nervous
system monitors and regulates all other body systems. Some of these functions are self-
protective and include the ability to think, be awake, respond, appropriately to the environment
and more about. Other functions are automatic and include the regulation of body temperature
and protective are automatic and include the regulation of body temperature and protective reflex
responses. When these protective functions are lost, the symptoms reflect the complexity of the
nervous system.

The word ‘unconsciousness’ means loss of conscious state or active state of a person. In our
body, the brain is responsible for conducting all activities and for consciousness, RAS, i.e.
reticular activating system is responsible. The reticular formation is composed of a complex
network of grey matter, ascending reticular pathways and descending reticular pathways. Its
nuclei extend from the superior part of the spinal cord to the diencephalon and communicate
with basal ganglia, cerebrum and cerebellum. The reticular formation assists in regulation of
skeletal motor movements and spinal reflexes. It also filters incoming sensory information to
cerebral cortex. About 99% of sensory information is disregarded as unessential. Only one
component of reticular formation controls the sleep wake cycle and consciousness.

CONSCIOUSNESS
Consciousness is the state of being wakeful and aware of self, others, and time.

-Phipps Cassmayer

UNCONSCIOUSNESS
It 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.

- Phipps Cassmayer

Periods of unconsciousness may be momentary (the common faint or syncope) or

may last for month for example, following a serious motor vehicle accident in which extensive
brain damage has been sustained.

To produce unconsciousness, a disorder must

a) Disrupt the ascending reticular activating for system that is found in the Centre of the brain
stem and thalamus.

b) Significantly disrupt the function of both cerebral hemispheres.

c) Metabolically depress the cerebrum or reticular activating system, such as drug overdose

COMPONENTS OF ALTERED LEVEL OF CONSCIOUSNESS

A client who is awake, alert, and fully oriented to self, others, place and time is considered to be
fully conscious. From the normal alert state, consciousness deteriorates in stages:

 CONFUSION
Loss of ability to think rapidly, and clearly, an impairment in judgment and decision
making.
 DISORIENTATION
Beginning loss of consciousness, disorientation of time, followed by disorientation to
place and inability to recognize others. The last stage of disorientation is the inability to
know self.

 LETHARGY
A lack of spontaneous movement or speech; the client is easily aroused with speech or
touch but is not oriented to place, person or time.
 OBTUNDATION
Reduced ability to be aroused and limited response to the environment. The client
sleeps unless stimulated with speech or touch. Verbal response to question is minimal.
 STUPOR
It refers to a higher degree of arousability in which the patient can be transiently
awakened only by vigorous stimuli, accompanied by motor behavior that leads to of
uncomfortable or aggravating stimuli.
 DROWSINESS
Drowsiness is familiar to all persons, simulates light sleep and is characterized by easy
arousal and the persistence of alertness for brief periods. Drowsiness and stupor are
usually accompanied by some degree of confusion.
 VEGETATIVE STATE
It signifies an awake but unresponsive state in a person who has emerged from coma. In
the vegetative state eyelids are open, giving the appearance of wakefulness. Respiratory
and autonomic functions are retained. The prognosis for regaining mental abilities once
 the vegetative state is declared is very poor, and after a year, almost nil; hence it is known
as persistent vegetative state.
 COMA
No motor or verbal response to the environment or any stimuli, even deep pain or
suctioning.
 BRAIN DEATH
It is the last and the severe stage characterized by complete irreversible damage to
cerebrum, cerebellum and midbrain. The damage is so severe that there is no hope for
recovery and the client’s life must be maintained with a respirator and vasoactive drugs.
Brain death occurs when there is no discernible evidence of cerebral activity or brain
stem activity.

CLINICAL CRITERIA FOR BRAIN DEATH

 Completion of all appropriate and therapeutic procedures

 Unresponsive coma with absence of motor and reflex response
 No spontaneous respiration (apnea)
 No occulocephalic or occulo motor response with dilated and fixed pupil.
 Isoelectric (flat) EEG
 Persistence of the above sign for 30 minutes to 1 hour and for 6 hours after the onset of
coma and apnea.
 Conforming test indicates the absence of brain circulation

DEGREES OR LEVELS OF UNCONCIOUSNESS

1. EXCITATORY UNCONSCIOUSNESS
The patient does not respond coherently but is easily disturbed by sensory stimuli
such as bright lights, noise, or a sudden movement. He may become excited and agitated
at the slightest disturbance.
 This stage of unconsciousness is commonly seen in patients who are going under
anesthesia or who are partially reacted from anesthesia. In caring for such a patient the
room should be kept dimly lighted, the environment should be quiet, talking should be
avoided, and any necessary moving of the patient or activity about him should be slow
and gentle.
2. SOMNOLENT
Patient is extremely drowsy and will respond only of spoken to directly and
perhaps touch. This response is rarely more than a mumble or a jerky body movement in
response to a stimulus.
3. STUPOROUS
Patient responds only to painful stimuli such as pricking or pinching of the skin. In
deep stupor he may respond only to supraorbital or substernal pressure. This response
may be reflex withdrawal from the painful stimulus. The patient in deep coma does not
respond to any stimuli.

ETIOLOGY
Three kinds of disorders produce sustained unconsciousness.
They are
(1)Structural lesions in the brain that place pressure on the brain stem or in the posterior
fossa, which destroy the reticular formation.
(2)Metabolic disorders, which impair the cerebrum and the arousal functions by
decreasing the supply of oxygen or allowing waste products to accumulate and it causes
suppression of neuronal activity.
(3)Psychogenic causes in which the patient looks comatose but self- awareness is usually
intact, such as is seen in catatonia

Structural lesions

 Supratentotorial lesions (causing upper brain stem dysfunction)

 Brain tumor
 Brain abscess(rare)
  Cerebral hemorrhage
 Cerebral infarction(large)
 Epidural hematoma/subdural hematoma.
These factors cause altered level of consciousness, especially brain abscess and
tumors by compressing the mid brain and sub thalamic region of the RAS. There may be
occurrence of lateral displacement or compression by herniation of temporal lobe.
 Subtentorial lesions (compressing or destroying reticular formation)
 Cerebellar abscess: It may compress the adjacent upper brain stem and may result in
hypoxia further lead to loss of consciousness.
 Infarction: It causes destruction of neuronal activity.
 Pontine or cerebellar hemorrhage/tumor: These may result in loss of consciousness by
directly damaging the neuronal activity.

Metabolic lesions and diffuse lesions

 Diseases of neurons
 Metabolic encephalopathy
 Disease of other organs e.g., liver, kidney
 Poisons, alcohol, and drugs Fluid and electrolyte imbalance
 Concussion and postictal states
 Infections
 Nutritional deficiency
 Hypoglycemia
 Anoxia or ischemia
 Common fainting
 Temperature regulating disorder

Psychogenic causes
 • Hysteria or catatonia

PATHOPHYSIOLOGY

 Consciousness is a complex function controlled by reticular activating system (RAS) and

its integrated components.
 The RAS begins in the medulla as the reticular formation that connects to the RAS
(located in the mid-brain which then connects hypothalamus and thalamus)
 Integrated pathways connect to the cortex via the thalamus and to the limbic system via
the hypothalamus. Feedback systems also connect at the brainstem level.
 The reticular formation produces wakefulness, whereas the RAS and higher connections
are responsible for awareness of self and the environment

To produce a coma, a disorder must affect both cerebral hemisphere and the brain stem itself (in
one of the three ways)
CLINICAL MANIFESTATIONS

Manifestations Metabolically induced Structurally induced coma

coma
History Behavioural changes Frontal headache,
Local seizures
Typical problem Hepatic coma, Tumor of bleeding in one
 Diabetic ketoacidosis area
Pupillary reaction Preserved Unequal reaction
( cranial nerve II)
Pupillary size May be mid position and May be unequal
fixed from anticholinergic Mid position from injury to
Fixed and dilated from the mid brain
anoxia, pinpoint from Pinpoint from injury to the
opiates. pons
Large from herniation
Corneal reflex Present and equal Unequal, may be absent
Extra ocular Eyes roll May have gaze paresis from
movement Cornea intact a trapped cranial nerve II
(CN III ,IV,VI ) Doll’s eye absent
Extremity movement Moves both sides equally Weakness or absent
movement on one side
Abnormal posturing Absent Present

Reflexes Deep tendon reflexes Deep tendon reflexes

present and equal plantar unequal, Babinski’s
flexion response
Responds to pain Equal Unequal

Common features are

 Decreased wakefulness
 Decreased attention to environment
 Confusion
 Disorientation
 Agitation
 Poor memory
  Decreased ability to carry out activities of daily living
 Decreased mobility
 Incontinence, may be due to the loss of control over the urinary sphincter
 Hallucinations: Subjective sensory perception that occur in the absence of
relevant external stimuli; may be auditory, visual , tactile , or somatic.
 Delusions: false, fixed personal beliefs that are not shared by others.
 Illusions: Misinterpretations or real external stimuli.

DIAGNOSTIC ASSESSMENT

1. Glasgow coma scale: It is designed as a standardized assessment of the patient

with disturbed consciousness. The coma scale (E+M+V) = 3 to 15. All
combinations equal to 7 or less define coma. Approximately 50% of scores that
equal to 8 also define coma. Patients achieving a score of 9 or more are not
comatose.

1 2 3 4 5 6
Eye Does not Opens eyes in Opens Opens eyes N/A N/A
open response eyes in spontaneou
eyes to painful response sly
stimuli to voice
Verb Makes Incomprehensi Utters Confused, Oriente N/A
 al no ble sounds inappropri disoriented d,
sounds ate words convers
es
normall
y
Moto Makes Extension to Abnormal Flexion / Localiz Obeys
r no painful stimuli flexion to Withdrawal es comman
moveme (decerebrate painful to painful painful ds
nts response) stimuli stimuli stimuli
(decorticat
e
response)

2. MRI and CT scan:

These scans are used to provide data that whether the coma occurs due to structural
abnormality or metabolic, through these scans tumors and areas of bleeding are
identified
3. Lumbar puncture:
It can be performed when it is conformed from CT scan or MRI that is coma.
Lumbar puncture can assist with the diagnosis of infection or bleeding as cause of
coma. CSF may be cloudy or bloody when the client has an infection or bleeding into
the ventricles or the subarachnoid space.
4. EEG( Electro Encephalography):
It can be used to determine whether the patient is comatose because of continuous
seizures. EEG results are abnormal in many patients in metabolic coma and do not
serve as clear diagnostic tool.
5. Doll’s eye
 In some comatose patients, doll’s eye can be noted as the rapid method for detecting
potential abnormalities of the brain stem. The presence of brisk doll’s eye movement
indicates a decrease in the levels of consciousness with an intact brain stem. The
absence of doll’s eye movement in a comatose patient does not always mean that the
brain stem is not functioning.

6. Laboratory studies:

 Complete blood count may show elevated levels of total WBC count, ESR, decreased
levels of neutrophils and Hemoglobin levels.
 Blood glucose .The patient is always at the risk of hypoglycemia, the RBS levels can be
depleted.
 Electrolytes studies may show the decreased levels of S. Sodium, S. Potassium,
S. Chloride.
 Liver function studies
 Serum osmolality will be decreased in prolonged states of unconsciousness.
 ABG, the PH levels can be altered, PaCo2 will be increased.
 Toxicology screens for opiates, alcohol, barbiturates, and antidepressants.
 Urine culture reports may show the signs of infections.
 CSF analysis may show the decreased levels of protein and glucose.

MANAGEMENT

First aid

Call or tell someone to call ambulance

1. Check the person’s airway, breathing, and pulse frequently. If necessary, begin rescue
breathing and CPR.
2. If the person is breathing and lying on the back, and if there is no spinal injury , carefully roll
the person toward the health personal onto the side. Bend the top leg so that both the legs and
knees at right angles. Gently tilt the head back to keep the airway open. If breathing or pulse
stops at any time, roll the person on to his back and begin CPR.

3. If there is a spinal injury, leave the person as found (as long the breathing continues). If the
person vomits, roll the entire body at one time to the side. Support the neck and the back to keep
the head and body in the same position while you roll.

4. Keep the person warm until the medical help arrives.

5. If a person is found fainting, try to prevent the fall. Lay the person flat on the floor and raise
the feet about 12 inches

6. If fainting is likely to due to low blood sugar , give the person something sweet to eat or drink
when consciousness returns.

DO NOT

•DO NOT leave the person alone.

•DO NOT place a pillow under the head of an unconscious person

•DO NOT slap on unconscious person’s face or splash water on the face to try retrieve him.

Call immediately for emergency medical assistance

If the person is unconsciousness and

 Is not breathing.
 Does not return to consciousness quickly( within a couple of seconds)
 Fell down or has been injured, especially if bleeding.
 Has diabetes
 Is pregnant
 Is over age 50.
 Feels chest pain, chest pressure, chest discomfort, or has a pounding or irregular
heartbeat.
  Can’t speak, has vision problems, or can’t move the arms or legs.
 Has seizures
 Loss of bowel control.

PREVENTION
 People with known medical conditions, such as diabetes, should always wear a medical
alert tag or bracelet.
 Avoid situations where your blood sugar levels get too low.
 Avoid standing in one place too long without moving, especially if prone to fainting.
 If you feel like you are about to faint, lie down or sit with your head bend forward
between your knees.

MEDICAL MANAGEMENT
Goal: To remove or correct the cause.

1. Patients airway and circulation must be maintained. Nasal or oral airway must be inserted for a
short time. If the patient is completely unresponsive, an endo tracheal tube is carefully inserted,
avoiding injury to the cervical spine.

2. Head injured patient may be hyperventilated for reducing paco2 to between 27 to30 mm Hg.
Hyperventilation is an effective way to reduce cerebral blood flow when coma is due to bleeding.

3. Circulation is maintained by monitoring blood pressure and using vaso active agents to keep
mean systolic B.P above 80 mm Hg. If the patient is breathing without assistance, the airway and
respirations need to be closely monitored because the airway may become obstructed and
aspiration may occur as consciousness decreases.

Immediate medical interventions

a) Glucose is given after the blood is drawn to reverse the potential insulin reactions. Thiamine is
commonly given because many comatose patients are malnourished and subject to wernicke’s
encephalopathy.
b) If the patient is having seizures, the patient is given intravenous diazepam. If the patient is not
intubated, the airway needs to be closely monitored because of the effects of the diazepam.

c) Fluid imbalances should be restored slowly for preventing rebound fluid shift to the brain.
Fluids may be given if the patients is dehydrated or withheld the patient is fluid overloaded.
Normal saline and hypertonic saline are the fluids of choices because these fluids will not
passively move into the brain and increase edema.

d) Cultures are taken of the blood, nose, throat, and wounds (if present). Once the cultures are
taken, antibiotics are given to combat any infection.

e) Reduction of body temperature with antipyretics

f) Gastric lavage may be used to remove ingested agents.

g) Naloxone may be given to reverse the effects of opioid overdose.

h) Flumazenil is a benzodiazepine antagonist used to reverse the effects of overdoses of drugs

such as diazepam or lorazepam

i) Anticonvulsants are administered, if seizures are the causes of LOC

j) A variety of medications are administered to treat increased intracranial pressure , a common

cause of LOC, such as osmotic diuretics( Mannitol), corticosteroids( Decadron) ,anticonvulsants,
and antibiotics etc.

SURGICAL MANAGEMENT
 Structural causes of coma may require surgery to decompress the cranial vault.
 Burr holes may be created to drain a subdural hematoma
 Craniotomy may be done to remove a tumour, abscess or intracerebral hematoma
 A ventricular shunt or catheter may be placed to relieve hydrocephalus.

MEDICAL COLLABORATIVE MANAGEMENT

 Identify and treat underlying cause

 Protect airway
  Provide ventilator assistance as needed
 Support circulation as needed
 Initiate nutritional support
 Provide eye care
 Provide skin integrity
 Initiate range of motion
 Prevention of complications
 Provide comfort and emotional support
 Plan for rehabilitation program me

NURSING MANAGEMENT OF UNCONSCIOUS PATIENT

Assessment

Health history: Assess for

• Date and type of onset (sudden or slowly progressive)

• When the change in consciousness is first noted.

• Patient’s and family’s awareness and understanding of the symptoms

• Recent history of falls, infection, or other trauma

• Medications in use-prescription and the over the counter drugs, alcohol, nutritional
supplements, herbal preparations.

• Other health problems, treatment regimen.

• Related symptoms- pain, headache, fever, nausea.

Physical examination: Assess for

• Level of consciousness, orientation, attention, use of language

• Motor status, presence of posturing

• Sensory status, perceptual problems

• Visual changes

• Protective reflexes, alteration s in cranial nerve response

• Breathing pattern

• Oxygenation status

• Lab results

• Drug levels

NURSING DIAGNOSES, OUTCOMES, AND INTERVENTIONS.

Nursing diagnoses according to priority

1. Ineffective breathing pattern related to neuromuscular impairment as evidenced by dyspnea.

2. Impaired tissue perfusion related to decreased blood flow ad evidenced by unresponsiveness to

stimuli.

3. Ineffective thermoregulation related to illness as evidenced by increased body temperature.

4. Impaired physical mobility related to neuromuscular impairment as evidenced by confinement

to bed.

5. Imbalanced nutrition less than body requirements related to swallowing difficulties as

evidenced by weight reduction.

6. Bowel incontinence related to neuromuscular impairment as evidenced by increased frequency

of passing stool.

7. Impaired urinary elimination pattern related to sensory motor impairment as evidenced by

bed wetting.

8. Self- care deficit related to cognitive and perceptual impairment as evidenced by poor hygiene.
9. Impaired family process and coping related to disease condition as evidenced by grieving of
relatives.

10. Risk for impaired skin integrity related to immobility as evidenced by redness over the skin.

11. Risk for complications related to progress of disease condition.

12. Risk or infections related to reduced immunity.

NURSING CARE OF AN UNCONSCIOUS PATIENT

While caring for the unconscious patient, the nurse must make provision for meeting his
physical and spiritual needs and his family’s emotional and spiritual needs. The objectives of
patient care are to maintain normal body function and to prevent complications that will hamper
the patient when consciousness is restored.

I. PHYSICAL CARE OF THE PATIENT

1. Maintenance of an adequate airway

Do not leave an unconscious patient unattended if he is lying on his back because the tongue
may fall back and occlude the air passages. When the placed on his side or abdomen, a small,
firm pillow rather than s soft one should be used under the head so that there is no danger of his
face becoming accidently smothered as a result of his face being buried in the pillow. An airway
can be inserted to maintain the airway. Cleansing or suctioning of the nasal passages of patients
to clear the airway. The patient’s head end can be elevated (semi fowler’s position) to ease the
breathing.

2. Maintenance of circulation

Circulation of blood is enhanced by muscle movement and exercise. The patient must not be left
in a position that hampers circulation to any part of the body. For example, lying for any length
of time with an acute angle bend at the knee joint will produce enough pressure on the popliteal
artery and accompanying veins to hamper circulation to the leg. Reddened areas to be gently
massaged .Plan and perform a routine for turning and for exercise; it not only improves the
circulation, but also helps to prevent hypostatic pneumonia or atelectasis.

3. Moving and position

A turning sheet can be used in moving an unconscious patient. It not only helps to maintain the
patient’s body alignment, by allowing the entire trunk to be moved at the same time, but also
lessens the strain on the nurse’s or attendant’s back. A routine plan of moving the patient should
be planned.

4. Mouth care

Since the unconscious patient tends to be a “mouth breather”, the mouth often becomes dry.
Therefore, mouth care should be given every 2-4 hrs. Dentures should be removed and safely
stored until the patient is fully conscious. The patient’s own teeth should be brushed at least two
times a day. Inside of the mouth, the gum line, and the tongue should be inspected daily, using a
flashlight and a tongue depressor, and the mouth should be cleansed thoroughly every two to
four hours with glycerin and lemon juice.

5. Eye care:

Patient’s eyes should be carefully inspected several times a day. If they appear irritated, if the
corneal reflex is absent .or the lids are incompletely closed .they should be covered with an eye
shield. Eye irrigation should be done using sodium chloride solution. Patient tends to open his
eyes at intervals, there also may an order of instillation of a drop or two of mineral oil or methyl
cellulose, 0.5% - 1%solution, in each eye daily to protect the cornea from lint and dirt and to
provide moisture and lubrication. Neglect of eye care may lead to drying of the cornea and
eventual blindness.

6. Foods and fluid

The comatose patients cannot be given fluids or food by mouth since he does not swallow
normally and would surely aspirate fluid into the lungs may be fed by intra venous infusion.
Proteins and carbohydrates can be administered as parentrally. Fats cannot be given
intravenously and it is difficult therefore to meet all the nutritional needs of the patient.
Feeding can be given through NG tube feeding and an amount of 100-200ml can be given at a
time and can be given every 2-3 hrs. If the stomach is overfilled the patient may vomit and
aspirate with serious consequences. All feeding should be followed with about 50 ml of water to
clear the tube. The tube should be removed at least every 5 days and inspected.

7. Hyperthermia

The temperature should be taken every 4 hrs, and if it is raised, it should be taken at least every
2 hrs. Elevation of temperature may also be a sign of complications such as pneumonia, wound
infection, dehydration, or urinary tract infection. The nurse should carefully observe the patient
for any signs that might indicate the onset of complications. If the temperature continues to rise
despite conservative treatment, ice caps may be applied to the groins and axilla. Alcohol sponge
baths are often ordered, and fans placed slightly to the side of the patient may be following the
treatment. Ice water enemas may be given, and the patient may be packed in ice or placed in a
tub of cool or cold water or on an ice mattress. The room should be kept cool so that the body
heat will be lost from the skin surfaces.

8. Hypothermia

Unconscious patients may have a body temperature that is too low. This condition may occur
when vital centers are depressed but control has not yet been lost. To prevent the further heat loss
protects the patient with extra covering.

9. A problem of elimination

The unconscious patient may often have both urinary and fecal incontinence. A Foley type of
catheter or external drainage apparatus may be used to control incontinence. The skin should be
kept dry and clean to prevent decubitus and add to comfort.

The urinary output should be measured. If measurement is impossible because of incontinence

output should be estimated by recording each time the patient is incontinent and whether or not a
large amount of urine was voided. The unconscious patient usually is given an enema every two
or three days to help prevent fecal incontinence and formation of complications. The patient
who is fed through a nasogastric tube may be given juice that has a laxative effect. Doctor may
order bisacodyl suppositories. A bowel movement usually occurs within half an hour after this
insertion. Soap suppositories also may be used.

If the patient has a vaginal discharge, it should be reported to the doctor. Sometimes cleansing
douches are ordered. The patient who is menstruating will need a perineal care every few hours.

10. Preventions of accidents

Precautions should be taken to prevent accidents to unconscious patients. No external heat

such as hot water bottles or heating pads should be used. Padded side rails should be kept on the
bed, since the patient might have a convulsion is anticipated, a mouth gag should be kept on the
bed. If a convulsion occurs the should be inserted at the sides of the mouth. If the patient is
semiconscious he may be placed in a chair twice a day. This improves the circulation and
prevents pulmonary and circulatory complications. To prevent from him falling, the nurse should
apply a chest hamness type belt or tie a twisted draw sheet about his waist and to the back of the
chair.

B. THE ENVIRONMENT AND THE FAMILY

A comfortable room should be provided at the temperature 0f 210 F. Very young and the very
old patient may be more comfortable in a warm temperature, 260 F. Since the patients with
depressed states of consciousness are often more disturbed in darkness, it is best to keep rooms
well ventilated. Comfortable chair should be provided. If the patient remains unconscious for a
long time, other family members should be urged to share the time spent with him. Sometimes
they can be encouraged to come only for short periods of time each day. The nurse have to
answer all the questions asked by the patient’s relatives, and help them to allay some of their
fears and help them to understand the condition of the patient.

C. OBSERVATIONS
The nurse should make and record detailed observations of an unconscious patient. The
diagnosis may be obscure and the nurse who notes such things as stiffness of the neck and
flaccid limbs or who carefully reports the course of a convulsion may provide the doctor with
essential information. The doctor may wish the vital signs, the pupillary response, and the and
the level of consciousness determined at periodic intervals. A strong blood pressure correlated
with a slowing of the pulse rate is indicative of increasing intracranial pressure and should be
reported at once. Any marked change in the pulse or respirations or any decrease or increase in
the in the level of consciousness should be reported.

D.CONVALESCENCE

A Patient may recover completely after being of conscious for several weeks. The will gradually
return through the stages of unconsciousness, and the he often test responds verbally to a familiar
face or vice versa. Efforts should not be made into arouse him until the level of unconsciousness
has lightened .During convalescence, definite rest periods should be planned each day. If the
patient becomes over tired, he will tend to regress. He will need the encouragement and security
of knowing that family and friends are concerned and interested in his recovery reoriented since
his memory will be blank for the time immediately before and during unconsciousness

E. DEATH OF THE PATIENT

Many patients die without regaining unconsciousness. When death occurs, members of the
family often need emotional support, since they are not only upset emotionally, but also may be
worn out physically.

SUMMARY
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.
Understanding the etiology, patho physiology, clinical manifestations of unconsciousness, may
help the health personnel to give a better care to such a patient. Returning back to the normal
stages of consciousness may depend on the care given by the health professionals and also the
involvement of the family members in the care.

CONCLUSION
Patients who are comatose are vulnerable to many complications, including
injury, skin breakdown, etc. Nurses provide a lifeline for these clients, giving protection and
promotion of normal body functions. The families of these clients require therapeutic
management because they face many difficult situations. It is the responsibility of the health care
professional to know about the psychopathology of unconscious patient and to give a better care
to him.

REFERANCES
1. Brunner & Suddharth’s. (2008). Text book of medical and surgical nursing. New Delhi:
Lippincott Publications, 11th edition, p-p 1850-1865.

2. Kozier. (2010). Fundamntals of nursing, concepts, process and practices. New Delhi: Jaypee
publications, 7th edition, p-p 772-776.

3. Potter & Perry. (1999). the text book of basic nursing. New York: Elsevier publications, 5th
edition, p-p 465, 1098-1099.

4. Shabeer, P. (2012). A concise text book of advanced nursing practice. Pune: Emmess medical
publications. 1st edition, p-p 255-264.

5. Linda. S. (2009). Text book of medical and surgical nursing. New Delhi: Jaypee publications,
4th edition, p-p 987-989.

6. Joyce. M. (2008). Medical and surgical Nursing-Clinical management for positive outcomes.
New York: Elsevier publications, 8th edition, volume I, p-p 1024-1030.