7 判断意识障碍程度disturbance of consciousness 区分嗜睡、意识模糊、昏睡、昏迷嗜睡somnolence ：病人呈持续睡眠状态，但可被轻度刺激唤醒，醒后能正确简单回答问题，但反应迟钝。意识模糊confusion ：病人对时间、地点、人物的定向能力发生障碍，思维混乱，可有错觉、幻觉、精神错乱、谵妄等表现。昏睡stupor ：病人处于沉睡状态，仅能被压眼眶、用力摇动身体等较强刺激唤醒。昏迷coma：是最严重的意识障碍。
8 Summary： Disturbance of consciousness is impediment(障碍) of having an awareness of one’s environmentand one’s own existence,sensations andthoughts.According to the degree of disturbance of consciousness, it can be divided: somnolence, confusion, stupor,coma.
9 What is Coma and Persistent Vegetative State? A coma is a profound or deep state of unconsciousness. An individual in a state of coma is alive but unable to move or respond to his environment. Coma may occur as a complication of an underlying illness, or as a result of injuries, such as head trauma.
10 A persistent vegetative state ( “brain-death”) sometimes follows a coma. Individuals in such a state have lost their thinking abilities and awareness of their surroundings, but retain non-cognitive function and normal sleep patterns. Even though those in a persistent vegetative state lose their higher brain functions, other key functions such as breathing and circulation remain relatively intact. Spontaneous movements may occur, and the eyes may open in response to external stimuli. They may even occasionally grimace(痛苦的表情), cry, or laugh.
11 Etiology 1.颅内病变 cerebral disease 2.全身性疾病 general disease （1）颅内感染：如脑膜炎 (meningitis) 等（2）颅脑疾患：脑脓肿；脑血管疾病；颅脑外伤；脑寄生虫病；癫痫、癫痫发作后昏迷。2.全身性疾病 general disease（1）急性感染性疾病（2）内分泌与代谢障碍（3）水电解质平衡紊乱（4）外因性中毒（5）物理性损害
12 Assessment History collection The degree of disturbance of consciousnessVital signsLaboratory examinationDifferentiate diagnosis
13 History collection 发病方式：发病过程、时间急或缓 首发症状 伴随症状 发病年龄和季节 发病现场 病人思想情绪生活情况 既往史
14 The degree of disturbance of consciousness昏迷程度的临床分级 浅昏迷：病人的随意运动丧失，对周围事物和声音、强光等刺激均无反应，仅对强烈的疼痛刺激，有肢体简单的防御性运动和呻吟伴痛苦表情。各种生理反射存在。脉搏、呼吸、血压无明显变化。可出现大小便潴留或失禁。中度昏迷：对周围事物及各种刺激全无反应，对剧烈刺激偶可出现 防御反射。各种生理反射均减弱。脉搏、呼吸、血压有所变化，大小便潴留或失禁。深昏迷：全身肌肉松弛，对周围事物和各种刺激全无反应，各种反射均消失。呼吸不规则，血压下降，大小便失禁。
15 The degree of disturbance of consciousness 格拉斯哥昏迷分级计分法（P187）
21 Is there any treatment?Once an individual is out of immediate danger, the medical care team focuses on preventing infections and maintaining a healthy physical state. This will often include preventing pneumonia and bedsores（褥疮） and providing balanced nutrition.Physical therapy may also be used to prevent contractures（挛缩）(permanent muscular contractions) and deformities （畸形）of the bones, joints, and muscles that would limit recovery for those who emerge from coma.
22 Nursing observation Keep airway open 1. 病情严重者每15～30分钟监测一次生命体征2. 病情稳定者每4小时一次Keep airway openKeep balance of water/electrolytes/acid-basse
26 What is the prognosis?The outcome for coma and persistent vegetative state depends on the cause, severity, and site of neurological damage. Individuals may emerge from coma with a combination of physical, intellectual, and psychological difficulties that need special attention.
27 Recovery usually occurs gradually, with some acquiring more and more ability to respond. Some individuals never progress beyond very basic responses, but many recover full awareness. Individuals recovering from coma require close medical supervision. A coma rarely lasts more than 2 to 4 weeks. Some patients may regain a degree of awareness after persistent vegetative state. Others may remain in that state for years or even decades. The most common cause of death for someone in a persistent vegetative state is infection, such as pneumonia.