TITLE:
Patients with disturbances in consciousness as observed by clinical nurses: Analysis of nursing records
AUTHORS:
Ryoko Tsuchiya, Kasumi Mikami, Keiko Aidu, Yoshiko Nishizawa
KEYWORDS:
Patients; Disturbances in Consciousness; Nurses; Observation; Nursing Records
JOURNAL NAME:
Open Journal of Nursing,
Vol.3 No.7,
November
15,
2013
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.