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: ryoko34@cc.hirosaki-u.ac.jp
Received 31 August 2013; revised 1 October 2013; accepted 15 October 2013
Copyright © 2013 Ryoko Tsuchiya et al. This is an open access article distributed under the Creative Commons Attribution License,
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
Copyright © 2013 SciRes. OPEN ACCESS
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
R. Tsuchiya et al. / Open Journal of Nursing 3 (2013) 467-471
Copyright © 2013 SciRes. OPEN ACCESS
469
Table 1. Patient characteristics.
JCS III group JCS II group
No Age Diagnosis Average num
b
er of nurses
who recorded patient No AgeDiagnosis Average num
b
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.
R. Tsuchiya et al. / Open Journal of Nursing 3 (2013) 467-471
Copyright © 2013 SciRes. OPEN ACCESS
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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