Effects of Systematic Orienting Stimuli on Comatose Patients : Six Case Studies
As a part of a larger, on-going, quasi-experimental research project, this study was an initial clinical trial for the early exploration of a therapeutic regimen of nursing care for the comatose patient. The overall objectives were to elucidate methods to improve the quality of care delivered to the comatose patient and to examine clinical estimates for their potential predictability regarding coma recovery outcome. More specifically, the aim was to investigate the effect of meaningful, systematic orienting stimuli (SOS) provided by professional nurse clinicians and a patient's significant others as evaluated by the criterion variables of Glasgow Coma Scale (GCS) scores to measure the level of arousal and serum thyroxine (T4) levels. Six comatose patients (male and female, ages 16-71) were studied. Criteria for sample selection were developed to exclude patients who demonstrated electrocerebral silence and those who were expected to regain consciousness once their underlying metabolic disorder was corrected . Patients considered for this study had all been comatose at least six hours, and scored below eight on the GCS. After the research staff determined the candidate met the sample criteria, consent was obtained from the patient's physician and next-of kin. Within 72 hours the patient was initiated into the study with baseline assessments of the patient's neurological status recorded. For the next 72-80 hours the patients were provided with individualized, meaningful, systematic orienting stimuli by the nurse researchers for 10-15 minutes during every hour between 0800 and 2200. During the three study days, data collection related to the dependent variables for the study included: (l) hourly GCS scores, and (2) daily serum thyroxine levels, uated by research peers, Muderspach and Swanson (1980) and Sayler (I98l). Serial EEGs were recorded and eval- In addition, data related to the confounding uncontrolled variables which could have influenced the measured outcomes were elicited when possible for descriptive application to the findings. After the third day, the nurse researchers terminated their role with provision of SOS; in some cases, the families vigorously continued to attempt reorientation. Between the 13th and 22nd day after the beginning of the study, a final evaluation was made of the dependent variables by the research team. The data collected pertinent to both the controlled and uncontrolled variables were presented using the case study format, and sub- sequently compared for similarities. A discussion of the data in response to the research questions yielded the following findings: Question 1: Were initial levels of arousal as measured by the GCS predictive of coma recovery? In this limited sample, lower initial GCS scores were associated with improved recovery outcomes. The four patients with low GCS scores (3 or 4) had 100 percent survival; three of these four patients regained functional independence. The two patients with higher GCS scores (6) died without regaining consciousness. Question 2: What effect did SOS have on level of arousal as measured by the GCS? No short-term associations between provision of nursing therapy, SOS, and changes in the GCS scores were detectable. Only two patients demonstrated immediate GCS score changes in response to SOS, but the direction of change was not consistent. However, when trends in the GCS scores were considered, there was evidence suggestive of a relationship between early initiation of the intervening variable, SOS, and coma recovery outcome. Question 3: Was there a relationship between GCS scores and serum T4 levels? No relationship could be illuminated from a critical descriptive analysis of the two dependent variables. Question 4: Were levels of serum thyroxine predictive of coma recovery outcome? No perdictive value was reflected in serum thyroxine levels. Only one patient had subnormal T4 levels; this patient's T4 levels consistently decreased; however his level of arousal continued to improve. A multiplicity of confounding variables could have had an impact on the findings of this study; suspected limitations were identified and elaborated on when specific information was known by the investigators. For instance, the variations in family involvement in providing orienting stimuli, the presence of pre-coma dysfunctions, a history of alcohol and drug abuse, the etiology of coma, post-coma complications, etc., were considered as having a bearing on the results. Based on the information gathered from this study and continued literature review, recommendations were made. Whether or not the positive results obtained in terms of the quantity and quality of survival from the comatose patients studied were a consequence of SOS, coincidental, or a product of time could not be ascertained with this small sample; however, these findings coupled with the evidence presented by LeWinn and Dimanescu (1978) were suggestive for doing further research. The results were encouraging enough to warrant the introduction of orienting stimuli into the repertoire of nursing care for the comatose patient.
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