Patients with disturbances in consciousness as observed by clinical nurses: Analysis of nursing records

Ryoko Tsuchiya, Kasumi Mikami, Keiko Aidu, Yoshiko Nishizawa

Hirosaki University Graduate School of Health sciences, Aomori, Japan.
Hirosaki University School of Medicine & Hospital, Aomori, Japan.

DOI: 10.4236/ojn.2013.37063                

Abstract

The objective of the present study was to discuss patients with disturbances in consciousness by analyzing nursing records. Observations from clinical nurses as well as patients’ responses about their care were selected from nursing records. Nursing records from one week of patient care were examined for patients who were unable to speak during hospitalization within a neuro-surgery ward of the hospital. Selected records were classified into the following eight categories: results from monitoring; results from observation; opening and moving the eyes to stimulus; movement of the limbs to stimulus; vocalization to stimulus; facial expression to stimulus; patient’s response to care; and miscellaneous. Patients comprised two groups. One group encompassed eight patients with Japan Coma Scale (JCS) II and the other was a group of eight patients with JCS III. When nurses use the JCS to assess patients with disturbances in consciousness, patients who awaken to stimulus are classified as JCS II, while those who do not are JCS III. The total nursing records selected for JCS II were 1551 and 1160 for JCS III. The category of “results from monitoring” was the most selected category within nursing records and accounted for 42.8% of the JCS III group, while “results from observation” accounted for 38.4% of the JCS II group. Furthermore, results indicated that the categories of “results from monitoring”, “results from observation”, and “movement of the limbs for stimulus” had peaked after two to three days, and then abruptly decreased. There were only a few records for the categories of “vocalization to stimulus” and “facial expression to stimulus”, both for the JCS II and the JCS III groups. Even though patients could not verbally indicate their intentions due to problems with consciousness, it is essential for nurses to pay careful attention to the details of patients’ reactions.

Keywords

Patients; Disturbances in Consciousness; Nurses; Observation; Nursing Records

Conflicts of Interest

The authors declare no conflicts of interest.

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