Monitoring the unconscious patient

Lam Sai Chu Sindy N.O. AHNH

Unconscious patient
Patient makes no appropriate response to stimuli either external (pain) or internal (thirst)

Stage of unconsciousness
Somnolence - state of unconsciousness from which patient can be fully awakened
Stupor - state of unconsciousness from which patient can be awakened to produce inadequate responses to verbal & physical stimuli

Stage of unconsciousness
Coma - state of unconsciousness from which patient who appears to be asleep, cannot be aroused by verbal and physical stimuli to produce any meaningful response

Cause of unconsciousness
Poisons & drug Vascular causes Infection Seizures Others

Objectives in monitoring
Assess adequacy of vital organ function Follow course of acute illness Assess patient discomfort and effect of measures Track the effects of therapeutic interventions Detect complications and other adverse event

Objectives in monitoring
Determine the need for interventions Assess the performance of monitors and support devices Detect readiness for and predict success of therapeutic interventions Evaluate patients nutritional / metabolic state

Adverse effects of monitoring

To patient pain uncomfortable position discomfort restricting movement Inconvenience and distress for family

Adverse effects of monitoring

Diversion of caregivers attention away from patient
Noise pollution for both patient and staff

Physiological Function
Oxygenation Circulation Neurological function Nutrition Fluids & electrolytes Elimination

Physiological Function
Physical activity & rest Senses Skin Integrity Endocrine function Psychosocial state

Scenario 1
A 45 year old woman was taken to hospital after falling 40 feet from the second floor. On arrival at hospital, RR 18 / minute, PR 100 / minutes, BP 145/90 mmHg, T 35.5 C, GCS - 6, pupils - equal and reacted sluggish to light, compound Rt. tibial fracture. After CT scan, she was admitted to ICU after wound debridement, insertion of subdural ICP monitor

Oxygenation - Airway
Patency Position of ETT Monitor taping of ETT - too tight or not +/- suction

Breathing
Breath sounds Coping with ventilation Presence of spontaneous breathing Amount of sputum Present of gap / cough reflex

Circulation and Cerebral Perfusion

ECG ( rate, rhythm and presence of ectopic beat) Blood pressure Pulses (peripheral) & capillary refill Presence of bleeding Level of consciousness, responsiveness

Neurological function
Level of consciousness Pupil size ICP monitor Glasgow Coma Scale Sedation level

Glasgow Coma Scale

Best Ocular Response Open spontaneously Open to verbal command Open to pain No response 4 3 2 1

Glasgow Coma Scale

Best motor response Obeys verbal command Localizes pain Flexion withdrawal Abnormal flexion Abnormal extension No response 6 5 4 3 2 1

Glasgow Coma Scale

Best verbal response Oriented and converses Disoriented and converses Inappropriate words Incomprehensible sounds No response 5 4 3 2 1

Ramsay Sedation Score

Awake levels
1. anxious and agitated or restless 2. co-operative, oriented and tranquil 3. responds to command only

Ramsay Sedation Score

Asleep level (response to glabellar tap or loud auditory)
4. brisk response 5. sluggish response 6. no response

Fluids and Electrolytes

IV fluids, IV line patency, Urine output Drain - NG tube Serum albumin level

Skin Integrity
Sign of edema Sign of dehydration Wound condition Sign of infection Personal hygiene Skin protection

Sensory-perceptual function
Pain score Hearing sensation Discomfort Thirst

Psychosocial State
Anxiety / worry Depression Agitation / restlessness

ICU Patients lament

Dont monitor me - my wedge pressures fine My QRS complex is not a straight line I dont have a pneumo or sepsis or gout; At least if I do, I dont want to find out. Your fancy new gizmos and beepers and light. Are vaulting my bill up to unforeseen heights. They poke me and probe me and add to my stress.

ICU Patients lament

But whether they help me is anyones guess. They havent been tested to see if they work, But using them youve gone completely berserk No one asks me how it feels here in bed ---you spend all your time with my data instead. I want to be cared for, and comforted too. But that doesnt happen with all that you do

ICU Patients lament

So go somewhere else with your new expertise ---Dont monitor me, just leave me in peace!

Hudson LD. Monitoring of critically ill patients : conference summary. 1985