[When all hope has gone…well-placed affection remains]

Cédric de Linage experienced coma through his wife, Amélie, after she suffered cardiopulmonary arrest. Here he describes the crucial role, during this period of uncertainty and fear, played by the nursing team. Through their care and day-to-day compassion, the team was able to treat the patient as a fragile but living patient.

[Pain and coma]

Pain is a complex notion which caregivers must be able to decipher. Its aspects vary depending on the patient's condition. In cases of verbal communication disorders, the subjectivity of the caregiver is enlisted. How should pain be assessed in situations of coma and how should it be treated?

How do you know when your patient is "waking up": coma recovery assessment in a complex continuing care setting

Coma, vegetative state (VS) and minimally conscious state (MCS) are disastrous outcomes following severe traumatic brain injury. Due to the extent of the resultant neurological deficits including hemisphere damage, loss of cellular integrity, altered and abnormal movements such as flexor and extensor patterns, and alterations in cranial nerve function, it can become difficult for the interprofessional team to identify when a patient is emerging from their coma. The Glasgow Coma Scale (GCS), commonly used to assess patients with traumatic brain injury (TBI) is not comprehensive or sensitive enough to provide concrete evidence that a patient is emerging from VS to an MCS. The purpose of this paper is to present a case study of a patient who has emerged from a persistent VS to promote a deeper understanding of what is involved when working with this clientele. Challenges in assessment of cognitive functioning, the development of successful communication through the use of technology and the goals of therapy amongst the various health team members will be provided. Collaborative support with the family will also be discussed. Members of the interprofessional team explored the literature to determine coma recovery assessment tools and best evidence guidelines to direct their interventions with this patient.

[How to use one's voice to take care of others]

Voice is something which can greatly help healthcare providers because it is a genuine relational tool. Knowing one's voice means finding one's ability to receive, listen, be heard and approach others. Thus, working on one's voice helps to attain self-knowledge which naturally leads to knowledge of others and better quality care for them.

The challenges forensic nurses face when their patient is comatose: addressing the needs of our most vulnerable patient population

Since 1996, the American Nurses Association has recognized forensic nursing as a formal specialty. Despite this recognition, Sexual Assault Nurse Examiners and Emergency Department nurses struggle with incorporating evidence collection into the care they give the unconscious or comatose patient they suspect has been sexually assaulted. Through case example, this article provides an abbreviated review of the circumstances under which these patients present for care, current challenges, and barriers in upholding the standard of forensic nursing care, as well as proposed interventions for the practicing forensic nurse.

Consciousness, coma, and caring for the brain-injured patient

In this article, a preliminary conceptual framework is presented for exploring nursing interventions and research aimed at improving care of the unconscious brain-injured patient during the early subacute phase of brain injury. The cue-response framework presented is derived from multidisciplinary sources and has specific clinical relevance to critical care nurses caring for unconscious brain-injured patients. A key aspect of this framework is the attention focused on the timing of nursing interventions in response to how nurses interpret the physical, physiological, and secondary cues they observe when caring for comatose patients. A case exemplar is used to present one example of how this framework may be used in the clinical setting.

[Intracranial pressure response during secretion aspiration after administration of a muscle relaxant]

Aspiration of secretions is a usual nursing technique in patients undergoing mechanical ventilation that may be the cause of increased Intracranial Pressure (ICP).

OBJECTIVE

This study aims to evaluate the repercussion of a muscle relaxant on ICP with secretion aspiration.

METHOD

Clinical trial using the same patient as case and control, performing two endotracheal aspirations in each patients, on of them after administration of a muscle relaxant (Cis-Atracurium) and another no. The bolus administration of the relaxant in the first or second aspiration was done randomly. Thirteen patients with intraparenchymatous ICP measurement catheter were studied within the first 36 hours post-placement and with sedoanalgesia for a score of 6 on the Ramsay scale. ICP and CPP were measured before, during and after each aspiration.

STATISTICAL METHOD

SPSS 11.0 program was used. Data analysis by Student's t test for paired data. Statistical significance level accepted was 95%.

RESULTS

On comparing the cases in which muscle relaxant was administered with those in which it was not administered, statistically significant differences were found in the ICP and CCP values during secretion aspiration.

CONCLUSIONS

According to the data obtained in the study, a lower increase of ICP was observed during secretion aspiration in those cases in which muscle relaxant was administered prior to the aspiration.

Planned eye care procedure in comatose head injury patients

A quasi experimental study to evaluate the effectiveness of planned eye care procedure in comatose patients with head injury admitted in the Neuro-Surgical Units of Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chlandigarh in the year 2003.

Cognitive-behavioral recovery in comatose patients following auditory sensory stimulation

Nursing therapies promote recovery following severe traumatic brain injury (TBI). However, the type and dose of treatment needed to stimulate functional plasticity have not been determined. In this quasi-experimental study, the effects of a structured auditory sensory stimulation program (SSP) were examined in 12 male patients, 17-55 years old, with severe TBI. SSP was initiated 3 days after injury and continued for 7 days. Recovery was measured by comparing baseline Glasgow Coma Scale (GCS), Sensory Stimulation Assessment Measure (SSAM), Ranchos Los Amigos Level of Cognitive Functioning Scale (RLA), and Disability Rating Scale (DRS) scores to ending scores between those who received SSP and those who did not. For the intervention group a positive recovery of function trajectory was found for mean GCS, and there was a greater improvement in GCS and RLA scores between baseline and at discharge testing periods. DRS and SSAM scores at baseline and at discharge were significantly different. SSP did not affect hemodynamic or cerebral dynamic status. Early and repeated exposure to an SSP may promote arousal from severe TBI without adversely influencing cerebral dynamic status.

[Coma and its impact on the process of being and living: implications for nursing care]

This is a hermeneutic phenomenological study based on the Van Manen's framework, that aimed to distinguish the meanings of the experiences lived in the state of coma and its impact on the being and living process. It was developed with four participants, three males and one female. Based on the analysis of the information three themes were identified: the unexpected as reality; the singularity of the modified states of consciousness, and the transformation of the being and living process. The coma emerged as an unexpected and unique process, permeated by different and modified states of consciousness; and possibly the unconsciousness as a state of inner life; and having a great impact on the life process of the participants. Finally we addressed some implications for the nursing care.

[Nursing intervention in the case of coma concerning the patient and his family]

This article presents a standardized treatment plan for the first few weeks an adult is in coma, after the acute phase, as a practical guide clarifying the treatment to follow in this process. First, the authors spell out the process to follow. Second, they standardize the characteristics which define persons undergoing these processes. As a fundamental aspect, the authors highlight the importance to work under treatment conditions which the patient and his/her family must confront so as to provide a standard preventive treatment for these problems. Nursing diagnoses are viewed as prevalent. The treatment situations and the diagnoses which enter in this study fall under the V. Henderson model.

Ethics and total parenteral nutrition: issues for intravenous nurse professionals

Healthcare ethics is a hot topic these days. Decisions to withhold or withdraw various forms of medical therapy are daily events in most hospitals and long-term care facilities. Intravenous nurse professionals do not need to be bioethicists; however, they do need to be able to identify problems quickly and know how to address them. Some of the ethical issues that could be encountered by i.v. nurse professionals involved in the provision of total parenteral nutritional support in various clinical settings are examined and explored.

Patients' and relatives' opinions and feelings about diaries kept by nurses in an intensive care unit: pilot study

The underlying aim of this study was to obtain knowledge about the questions which could be of interest for a qualitative interview study, and for the planning and construction of a comparative study. The immediate aim was, however, to investigate whether the diary was of importance to patients after their discharge from the ICU or for relatives, following patients' deaths in the ICU. A diary was kept for nine months concerning ten patients together with eight patients who later died in the ICU. All of the ten patients, and four of the eight deceased patients' relatives, answered a questionnaire consisting of five close-ended and two open-ended questions. The participants were encouraged to comment upon all the questions. All participants read the diary. Seven patients stated that it helped them to remember their ICU stay and two that it did not. It helped them to re-live and come to terms with their serious illness/injury and recall what had happened. For those who could not recollect their ICU stay, the diary helped them to remember 'the lost time'. All the relatives except one stated that it helped them to return and adjust to everyday life; made it easier to accept what had happened; and to understand the seriousness of the patient's injury or disease.

Experiences of critical care nurses caring for unresponsive patients

Grounded theory methodology was utilized to explore the experiences of critical care nurses caring for patients who were unable to respond due to a traumatic brain injury or receiving neuromuscular blocking agents. The registered nurses participating in the study worked in a neuroscience intensive care unit. Saturation of the categories was achieved with 16 interviews. The core category that emerged from the study is Giving the Patient a Chance. The subcategories of Learning about My Patient, Maintaining and Monitoring, Talking to My Patient, Working with Families, Struggling with Dilemmas and Personalizing the Experience all centered upon the focus of doing everything to help the patient attain the best possible outcome. Factors influencing each of the subcategories were identified such as the acuity of the patient, experience level of the nurse and the presence or absence of family members or significant others. These factors accounted for the variations in the nurses' experience. Several reasons accounting for the variations were determined. The study identified areas that need to be addressed in both general nursing education and nursing practice, such as instruction on talking to comatose patients, working with families and orientation information for nurses new to caring for these populations. Recommendations for improvement in these areas, as well as for future studies are discussed.

Verbal communication: what do critical care nurses say to their unconscious or sedated patients?

The importance of using verbal communication in the care of critically ill patients has long been known. Both qualitative and quantitative studies have presented evidence of the benefits of effective communication. This non-participant observational study aimed to explore how much and what types of verbal communication critical care nurses use when caring for unconscious or sedated patients. Sixteen critical care nurses were observed in 4-hour episodes and their verbal communication was transcribed and timed at source. Seven categories of verbal communication and a 'core concept' emerged on analysis of the raw data. Medical investigations/interventions performed on the patients increased the amount of communication used. The participants in this study were found to use a greater variety and amount of verbal communication than participants in other studies. The findings of this study highlight the need for formal support systems and continued education for nurses about the benefits of verbal communication.

The ciliospinal reflex in pentobarbital coma

OBJECT

This study was conducted to delineate the ciliospinal reflex (CSR), which is defined as pupillary dilation caused by a noxious stimulus to the face or head. The authors anecdotally observed that patients in a pentobarbital coma have a CSR that can mimic pathological conditions. A pentobarbital coma obscures the results of the neurological examination in patients with potentially life-threatening cerebral edema; pupil size and reactivity are the only readily monitored signs. Any condition that incorrectly suggests evolving intracranial pathological processes can lead to unnecessary clinical actions.

METHODS

The authors evaluated six consecutive patients in the neurointensive care unit in whom a pentobarbital coma had been induced, documenting the presence and duration of the CSR. The CSR was always bilateral and symmetrical, manifesting as enlarged (6-8 mm), seemingly nonreactive pupils continuing from 1 to 6 minutes and was usually seen after routine nursing maneuvers. The pupils appeared nonreactive to short flashes of direct light but did react if longer flashes were used.

CONCLUSIONS

Recognition of the CSR can potentially lead to reduction of unnecessary transportation and complicating medical interventions in critically neurologically ill patients in whom a pentobarbital coma has been induced.