Decrease Awareness

Awareness is: The state that reflects the integration of all the afferent and efferent impulses.

Unconsciousness
Unconsciousness is when a person is unable to respond to people and other stimuli around him or her. Often, this is called a coma or being in a comatose state. Coma is a state in which the patient is totally unaware of the self and the environment and can not respond fully to an external stimulus (Dr Gary Enever, October 1999). Coma is a state of unconsciousness that can not be woken pathological (John J corona 1997)



• Range of awareness
• 1. ComposMentis - normal consciousness, fully conscious,
• 2. Apathy - states of consciousness hesitate to get in touch with the surroundings, indifferent attitude.
• 3. Delirium, ie restlessness, disorientation (person, place, time), rebellious, screaming, hallucinating, sometimes to fancy.
• 4. Somnolence are reduced alertness, psychomotor response is slow, easily fall asleep, but consciousness can be recovered when stimulated (easily awakened) but it is easy to fall asleep again, able to give a verbal answer.
• 5. Stupor (soporo coma), ie a state like deep sleep, but no response to pain.
• 6. Coma is not woken up, no response to any stimuli (no
response of corneal and gag reflexes, may also no pupillary response to light).

• Some causes of coma include:
• Focal brain disfunction
o Brain tumors
o Demmyelinisasi
o Infection (cerebral abcess)
o Head injury
• Diffuse brain dysfunction
o Infection: meningitis, encephalitis
o Hypoxia / hypercarbia
o Drugs overdose
o Metabolic / Endocrine: DKA, hepatic, renal failure
o Hypothyroidism / hyperthyroidism / thyroid crisis
o Electrolyte Abnormalities
o Hypotension / hypertension crisis
o Head injury diffuse
o Hypo / hyperthermia
o Sub-arachnoid haemoragi

• Signs and symptoms
• GCS less than 15 and the cause of the signs and symptoms of impairment of consciousness / essence disease

• Diagnostic
o radiographs to determine the function of cerebral MRI, CT scan, EEG
o Laboratory according to the probable cause coma, such as:
 Blood Sugar
 BUN
 Ketones
 AGD

• Management at IGD: ABCDE
• First make sure the patient has a change of consciousness, not for sleeping, with a shake / pat on the back, calling her name.

• If you really do not realize the management of basic life support (airway, breathing and Circulate)
• If ABC has handled the new do the DE F
• D: diagnosis.
• Do assessment of a patient's disease history. Diagnosis is important because it is directly related to therapy. If therapy is delayed there is the possibility of irreversible damage to the brain.

• E: evaluation
• Evaluation using a coma scale:
• 1 = fully awake
• 2 = conscious but Drowsy
• 3 = unconscious but responsive to pain with purposeful movement eg flexion / withdrawal
• 4 = unconscious but responding to pain by extension
• 5 = unconscious and unresponsive to pain

• evaluation of the level of awareness can be done also with GCS (Glasgow Coma Scale)
• value range is 3-15, a value of 8 or less into the category of a coma.

• GCS
• Response Opens Eyes
• a. Spontaneous: 4
• b. Against Talk: 3
• c. Against Pain: 2
• d. No response: 1

• Verbal Response
• a. Oriented: 5
• b. Conversations are confusing: 4
• c. The use of words that do not fit: 3
• d. Voice murmured: 2
• e. No response: 1

• motor response
• a. Following orders: 6
• b. Pointing spot stimulation: 5
• c. Avoidance of stimulus: 4
• d. Flexion abnormal (decortication): 3
• e. Abnormal extension (deserebrasi): 2
• f. No response: 1
• F: further management
• Care provided in the ICU
o Pressure area care
o Care of the mouth, eyes and skin
o Physiotherapy to protect muscles and joints
o Risks of deep vein thrombosis
o Risks of stress ulceration
o Nutrition and fluid balance
o Urinary catheterization
o Monitoring of the CVS
o Infection control
o Maintenance of adequate oxygenation, with the assistance of artificial ventilation
o Maintain security (fence bed / resttrin)
o Maintaining the integrity of the cornea
o Perthankan thermoregulation
o Improve the function of defecation
o Improving the sensory stimulation


• First Aid
o Call or INSTRUCT someone to call 911.
o Check the person's airway, breathing, and circulation frequently. If Necessary, begin rescue breathing and CPR.
o If the person is breathing, and a spinal injury is NOT suspected, and he is lying on his back, carefully roll him onto his side toward you. Bend the top leg so both hip and knee are at right angles. Gently tilt the head back to keep the airway open. If breathing or circulation stops at any time, roll the person on to his back and begin CPR.
o If a spinal injury is suspected, leave the person as he was found (as long as he is breathing freely). If spinal injury is suspected and the person Vomits, "log roll" the person to his side. Support the neck and back to keep the head and body in the same position while you roll.
o Keep the person warm until medical help arrives.
o If you witness a person fainting, try to Prevent him or her from falling. Lie the person flat on the floor and elevate the feet about 12 inches.
o If fainting is Likely due to low blood sugar, have the person eat or drink something sweet when he or she fully regains consciousness

• Do Not
o DO NOT give an unconscious person any food or drink.
o DO NOT leave the person alone.
o DO NOT place a pillow under the head of an unconscious person.
o DO NOT slap an unconscious person's face or splash water on the face to try to revive him

• Nursing
• Assessment
• The assessment focused on:
o Awareness (GCS: eye opening, motor and verbal skills), pupil reaction.
o Airway: the state of the airway due to decreased refek cough, or obstruction of the tongue falling back.
o Breathing: cheynes stoke, kusmaul, or hyperventilation.
o Circulation: haemodinamik state (blood pressure, HR, peripheral pulse, akral warm or cold.)
o Pupils (size and reaction to light)
o corneal reflex: rubbed with clean cotton.
o Pathological reflexes: Babinski reflex
o abnormal posture: decortication or deserebrasi
o Assessment of Systemic: head to toe, assessment of basic human needs

• nursing diagnostics and action plans
• Breath road clearance is not Effective
• Definition: Inability to clear secretions or obstruction of the respiratory tract to maintain the cleanliness of the airway.
• Limitation Characteristics:
o dyspnoea, Decreased breath sounds
o Orthopneu
o Cyanosis
o Abnormalities breath sounds (rales, wheezing)
o Difficulty speaking
o Cough, not efekotif or no
o Eyes widened
o Production of sputum
o Restless
o Changes in the frequency and rhythm of breath

• Factors related to:
o Physiological: or neuromuscular dysfunction of the central nervous
o obstruction of the airway: airway spasm, secretion retention, much mucus, the artificial airway, bronchial secretions, exudate in the alveoli, foreign bodies in the airway.

• NOC:
o Respiratory status: Ventilation
o Respiratory status: airway patency
o Aspiration Control
• Results Criteria:
o Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspneu (capable of removing sputum, able to breathe easily, no pursed lips)
o Demonstrate a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
o Ability to identify and avoid factors that may inhibit airway

• NIC:
• Airway suction
o Ensure that the needs of oral / tracheal suctioning
o Auscultation of breath sounds before and after suctioning.
o Inform the client and family about suctioning
o Ask the client a deep breath before suction done.
o Give O2 by using a nasal to facilitate suksion nasotrakeal
o Use a sterile sitiap action
o Instruct the patient to rest and breath in after catheter removed from nasotrakeal
o Monitor patient's oxygen status
o Stop suksion and give oxygen if the patient showed bradycardia, increase in O2 saturation, etc..

• Airway Management
o Open the airway, guanakan techniques jaw thrust or chin lift if necessary
o Position the patient to maximize ventilation
o Identification of patients need artificial airway device installation
o Put mayo if necessary
o Perform chest physiotherapy if necessary
o Remove secretions by coughing or suctioning
o Auscultation of breath sounds, record any additional voice
o Perform suction on the mayo
o Give bronchodilators if necessary
o Provide Kassa humidifier wet Moist NaCl
o Set the intake to optimize fluid balance.
o Monitor respiration and O2 status

• ineffective breathing pattern
• Definition: The exchange of air inspiration and / or expiration inadequate
• Limitation characteristics:
o Pressure drop of inspiration / expiration
o Decrease in air changes per minute
o Using additional respiratory muscles
o Nasal flaring, Dyspnea, Orthopnea
o Changes in deviation chest, Shortness of breath
o Breathing pursed-lip
o Increased anterior-posterior diameter
o Respiratory rata-rata/minimal
• a) Infants: <25 or> 60
• b) Age 1-4: <20 or> 30
• c) Ages 5-14: <14 or> 25
• d) Age> 14: <11 or> 24
• The depth of respiration, Adult tidalnya volume 500 ml at rest, Baby tidalnya volume 6-8 ml / kg
• Timing ratio
• Decrease in vital capacity

• Factors related:
o Hyperventilation
o bone deformity
o chest wall deformity
o Decreased energy / fatigue
o Destruction / musculoskeletal impairment
o Obesity
o The position of the body
o respiratory muscle fatigue
o Hypoventilation Syndrome
o Pain
o Anxiety
o Neuromuscular Dysfunction
o Damage perceptual / cognitive
o Sores on spinal cord
o Neurological Immaturity

• NOC:
o Respiratory status: Ventilation
o Respiratory status: airway patency
o Vital sign Status

• Results Criteria:
o Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspneu (capable of removing sputum, able to breathe easily, no pursed lips)
o Demonstrate a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
o Vital Signs within the normal range (blood pressure, pulse, respiration)

• NIC:
• Airway Management
o Open the airway, guanakan techniques jaw thrust or chin lift if necessary
o Position the patient to maximize ventilation
o Identification of patients need artificial airway device installation
o Put mayo if necessary
o Perform chest physiotherapy if necessary
o Remove secretions by coughing or suctioning
o Auscultation of breath sounds, record any additional voice
o Perform suction on the mayo
o Give bronchodilators if necessary
o Provide Kassa humidifier wet Moist NaCl
o Set the intake to optimize fluid balance.
o Monitor respiration and O2 status
o Oxygen Therapy
 Clean the mouth, nose and trachea secret
 Maintain a patent airway
 Set oxygenation equipment
 Monitor the flow of oxygen
 Maintain patient positioning
 Onservasi any signs of hypoventilation
 Monitor the patient's anxiety towards oxygenation

• Vital sign monitoring
o Monitor BP, pulse, temperature, and RR
o Note the fluctuations in blood pressure
o Monitor VS while the patient lying down, sitting or standing
o Auscultation TD on both arms and compare
o Monitor BP, pulse, RR, before, during, and after activity
o Monitor the quality of the pulse
o Monitor respiratory rate and rhythm
o Monitor lung sounds
o Monitor abnormal breathing patterns
o Monitor temperature, color, and moisture
o Monitor peripheral cyanosis
o Monitor the Cushing's triad (a widened pulse pressure, bradycardia, increased systolic)
o Identify the causes of changes in vital sign

• Risk of aspiration b / d no gag reflex
• Definition: The risk of gastrointestinal influx secret secret, secret secret oropharingeal, solid objects into liquids atai tracheobronkhial.
• Factors of risk factors:
o Increased pressure in the stomach
o After the food
o Decreased levels of consciousness
o The tracheotomy or endotracheal tube
o The need treatment
o The wire jaw
o Increased gastric residuals
o Decreased function of the esophagus spingter
o Impaired swallowing
o Decrease in gastrointestinal motility
o The delay in gastric emptying

• NOC:
Respiratory Status: Ventilation
Aspiration control

Criteria results:
The patient was able to swallow without any aspiration
Patent airway and breath sounds clean

• NIC:
• Aspiration precautions
o Monitor the level of consciousness, cough reflex and swallowing ability
o Monitor the status of pulmonary
o Maintain airway
o Perform suction if necessary
o Check nasogastric before eating
o Avoid eating when residues are still many
o Blend the drug before administration
o Raise the head 30-45 degrees after eating

• Diagnosis nursing in ICU
• Self care deficit: bathing, eating, dressing / make up
• Definition:
• Impaired ability to perform ADLs on self
• Limitation characteristic: the inability to bathe, inability to dress, inability to eat
• Factors related: weakness, cognitive or perceptual damage, damage to the neuromuscular / muscle nerve
• NOC:
• Self care: Activity of Daily Living (ADLs)
• Results Criteria:
o Client rid of body odor
o Stating comfort to the ability to perform ADLs
o Can be done with the help of ADLS

• NIC:
• Self Care assistance: ADLs
o Monitor the client's needs for assistive devices for personal hygiene, dressing, ornate, toileting and eating.
o Provide assistance to clients fully able to perform self-care.
o Encourage the client to perform activities of daily living a normal fit capabilities.
o Encourage to perform independently, but give assistance when clients are not able to do so.
o Teach clients / families to promote independence, to provide assistance only if the patient is unable to do so.
o Provide routine daily activities according to ability.
o Consider the age of the client if it encourages the implementation of daily activities.
o other nursing diagnosis
o ineffective cerebral tissue perfusion
o Impaired physical mobility
o The risk of damage to skin integrity