Case Studies of the Effects of Orienting Stimuli on the Electroencephalogram and Levels of Coma
A comatose patient has long been a problem for nurses. Even though this problem has been recognized, very few studies have been conducted by the nursing profession to determine the best course of treatment for these patients. The physical care of the comatose patient has been dealt with in many nursing texts; in contrast, that portion of the care which the nurse could direct to the arousal of the comatose patient has not been documented. The purpose of this study was to assess the effect of orienting stimuli on the individual level of consciousness as measured by Glasgow Coma Scale (GCS) scores and the electroencephalogram (EEG) in four comatose patients. The problems were: (1) to investigate whether brain activity was predictive in assessment of the comatose patient as measured by the EEG; (2) to investigate whether levels of coma were predictive in assessment of the comatose patient as measured by the GCS; (3) to define the effectiveness of a planned series of orienting stimuli in producing more normal brain waves, and/or arousal as noted on the EEG; and (4) to integrate this new-found knowledge into the nurse's repertoire of care for the unconscious patient. These were stated in the form of null hypotheses listed as follows: (1) there will be no difference In the EEG of selected patients either during or after orienting stimuli; (2) there will be no predictive value to the EEG when related to levels of coma; (3) there will be no difference in the GCS of selected patients either during or after orienting stimuli; and (4) there will be no predictive value to the GCS when related to levels of coma. The variate variable of this study was the use of stimuli. The sample was a convenience sample. The criteria for the sample selection were designed to eliminate as many of the uncontrolled variables as possible. Patients who met these criteria were selected. Family con- sent was obtained. Patients were provided orienting stimuli in the form of tapes from family and tapes of music and sports. The researchers also spent time talking with and reading to the patient, etc. The patient's likes and dislikes were determined from the family so that the things that were important to the patient could be utilized. The objective of this maneuver was to reorient the patient and to lessen the amount of time and degree of coma. The initial assessment consisted of a complete neurological assessment, a record of vital signs, any avail- able laboratory data, and an EEG. The patient's complete neurological assessments were done twice a day and the usual neurological checks were done every hour. The vital signs were done every hour. Biochemical data were recorded as they were drawn. The EEG was also done twice a day . The final assessment of criterion variables included an EEG, neurological assessment, vital signs, and any available laboratory work. The data were described by using measures of central tendency for the biochemical and biophysical data. This material was related in a descriptive manner, for it failed to yield any apparent trends. The results of this descriptive study will be summarized in the following The findings paragraphs. were related to each statement of the main hypothesis as listed above. Hypothesis 1: There will be no significant difference in the EEG of selected patients either during or after orienting stimuli. There appeared to be more of a trend of change to the EEG. The change was not every time, and was not necessarily a meaningful change. There were several patients who were talked to while the EEG was being done. If any changes were noted, they were very subtle and even of questionable difference according to the neurological consultant. There was no change in the EEG either during or following orienting stimuli. The hypothesis was retained. Hypothesis 2: There will be no predictive value to the EEG when related to levels of coma. All patients started out with poorly regulated EEC's. A return of delta waves to prominence after some recession was interpreted as a poor prognostic sign. Alpha waves were seen in three of the four patients, but none had any significant runs. As a patient's condition worsened, what alpha waves were present decreased in number and lengths of runs. Even the patient who did best clinically had only rare alpha waves on the last EEG of the study. As the patient's condition deteriorated, the organization of the waves decreased. The patient who did better clinically had a basic underlying theta activity, usually in the upper range. It appeared that prognostic use of the EEG was in the trends that developed until the EEG was flat. There was no predictive value in the It was EEG. important to note the reciprocation between clinical condition, GCS, and EEG's, for there appeared to be a very close relationship. Hypothesis 3: There will be no difference in the GCS of selected patients either during or following orienting stimuli. Only one patient had GCS scores which changed either during or after the orienting stimuli. The change was bidirectional and occurred several times. There were changes from shift to shift or from day to day. The change in the GCS score related to the patient's clinical condition and the EEG. Hypothesis 4: There will be no predictive value to the GCS when related to levels of coma. There was a relationship, as noted before, between the GCS, levels of coma, clinical condition, and the EEG. These data gave the researchers more information upon which clinical decisions could be made. All hypotheses were retained. One or more of the following factors may have influenced this conclusion: Several uncontrolled extraneous variables could have had a negative effect on the outcome of this study, such as the use of pharmacological drugs whose effects on the brain were not understood, and complications following the initial insult. Inexperience of the investigators in recording the EEG may have limited the reliability of the findings. Size and type of sample were also limiting factors. There was a lack of precise control over the type of amount of orienting stimuli received by the patient. Awareness by the nursing personnel that a study was under way may have reminded them to talk to the patient, thus offering orienting stimuli. Several times there was not a c]ear picture as to the rating of the GCS for a certain patient. This could have altered the predictive value of the GCS. Also, the ability of the patient's family to be involved in the orienting stimuli could have made a difference in the quality of the orienting stimuli being offered to the patient.
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