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Coma
Care of the Comatose Client - K. Wolz - NU260
| Question | Answer |
|---|---|
| What information is provided by an MRI? | Identifies geographic location, perfusion, and occlusion of the vessels ie. Is there something there that shouldn't be there? Is there something pushed to the side? |
| What information is provided by a CT scan? | Identifies geographic location, perfusion, and occlusion of the vessels ie. Is there something there that shouldn't be there? Is there something pushed to the side? |
| What information is provided by a PET scan? | Identifies the physiology of the brain and if a part of the brain is working. |
| How does a PET scan identify functioning tissue? | Glucose |
| If the patient requires an EMERGENT test, which does he/she receive? A CT scan or an MRI and why? | CT scan is an emergent test. An MRI is NOT an emergent test because it requires a procedure to make sure that the patient has no metals in there body that could move during the MRI. |
| When might a procedure be done even if their is a risk to the patient? | When the benefits far outweigh the risks |
| Define coma. | A state of unconsciousness in which both wakefulness and awareness are lacking. The client cannot be aroused and demonstrates no voluntary movements. It is a symptom. |
| What are two common causes of coma? | Hypoglycemia and Hypoxia. |
| What are two easy things we can do for a patient who is unresponsive? | Apply oxygen and do an Accucheck. |
| What types of movements is a person in a coma capable of? | Moving their head, gritting their teeth, moaning, smiling, etc. It is important to note that these movements are spontaneous, and involuntary and are not in response to someone talking to the patient. |
| What are Structural Etiologies for coma? | Vascular lesions Trauma Brain tumors & brain abcesses |
| What are Metabolic or Toxic Etiologies for coma? | Cardiopulmonary decompensation, poisoning and alcohol, hypertensive encephalopathy, and acute HTN crisis, meningitis, and other metabolic disturbances |
| How does a heart issue cause coma? | Cardiomyopathy with a low ejection fraction that is not pumping blood to the brain. |
| What types of poisonings cause coma? | Lead poisoning has an affinity for the brain. Also, Acute alcohol poisoning. |
| What are "Other" metabolic disturbances that cause coma? | Diabetes, Hepatic encephalopathies, renal disease, drug overdoses. |
| Pathophysiology of Coma / Definition of Consciousness | Involves both arousal (or wakefulness) and awareness. |
| What are common dysfunctions that can cause coma? | Reticular Activating System; damage to the cerebral hemisphere, the midbrain or pons; ischemia; hypoxia; infection; metabolic exposure |
| What is the Reticular Activating System? | It is a bundle of fibers that runs from your spine, up through the base of your brain to the hypothalamus. The hypothalamus is the relay center for the brain. |
| What is the function of the RAS? | It causes medication and anesthesia to work. It depresses the CNS. |
| What is the pathophysiologic stages of coma comparable to? | Stages of anesthesia: Light, deep, fixed & dilated and non-responsive, spontaneous movements like a newborn, changes in LOC, pupillary responses, ocular positioning and reflexes, motor responses. |
| What is an immature nervous system like, as in a newborn? | Like a decompensating or insulted nervous system. |
| The type of symptoms are an indication to the physician of what? | The location of the brain injury and how extensive the injury is. |
| What is the MOST CRITICAL INDEX of CNS dysfunction? | Level of consciousness. |
| What is an indicator of improvement or deterioration in CNS function? | Level of consciousness. |
| What types of levels of consciousness occur along the continuum? | Confusion, disorientation, lethargy, obtundation (less than full mental capacity), stupor, coma, |
| In what type of patient will the passage of LOC along the continuum occur slowly? | Nursing Home patients, End stage dementia, end stage alzheimers, end stage parkinsons, trauma that leads to swelling, etc. Changes will be subtle because there are billions of cells in the brain. Allot of them must be destroyed before there is symptoms. |
| What are late signs? | Eye signs and pupil dilatation. |
| Patterns of Breathing should be described as you observe it. Name some descriptors. | Cheyne-Stokes, abnustic (sp?), beyotes (sp?), cluster, Rate, Rhythm regular or irregular, length of periods of apnea if any, Pattern. |
| What controls your pupils? What else does it control? | Your brainstem controls your pupils and arousal. |
| Pupillary changes are a guide to what? | Present level of brainstem dysfunction. |
| By the time the brainstem is affected, what has already been damaged? | The cerebrum and higher levels of functioning. |
| What are other things that may affect the pupils? | Drugs, ischemia, hypothermia |
| If you observe a change in the patients condition, ie change in pupil status, what can you do? | Go back and see what has changed with that patient (in the chart). ie. meds, ischemia, hypothermia. Look at the patient! |
| What is a cause of Nystagmus? | Brainstem stroke. |
| What is an Abnormal Normal? | It is a condition in the patient, which would be considered abnormal on an intake, but which is a constant condition for the patient. It has become the patients' "Abnormal Normal." |
| How do you assess motor response to stimuli? | Put the extremity in a neutral position, ie bend the arm at 90 degree angle to observe a little bit of movement toward the noxious stimuli of a sternal rub. That would be a very good sign that the patient on some level is responding to the stimuli. |
| What is the goal in the medical management of coma? | Identify and treat the underlying cause of the condition, ie. treat hypoglycemia with glucose. Often may not be able to treat. |
| If you are unable to treat the underlying cause of the coma, what is the treatment strategy? | To preserve and support the function the patient has when they arrive. Support vital functions and prevent further neurologic deterioration. |
| In Chronic Coma, what is our medical management approach? | Prevent and treat chronic problems, ie UTI, pneumonia, sepsis, etc. |
| Nursing management for the comatose patient includes assessing for changes in neurologic status. How do we do that? | We have to know where the patient started. We do the same neurological assessment that we do on any patient, but we expect a different result. |
| What is a unique aspect of the comatose patients processing in the mind? | It stops from the point of coma. ie. it's still 1987 or patient doesn't know why they are in a wheelchair. |
| Nursing management for the comatose patient includes supporting all bodily functions. Give some examples. | Turning and repositioning, hunger, thirst, coughing, managing bowel and bladder. |
| Nursing management for the comatose patient includes prevention of complications. Give some examples. | UTI, bed sores, etc. |
| Nursing management of the comatose patient includes providing psychosocial and informational support to the family. Such as? | These are ethical dilemnas with strong feelings and emotions. |
| Nursing management of the comatose patient includes initiating rehabilitation measures. Give examples. | Range of motion exercises, |
| The issues that patients present with will depend of their status. Chronic vs acute patients may have different issues. Give some examples. | Oxygenation, etc. |
| A worsening of a coma, a deepening of a coma, a lessening of response, a change in status, automatically does what to your assessment? | Kicks it back to ABC airway, breathing, and circulation. |
| What are nursing considerations for oxygenation? | Maintain a patent airway. |
| What do we assess for oxygenation? | Rate, depth, rhythm |
| What do we plan for oxygenation? | Positioning, chest PT, oxygen, physical therapy. |
| What are interventions for oxygenation? | Supply oxygen, monitor ABGs, suction PRN, plan activities spaced out, maintain normothermia |
| What are objective evaluations for oxygenation? | Color, rate, rhythm, depth, pulse ox, normal temperature. |
| What are nursing considerations for Disuse Syndrome? | Impaired Skin Integrity |
| What are interventions related to Disuse Syndrome and Impaired Skin Integrity? | Turn and reposition in bed, Vary position of bed, auscultate lung fields q2-4h, and TURN OFF tube feeding when lying the patient flat. |
| What are nursing considerations for Food and Fluids? | Altered Nutrition |
| Why does the patient have altered nutrition? | Because they can't tell you when they need a drink or are thirsty or hungry. |
| What are assessments related to Food and Fluids? | Assess hydration and nutrition status by skin turgor, mucous membranes, intake and output, intake through PEG tube, formula, nutritional assessment, swallow studies, accurate I&O. |
| What are OBJECTIVE Evaluations related to Food and Fluids? | Weight, I&O, mucous membrane status, etc. |
| Why is a comatose patient at risk for aspiration? | Because they can't swallow and are NPO, but they can aspirate their own secretions or their tube feedings. |
| What nursing interventions can help prevent aspiration in a comatose patient? | Suction at the bedside, elevate HOB 45 degrees for tube feedings, hold feedings if HOB is lowered, check placement of tube for NG feedings, monitor residual q4h, monitor for abdominal distention, and TURN OFF tube feeding when HOB is lowered. |
| At end of life, body systems start to shut down. How does this affect the patients risk for aspiration? | Patient had been tolerating tube feedings, but suddenly is not. The GI is shutting down because the blood supply is being sunted to other systems at end of life. You are getting tube feedings coming out the nose and mouth. |
| What do you do for a patient who is not tolerating a tube feeding? | Elevate HOB and suction the nose and mouth (if feeding has come out nose and mouth). Open the PEG tube and draw out the tube feeding! |
| What are interventions for altered urinary and bowel elimination? | Adequate fluid intake, maintain urine pH below 6.0, give ordered water q shift, suppositories, enemas, medications (Colace). |
| Why are rectal stimulations and rectal disimpactions not done anymore? | Because of the vaso-vagal response. |
| What are activity and exercise considerations in the comatose patient? | Perform PROM exercises, support extremities with pillows, turn & reposition pt q2h, maintain good body alignment, and use footboard or tennis shoes to prevent foot drop! You may consult PT/OT for recommendations. |
| What are factors resulting in pressure ulcers? | Nutrition, immobility, coma process. Coma causes tremendous physical aging because the body is not meant to be in a coma state. |
| What are prevention measures for pressure ulcers? | Reposition pt q2h, prevent shearing force, use special beds, meticulous skin care, get pt up in cardiac chair if poss, massage nonreddened areas/aloe, keep dry, skin care consult, adequate nutritional support, good output, check daily wt, assistive device |
| Immobile, comatose patients are at risk for what? | DVTs |
| How can we promote factors that improve venous blood flow? | Elevate extremities, use antiembolic stockings and/or devices, avoid leg crossing, turn & reposition pt q2h, use lovenox |
| What is unique about the effectiveness of SCDs? | It is not necessary for the SCD to be worn on the legs. It can be worn on any limb. It triggers the release of a hormone, which in turn causes the blood to move to the heart. |
| Why do we use Lovenox? | Less side effects, relatively easy to administer, good at preventing DVTs. |
| What is the lab test that we look for before administering Lovenox? | Platelets |
| What is the antidote to Lovenox? | Protamine Sulfate |
| Why are we cooncerned about bone demineralization in the comatose patient? | Because these patients are immobile, they are going to have the calcium leech out of their bones and the phosphorous come in. |
| What are nursing considerations related to bone demineralization in the comatose patient? | Monitor for hypercalcemia through serum levels, and side effects: nausea/vomiting, polydipsia, polyuria, lethargy. |
| What happens when the patient has a fever? | It increases the metabolism of the brain tissue. It makes the tissue work harder, which is bad because it is sick and it should be resting. |
| Why might we see a fluctuation in temperature in the comatose patient? | Because of neurological insult that damaged the hypothalamus (where regulation of temperature takes place). |
| What are nursing interventions related to temperature regulation? | Warm bear hugger, cool bear hugger, fans, sheets, blankets, tylenol/motrin. |
| Another thing that will increase the cerebral metabolic rate is agitating the patient or seizures. What can we do to prevent these? | Administer sedatives, barbituates, or paralyzing agents, and counsel the family in maintaining a calming atmosphere. |
| What might happen in response to a patient becoming agitated? | They drop their sats, their HR is elevated, their BP is elevated, etc. There is a physiological response that increases the cerebral metabolic demands. |
| What are ways that we can encourage the patient and their significant other to meet their Maslow need for Sex? | Encourage visits, closeness, provide privacy, it is OK for the spouse to lie with the patient. |
| What can we do to facilitate the closeness of the family and patient? | Make sure the patient doesn't smell, isn't dirty. On occasion, patients armpits and legs have been shaved. |
| What are safety considerations for the comatose patient? | Risk for injury, risk for falls r/t decrease in LOC. (when we move them) |
| What are nursing considerations related to safety? | Protection of body systems (ie Foley not draining), med administration (pt doesn't know), prevention of nosocomial infections (handwashing), bed in low postn with siderails up, padded siderails (if pt thrashing), restrain pt if ordered and appropriate. |
| What are nursing considerations for Love and Belonging/Psychosocial? | Encourage family and friends to visit, decorate room, talk with pt (if no ICP), play music or TV, and have pt wear their own clothes. |
| How can we help with the patients Self-Esteem? | You don't know what the patient is aware of. Do everything right! Talk with them, explain what you are doing. Patient may hear and feel. The patient has a self care deficit and anxiety. |
| What is an important factor in Levels of Prevention with the comatose patient? | We have to base the Levels of Prevention on where the patient is RIGHT NOW! |
| Why is fever common in the comatose patient? | Because the temperature center is the hypothalamus, which is in the brain, which could have been damaged. |
| Why might a comatose patient have an elevated HR and low BP? | Comatose patients maintain a higher HR in order to maintain the BP. Patients need an intact nervous system in order to maintain neurovascular tone, and move blood around. |
| Do we medicate Parkinsons, Alzheimers, spinal cord or coma patients to reduce an elevated HR? Why or why not? | NO!! Because if you reduce the HR you will further reduce the already low BP. |
| What is the difference in the neurological assessment we conduct in a coma pt vs an alert patient? | NONE. We conduct the same assessment. We just expect a different outcome. |
| How do you approach a coma patient? | The same way you approach an alert patient. You introduce yourself and treat the patient with respect. |
| What are independent nursing measures that we can implement for a comatose patient? | Administer oxygen, monitor pulse ox, perform cardiac monitoring, elevate HOB, suction, I&O, Daily weight, diapers, turn & reposition, nasal or oral airway for suction, positioning, seizure pads. |
| What information would you need to report to the physician to receive accurate medical orders? | VS, Weight, Meds from home, head to toe/front & back asst, and then anticipate what you want from the doctor. |
| What are examples of orders you might be seeking on an admitted comatose patient? | Cultures, Tylenol, Protonic, Tube feeding, Chest PT, Lasix (for edema, but watch BP), CBC, CMP, Chest X-ray, Constipation: Colace, Antibiotic, If 3rd gen cephalosporin, then yeast Tx with Flagyl. |
| What can you delegate to the PCT? | Record, empty, take VS. NO ASSESS, TEACH, EVALUATE, PERFORM, MONITOR. Can only perform if you have taught them the task. |
| What are synonyms for Assess? | Judge, evaluate, appraise, look over, consider. |
| What are synonyms for Teach? | Instruct, educate, tutor, coach, drill, exercise, discipline, prepare, prime, inform, enlighten, edify, indoctrinate, inculate, implant. |
| What are synonyms for Evaluate? | Appraise, rate, assess, judge, estimate, guage, size up, value, assay. |
| What are synonyms for Monitor? | watch, observe, censor, supervise, oversee, tend, teach, guide, direct. |
| What are synonyms for Perform? | do, accomplish, execute, perpetrate, achieve, effect, realize, attain, fulfill, finish, consummate, discharge, dispose. |
Created by:
Kitty Groebli
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