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Questions and Answers
The highest possible score on the Glasgow Coma Scale is 10.
False
A coma is a brief state of unconsciousness.
False
A score of 8 or more on the GCS usually indicates coma.
False
Unconsciousness is a disease that can be diagnosed.
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Elevating the head of the bed to 15 degrees helps prevent aspiration.
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Suctioning is performed to remove secretions from the lungs.
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Assessment of the critically ill patient includes a review of the patient's laboratory data.
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A complete neurologic examination only requires an assessment of the patient's level of consciousness.
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Chest physiotherapy and postural drainage may be initiated to promote cardiac hygiene.
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Side rails are kept in the raised position during the night to protect the patient.
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Arousal and awareness are two interchangeable terms in the context of level of consciousness.
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Familial occurrences are not important in collecting a comprehensive neurologic history.
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Study Notes
Unconsciousness
- Unconsciousness is an abnormal state where the patient is unarousable and unresponsive.
- It is a symptom rather than a disease.
- The degree of unconsciousness varies in length and severity, ranging from brief (fainting) to prolonged (deep coma).
Coma
- Coma is the deepest state of unconsciousness, characterized by a lack of arousal and awareness.
Assessment of the Unconscious Patient
- A comprehensive history of events preceding hospitalization is essential, including information about clinical manifestations, associated complaints, precipitating factors, and familial occurrences.
- The physical examination includes five major components:
- Level of consciousness
- Motor function
- Pupillary function
- Respiratory function
- Vital signs
- A complete neurologic examination requires assessment of all five components.
Level of Consciousness
- Level of consciousness has two components: arousal and awareness.
- Arousal refers to the state of wakefulness, while awareness reflects the content and quality of interactions with the environment.
- Arousal reflects the function of the reticular activating system and brain stem, and awareness indicates the functioning of the cerebral cortex.
- The Glasgow Coma Scale (GCS) is used to assess the level of consciousness, with a score of 7 or less indicating coma.
Nursing Management of the Unconscious Patient
- Major nursing diagnoses may include:
- Ineffective airway clearance and impaired gas exchange
- Ineffective cerebral tissue perfusion
- Deficient fluid volume
- Imbalanced nutrition
- Risk for imbalanced body temperature
- Risk for impaired skin integrity
- Disturbed sleep pattern
- Nursing management involves:
- Maintaining the airway (ABC management)
- Assessing and managing swallow and pharyngeal reflexes
- Elevating the head of the bed to 30 degrees to prevent aspiration
- Positioning the patient in a lateral or semi-prone position to promote drainage of secretions
- Suctioning and oral hygiene to remove secretions and prevent aspiration
- Chest physiotherapy and postural drainage to promote pulmonary hygiene
- Monitoring arterial blood gas measurements and providing frequent oral care for mechanically ventilated patients.
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Description
This quiz assesses your understanding of the concepts related to consciousness, including arousal, awareness, and the Glasgow Coma Scale. It also covers nursing management of unconscious patients, including diagnosis and care. Test your knowledge of these critical concepts in healthcare!
