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

doi:10.4236/ojn.2013.37063

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Open Journal of Nursing, 2013, 3, 467-471 OJN

http://dx.doi.org/10.4236/ojn.2013.37063 Published Online November 2013 (http://www.scirp.org/journal/ojn/)

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Patients with disturbances in consciousness as observed by

clinical nurses: Analysis of nursing records

Ryoko Tsuchiya1, Kasumi Mikami2, Keiko Aidu2, Yoshiko Nishizawa2

1Hirosaki University School of Medicine & Hospital, Aomori, Japan

2Hirosaki University Graduate School of Health sciences, Aomori, Japan

Email: [email protected]

Received 31 August 2013; revised 1 October 2013; accepted 15 October 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

The objective of the present study was to discuss pa-

tients with disturbances in consciousness by analyzing

nursing records. Observations from clinical nurses as

well as patients’ responses about their care were se-

lected from nursing records. Nursing records from

one week of patient care were examined for patients

who were unable to speak during hospitalization wi-

thin a neuro-surgery ward of the hospital. Selected

records were classified into the following eight cate-

gories: results from monitoring; results from obser-

vation; opening and moving the eyes to stimulus;

movement of the limbs to stimulus; vocalization to

stimulus; facial expression to stimulus; patient’s re-

sponse 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 con-

sciousness, patients who awaken to stimulus are clas-

sified 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. Further-

more, 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

Consciousnes s ; Nurses; Observation; Nu rsin g Records

1. INTRODUCTION

Nursing provides great support for health-related needs.

Communication is the process that gives meaning to the

content and the relation of messages. Communication is

a key basis of nursing because communication plays an

important part in understanding patients, winning their

confidence, sympathizing with them, and supporting

their needs. The sender exchanges thoughts with the

receiver, and both interact with one another. However,

when nurses care for patients with disturbances in their

consciousness, communication may be unclear and dif-

ficult to decipher. This may be the reason why nurses feel

uneasy, and confusion is not rare in these circumstances.

Therefore, by accurately assessing a patient’s level of

consciousness, the nurse is able to detect neurological

changes and communicate with the medical staff to ini-

tiate prompt action, in order to improve survival out-

comes and minimize long-term sequelae [1]. Therefore,

studies of patients with consciousness disturbances have

been investigated in order to verify the reliability and

accuracy of assessment tools for assessing various levels

of consciousness such as the Glasgow Coma Scale and

the National Institutes of Health Stroke Scale [2-8].

In Japan, the previous studies investigating patients

with consciousness disturbances mainly focused on

verifying the validity of nursing care aimed at life assis-

tance, functional improvement, and consciousness reco-

very [9-11].

Studies that have developed a new consciousness eva-

luation scale [12], and analyzed it for use within different

situations [13] have been conducted.

Moreover, although the viewpoints of nursing assess-

ments during consciousness level have been investigated

[14,15], there have been only a few studies which have

R. Tsuchiya et al. / Open Journal of Nursing 3 (2013) 467-471

468

investigated observations from nurses who were perfor-

ming these observations to grasp the concept of nursing.

In Japan, nursing records are regarded as one of a nur-

se’s chief duties. Nursing records show a nurse’s enforce-

ment and judgment and should reflect nursing practice

and methodology. It was expected that an analysis of

nursing records (a nurse’s thoughts, judgments, and ob-

servations) could clarify patient status.

Thus, the objective of the present study was to clearly

define clinical nurse’s observations of patients with con-

sciousness disturbance through the analysis of nursing

records.

2. METHODS

2.1. Sample

The nursing records for one week from patients who

could not speak during hospitalization within a neuro-

surgery ward of a hospital. Patients were classified into

two groups: a group of eight patients with Japan Coma

Scale (JCS) II and a group of eight patients with JCS III.

Nursing records were specified by nurses from January

of 2008 to April of 2012.

2.2. Data Collection

The nursing records indicated within the period were

chosen from patient ID numbers at random. All data

were collected in 2012.

2.3. Ethical Considerations

The ethics committee at Hirosaki University Graduate

School of Medicine provided ethical approval and the

study was registered. We informed potential participants

about the study through poster printouts explaining the

contents of the study, aspects of confidentiality and that

the study was strictly voluntary. Study posters were

placed in hospitals within the neuro-surgery ward and in

outpatient clinics.

2.4. Analysis

We selected observations and patient’s responses to their

care from nursing records. Selected records were clas-

sified into eight categories.

We denoted the eight categories as follows: results

from monitoring, results from observations, 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

vocalization. We referred to the previous literature for

guidance in constructing the category names [15] as well

as using the Kohnan score [16,17]. We totaled these

records and compared the number of categories ob served

for one week, in them JCS II with JCS III. All statistical

analyses were performed using the Statistical Package

for Social Science 12.0 for Windows and the level of

significanc e used was p < 0.05.

3. RESULTS

3.1. Patient Characteristics

Table 1 shows the patient characteristics. The main

diagnosis of the patients was a subarachnoid hemorrhage

or a cerebral hemorrhage. The average age of the patients

was 63.4 ± 19.8 for the JCS II gr oup, and 66 .4 ± 22.8 for

the JCS III group. The average number of nurses

working on nursing records w as 10 ± 2.0 people fo r JCS

II, and 8.6 ± 2.1 people for JCS III. This difference was

not significant.

3.2. Number of Categories within One Week

Table 2 shows the number of selected nursing records.

The total number of nursing records was 1551 for

patients in JCS II, and 1160 for patients in JCS III.

According to these nursing records, the category of

“results from monitoring” was selected the most and

accounted for 42.8% of the JCS III group, while “results

from observations” accounted for 38.4% of the JCS II

group. The category of “results from monitoring” was

significantly different between the JCS II and JCS III

groups. On the other hand, “results from observation”,

“opening and moving the eyes to stimulus”, “movement

of the limbs to stimulus”, and “vocalization to stimulus”

were more prevalent in the JCS II group.

3.3. Fluctuation in the Number of Categories

Table 3 shows the fluctuation in the number of cate-

gories for one week. Results from monitoring, results

from observation, and movement of the limbs to stimulus

had peaked within two to three days (of monitoring ), and

subsequently decreased. The categories of “opening and

moving the eyes to stimulus” and “patient’s response to

care” had peaked within two to three days, repeatedly

increasing and decreasing. There were more records of

“vocalization to stimulus” in the JCS II group than in the

JCS III group. The fluctuation in records of “vocalization

to stimulus” was uniformly maintained. The category

“facial expression to stimulus” was rarely recorded for

patients in both groups.

4. DISCUSSION

4.1. Number of Categories within One Week

The present study’s results indicated that more patient

states were recorded for the JCS II than for JCS III. Even

though patients h ad disturbances in consciousness, it was

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469

Table 1. Patient characteristics.

JCS III group JCS II group

No Age Diagnosis Average num

er of nurses

who recorded patient No AgeDiagnosis Average num

er of nurses

who recorded patient

1 28 cerebral hemorrhage 8 1 64subarachnoid hemorrhage 10

2 40 subarachnoid hemorrhage 7 2 80suba rachnoid hemorrhage 13

3 76 cerebral hemorrhage 6 3 83cerebellar hemorrhage 9

4 61 brain tumor 11 4 15head injury 10

5 69 cerebral hemorrhage 7 5 69cerebral hemorrhage 10

6 83 subarachnoid hemorrhage 10 6 58cerebral hemorrhage 6

7 82 acute subdural hematoma 8 7 85subarachnoid hemorrhage 11

8 68 subarachnoid hemorrhage 12 8 77cerebral hemorrhage 11

Table 2. Frequency of categories within one week.

Patient record (Percentage of record: %)

category JCS III JCS II

Result of monit o ring 497 (42.8) 319 (20.6) *

Result of observation 458 (39.5) 596 (38.4)

Opening and moving the eyes to stimulus 18 (1.6) 159 (10.3) *

Movement of the limbs to stimulus 107 (9.2) 220 (14.2) *

Vo calization to stimulus 7 (0.6) 138 (8.9) *

Facial expression to stimulus 4 (0.3) 1 1 (0.7)

Patient’s response to care 54 (4.7) 78 (5.0)

Miscellaneous 16 (1.4) 30 (1.9)

total 1160 (100.0) 1551 (100.0)

χ2 test: *p < 0.05.

Table 3. Change in the number of categories within one week.

Category First day Second dayThird day Fourth day Fifth day Sixth day Seventh day

JCS III 7.6 ± 7.3 12.8 ± 4.7 12.4 ± 8.3 10.4 ± 8.3 6.6 ± 5.4 6.5 ± 5.5 5.9 ± 4.6

Results from

monitoring JCS II 5.0 ± 3.2 4.9 ± 4.4 6.3 ± 5.4 6.9 ± 5.2 6.8 ± 4.3 4.4 ± 3.2 5.8 ± 5.9

JCS III 9.4 ± 4.8 12.4 ± 4.3 10.6 ± 4.2 8.6 ± 6.9 4.9 ± 2.6 5.4 ± 2.9 6.5 ± 5.1

Results from

observation JCS II 11.8 ± 4.9 12.1 ± 6.2 16.1 ± 8.5 12.4 ± 6.0 7.1 ± 4.7 6.6 ± 4.6 8.9 ± 5.7

JCS III 0.1 ± 0.4 0.8 ± 1.4 0.4 ± 0.7 0.1 ± 0.4 0.1 ± 0.4 0.5 ± 0.5 0.3 ± 0.7

Opening and moving the

eyes to stimulus JCS II 2.3 ± 1.8 4.1 ± 2.6 2.1 ± 1.9 3.9 ± 2.0 3.1 ± 2.5 3.0 ± 2.7 1.5 ± 3.1

JCS III 3.0 ± 3.0 5.4 ± 4.9 1.6 ± 1.8 1.4 ± 1.7 0.4 ± 0.5 0.9 ± 1.1 0.8 ± 1.2

Movement of limbs to

stimulus JCS II 5.4 ± 2.1 6.1 ± 3.9 2.9 ± 2.1 4.0 ± 3.2 3.1 ± 2.0 3.1 ± 2.9 3.4 ± 3.3

JCS III 0 ± 0 0.4 ± 0.7 0 ± 0 0.1 ± 0.4 0.1 ± 0.4 0.1 ± 0.4 0.1 ± 0.4

Vo calization to stimulus JCS II 2.1 ± 2.0 3.0 ± 2.6 1.9 ± 3.4 2.9 ± 3.9 2.5 ± 3.1 2.4 ± 3.1 2.3 ± 2.9

JCS III 0.1 ± 0.4 0.1 ± 0.4 0 ± 0 0.1 ± 0.4 0 ± 0 0.1 ± 0.4 0 ± 0

Facial expression to

stimulus JCS II 0.8 ± 1.0 0.1 ± 0.4 0 ± 0 0.1 ± 0.4 0.1 ± 0.4 0 ± 0 0.3 ± 0.5

JCS III 0.3 ± 0.7 1.0 ± 0.5 2.4 ± 2.6 1.4 ± 1.8 0.8 ± 1.2 0.6 ± 0.9 0.4 ± 0.5

Patient’s response to care JCS II 0.5 ± 0.8 2.1 ± 2.5 1.9 ± 1.8 0.8 ± 1.2 1.4 ± 2.3 1.4 ± 2.4 1.8 ± 2.2

(n = (8); JCS II (n = 8). Split plot design. *p < 0.05.

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470

considered that responses for JCS II were more prevalent

than for JCS III. Because the patients were diagnosed as

seriously ill, nurses had recorded various characteristics,

including the patients circulation, respiration, nerve mo-

vements, blood pressure, and papillary reflex for the ca-

tegories of “results from monitoring” and “results from

observation”. In the present study, it was suspected that

medical practice as well as nurses may place great im-

portance on life support methods. It may be assumed that

the categories of “opening and moving the eyes to stimu-

lus”, and “movement of the limbs to stimulus” were re-

corded more frequently than the category of “facial ex-

pression to stimulus” because a change in a patient’s eye

movements or limb movement was probably more easily

observed than a change in their facial expression.

4.2. Fluctuation in the Number of Categories

A peak in the number of nursing records were seen for

many of the categories on the second or third day, which

corresponds to the acute period when patients took ill

and were hospitalized; this is known from a clear change

in status in the patient analyzed. Moreover, since there

were patients among the analyzed who were hospitalized

during the night, it was thought that the number in the

contents for the first record decreased compared to the

other day s .

There were only a few records for the categories of

“vocalization to stimulus” and “facial expression to sti-

mulus”, both for JCS II and JCS III. Sugimoto et al. [18]

stated that when nurses felt that a patient was behaving

abnormally, they caught nonverbal signs, and catching

these signs and considering their meaning was important.

Moreover, accurately reading a patient’s minute changes

is an important ability for a nurse. Even though patients

could not verbally indicate their intentions due to pro-

blems with consciousness, it is essential for nurses to pa y

careful attention to the details of patients’ reactions.

5. LIMITATIONS OF THE REVIEW

We suspected that nurses may not have recorded every-

thing they observed. Because it is evident that nurses

have certain cues and signs they focus on and pay more

attention to, a more detailed study of nursing records is

necessary.

6. CONCLUSIONS

In order to study clinical nurses’ observations of patients

with consciousness disturbance, we analyzed nursing re-

cords of patient progress.

Nursing records were indicated more for patients with

JCS II than for patients in JCS III. “Results from moni-

toring” and “results from observation” were found to be

the most recorded categories in nursing records.

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