As a part of a larger research project with comatose patients the problem stated for this portion of the research study was to investigate the potential for identifying whether or not the quality of nursing care for comatose patients could be improved by nursing therapy with environmental enrichment and meaningful systematic orienting stimuli given by professional nurse clinicians and a patient's significant others. The effects of the orienting stimuli were measured by observable changes in arousal patterns in serial electroencephalograms (EEGs) , level of arousal as scored on the Glasgow Coma Scale (GCS), and selected measures of recovery outcome (RO).
Criteria for sample selection were developed to exclude patients who demonstrated electrocerebral silence and those who were reasonably expected to regain consciousness once their underlying metabolic disorder was corrected (as in patients with a diagnosis of drug overdose). The first two patients who qualified for inclusion in the study had both experienced traumatic head injuries as a result of vehicular accidents. The first patient was assigned to the clinical trial (experimental) group, the second to the clinical comparison (control) group several days later.
After the research staff determined the candidate met the sample criteria, consent was obtained from the patient's physician and next of kin. At 72 hours or less after loss of consciousness (LOC) each patient was admitted to the study. An initial 10-montage EEC was done followed by daily 3-montage EEGs for the next 80 hours. During that time the experimental patient received systematic orienting stimuli and environmental enrichment every hour between 8 A.M. and 10 P.M. for 10 to 15 minutes. The family was encouraged to participate in providing these stimuli. The control patient did not receive systematic orienting stimuli from the research staff. However, after mingling with the experimental patient's family, the control patient's mother vigorously presented similar types of stimuli to her son as had been presented to the experimental patient.
Data collection for the study included recording hourly GCS scores, biophysical data (temperature, pulse, respiration and arterial mean) and pupillary size and reactivity. Biochemical data were also recorded when results of lab tests were available. Final 10-montage EEGs were done on the final day of the study, 14 and 17 days post onset of coma.
Because of the contamination of the clinical control group a case study approach was used to describe the clinical courses of both patients and to present the data. Thus this study became an extension of the pilot study for the larger research project.
The initial EEGs of the experimental patient showed predominant slow wave activity with occasional alpha and beta waves. Although a near normal pattern emerged by day 14, the same improvement was not seen in his GCS scores (4) and his clinical status (unresponsive except to deep pain) After 31 days in coma, the patient began regaining consciousness. By day 37 he started verbalizing. After 66 days in a rehabilitation center he was discharged to home having demonstrated a good recovery with only a few limitations in articulation and fine motor movements.
The second patient, the control patient, experienced a less stable clinical course, and demonstrated intermittent increased intracranial pressure and some alterations in blood pH. As stated earlier, this patient received more than the routine ICU care, since his mother provided orienting stimuli similar to that received by the experimental patient. His EEGs showed a predominance of delta or slow wave activity with occasional alpha and theta rhythms and rare beta activity. The mean of his GCS scores at the end of the study was 9. After 32 days in coma the patient began to slowly regain consciousness. After spending 75 days at the rehabilitation center he was discharged to home. He had made a good recovery with only a few limitations, primarily in speech and mobility of the left upper extremity.
With only two patients in the sample, no conclusions were drawn. Even though the beneficial effect of orienting stimuli could not be demonstrated by immediate arousal movement on the EEG or GCS scores, some potential support for this intervention exists in that both patients made good recoveries at six months, despite the fact that they remained in prolonged deep coma with GCS scores of less than 8 or less than 4 most of the time. Previous investigators reported 95-99 percent of such patients die (Jennett; Teasdale, 1975, 1977).
A number of factors influenced the outcomes of this study. Standardizing the medical and nursing care received by the patients was not possible. As known from the inception of the overall research project, factors such as the personalities, philosophies and education of the different nurses injected a number of uncontrollable variables. The continuity of care provided by regular neurosurgical follow-up varied with each patient. The research staff were unable to obtain blind scoring of the EEGs by the consulting neurologist. The inexperience of the EEG technician compounded by the noise of the intensive care unit affected the quality of the EEGs but did not render them unscorable.
Patient and family-related variables presented potential limitations. These included the extent and existence of precoma dysfunctions; the precoma abilities and psychological state of each patient including overwhelming recent stress or loss; history of use of cigarettes with or without Cannabis or PCP and/or misuse of drugs, alcohol, or other substances; and the ability, need and desire on the part of the family to provide meaningful orienting stimuli and environmental enrichment. As previously stated, the differentiation between the therapeutic treatments received by the control and experimental patients was obscured by the fact that the control patient's mother vigorously provided orienting stimuli to her son.
Other limitations included fatigue of the researchers, and rarely, the unavailability of the hospital's EEG machine. The extent of the influence of the research staff's presence on the care given to the patients by hospital staff was not accessible. Coinvestigators of the larger research project assisted the graduate student in this portion of their study.
Several nursing implications arose from the data collected. What effect did routine nursing care other than suctioning, systematic orienting stimuli (SOS), and environmental enrichment have upon the patient's intracranial pressure? How reliable were the polygraphs and other equipment in the I CD environment? Can the ethical dilemma of comatose patients in a control group be resolved? How assertive ought nurse researchers be in intervening to provide patients with more aggressive care when warranted by the patient's clinical status? These questions and many more related to this research must await future study for resolution.
Evelyn L. Elwell
Annette M. Ross
Darlene B. Johnson
Master of Science (MS)
Year Degree Awarded
Date (Title Page)
Library of Congress/MESH Subject Headings
Coma -- therapy; Coma -- rehabilitation; Nursing Care.
Loma Linda University Libraries
This title appears here courtesy of the author, who has granted Loma Linda University a limited, non-exclusive right to make this publication available to the public. The author retains all other copyrights.
Sayler, Marilyne R., "Environmental Enrichment and Nursing Therapy with Comatose Patients : Two Case Studies" (1981). Loma Linda University Electronic Theses, Dissertations & Projects. 768.
Loma Linda University Electronic Theses and Dissertations
Loma Linda University. Del E. Webb Memorial Library. University Archives