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