CARE OF THE UNCONSCIOUS CLIENT

A Simple Guide For Student NursesH. Deepani

RN, BN, Nursing TutorSchool of Nursing

ColomboSri Lanka

Unconsciusness

A condition in which there is a depression of cerebral function ranging from stupor to coma.

Level of consciousness 1. Alert open eyes spontaneously responds all stimuli appropriately

2. Drowsy /lethargy/sleepy Slow to respond but appropriate Oriented

3. Stupor/ confused Aroused by painful stimuli Unclear conversation

4. Semiconscious Moves in painful stimuli Never fully awake No verbal response Blinking/ swallowing reflexes present

5. Coma/ unconscious Unresponsive No voluntary movement No reflexes

Causes

1. CEREBRAL Head injury Cerebral heamorrhage Tumors Abscess CVA Diseases -meningitis, encephalitis

,cerebral malaria, toxaemia

2. METABOLIC DISEASES Hepatic coma Renal failure Diabetic coma-hyperglycaemic

hypoglycaemic Diabetic ketoacidosis Dehydration

3.POISONING Drug over dosage Snake bites Pesticides Alcohol4. SEPTICAEMIA

Signs No response to external stimuli No reflex action Changes in vital signs(BP ,pulse,

respiration, temperature) Changes in pupil size and reaction Decreased sphincter action

Fecal incontinenceConstipationUrinary incontinenceRetention of urine

Signs of dehydration Changes in skin Abnormal involuntary

movementsDecorticationsdecerebration

contd…

Complications Head –lice/pressure soreEye – corneal ulcersMouth – parotitis, cracked lips, dry lips

Lungs – pneumoniaMalnutritionFoot dropWrist drop

Pressure ulcersJoint contracturesMuscle wastingDehydrationUrinary tract infections

Nursing assessment

1. Neurological -GCS2. Physical 3. Investigations

1. Glasgow Coma Scale (GCS) Assess neurological function by using Glasgow Coma Scale (GCS) Parameters

eye openingVerbal responseMotor responsePupil size & reactionVital signs

Score range - 3 to 15 3- death /unconscious 15- conscious &alert

GCS contd…

1.

2. Best verbal response Oriented 5 confused 4inappropriate speech 3incomprehensible sound

2

no verbal response 1

PARAMETER FINDINGS SCOREEye opening spontaneous 4

to speech 3To pain 2 no eye opening

1

contd…Best motor response obeys command 6

localizes pain 5

withdraws from pain 4

Abnormal flexion(decorticate posture)

3

abnormal extension (decerebrate posture)

2

No motor response 1

Physical assessment1. Vital signs2. Eyes3. Facial symmetry4. Reflex actions-

swallowing Blinking Tendon reflexes5. Neck- stiffness

Motor responseMonoplegiaParaplegiaHemiplegiaQuadriplegiaDecerebration Decortication

Skin - pressure ulcers Fecal or urinary incontinence Edema

Investigations CT Scan MRI Scan Lumber Puncture -CSF analysis EEG Monitoring of ICP Blood sugar Blood urea S.E. urine and other investigations

Nursing diagnoses Ineffective airway clearance r/t

accumulation of secretion Ineffective cerebral tissue perfusion r/t

pathological changes of the brain Risk for injury r/t unconsciousness Risk for fluid volume deficit r/t inability to

ingest fluid Ineffective thermoregulation r/t

pathological changes in the brain Risk for corneal tissue injury r/t absence

of corneal reflex

Altered oral mucous membrane r/t absence of pharyngeal reflex

Risk for altered nutrition less than body requirement r/t inability to eat and swallow

Impaired urinary elimination Impaired bowel elimination Impaired physical mobility Self care deficit : bathing, grooming r/t

unconsciousness Risk for complications: pressure sore,

contractures, hypostatic pneumonia, r/t immobility

objectives of care To maintain air way patency To maintain optimal cerebral perfusion To prevent injury To maintain fluid balance To maintain thermoregulation To prevent corneal tissue injury To maintain intact oral mucous

membrane To maintain balanced optimal nutrition

To maintain normal urinary elimination

To maintain normal bowel elimination

To maintain normal physical activity To improve self care To prevent complications

Nursing interventions

1. To maintain airway patency Assess respiratory status (RR/ SaO2/

chest movement/lung sounds/ cyanosis) Place in lateral or semi prone position Insert oro-pharingeal airway to avoid

tongue falling back Suck out oral and nasal secretions Administer humidified oxygen Provide chest physiotherapy Monitor ABG (Arterial Blood Gas)

Prepare for endotracheal intubation if respiration inadequate

Provide artificial ventilation with ventilator

Provide special care for the ventilated patient

2. To maintain optimal cerebral perfusion

Assess GCS and vital signs at regular intervals Monitor ICP (if available) Keep the head and neck aligned Keep head of bed elevated 30 degrees Administer O2 to prevent hypoxic brain injury Check ABG to assess CO2 level Take measures to prevent ↑ICP

-give analgesics before suctioning of airway-give osmotic diuretics & dexamethazone-give stool softeners to prevent straining- give mild sedation if patient is restless

3. To prevent injury Assess risk factors which can cause

injuries Keep side rails up and keep them padded Observe for convulsive attacks Avoid over sedation Keep client nails short Use light restraints if restless Allow a family member to stay with the

client Keep the bed linen clean, dry and wrinkle

free

4. To maintain fluid balance Assess hydration status Monitor intake and output hourly Give IV fluid initially as ordered Initiate NG feed as soon as possible Provide diuretics and

dexamethazone as ordered if cerebral edema suspected

5. To maintain thermoregulation Assess body temperature 4houly Assess all possible sites for infection

(urine, wound, lung, IV sites) Send specimen from all possible

sites(urine, wound swab, phlegm, blood, CSF)for culture & ABST (septic screen)

Take measures to reduce fever (loosen cloth, open doors windows, tepid bath, antipyretics)

Give antibiotics a/c to culture report Give adequate fluid

6. To prevent corneal injury Asses eye for dryness, redness or any

abnormalities Remove contact lenses if worn Clean eyes at regular intervals Instill artificial tears as prescribed Instill eye drops and ointments as

prescribed Use aseptic techniques while giving eye

care Cover eyes with sterile eye patches Prepare for tarsorrhaphy if indicated

7. To maintain intact oral mucous membrane

Asses for dryness, cracks of lips, white or reddened patches , coated tongue etc

Remove dentures if worn Give mouth care every 2-4 hourly Apply glycerin to lips Put crushed Nystatin tablet or anti

fungal solutions for oral thrush as ordered

Clean nostrils to avoid congestion Move endotracheal tube to the other

side of the mouth daily

8. To maintain balanced optimal nutrition

Assess bowel sounds Give NG feeds every 3-4 hourly if

bowel sounds present Give high calorie, high protein and

vitamin rich diet in the liquid form Start TPN if the client cannot

tolerate NG feed Assess signs of any complications

during NG feed & TPN

9. To maintain normal urinary elimination

Asses for any abnormalities of urination Insert an indwelling catheter if retention

of urine present Give catheter care to prevent catheter

related infections Send urine sample for culture & ABST to

asses presence of organisms Apply a condom catheter if incontinence

is present Provide adequate fluid intake

9. To maintain normal bowel elimination

Assess patient for constipation, incontinence or any abnormalities

For constipation Give fruit juice, vegetable soup & juice

through NG tube to facilitate stool softening

Insert suppositories as orderedFor incontinence Wear incontinent pad or diapers Provide perineal care soon the bowel

opened Keep the perineal area clean and dry

10. To maintain normal physical activity

Asses all joints for any deformities and muscle wasting

Provide passive exercise for all joints at every possible times

Turn pt every two hourly Use supportive devices to prevent

deformities Teach and encourage family members to do

the exercises frequently Refer to the physiotherapy unit for special

physiotherapy needs When recovering encourage active exercises

11. To improve self care Provide bed bath daily Provide pressure point care Provide mouth care 2-4 hourly Comb hair as needed Provide perineal care twice a day Change cloth every day and whenever

needed Perform hair wash twice a week Cut nails short Shave beard and mustache of male client

daily Teach family members about performing

hygienic care

12. To prevent complicationsPressure sores Keep skin clean & dry Turn pt 2hourly Provide pressure point care Use supportive devices to avoid

pressure on bony prominences

Joint contractures, foot drop & wrist drop

Provide exercises to all joints Use supportive devices (foot

board, splints) to maintain body alignment

Give high protein diet to promote tissue growth

Deep Vein Thrombosis(DVT) Elevate lower limb above heart level

intermittently Provide passive ROM exercise every

4hourly Use elastic stockings to lower limbs Monitor and compare temperature of both

legs Check Posterior Tibial & Dorsalis Pedis

pulse regularly Monitor for pain ,swelling, redness of the

legs Give S/C heparin if prescribed

Pneumonia Suck out secretions at regular

intervals & whenever necessary Change positions 2 hourly Give chest physiotherapy & use

postural drainage to remove secretions

Keep in head elevated position while feeding

Keep the head tuned to a side always to facilitate drainage of oral secretions

Provide emotional support Reassure client and family Explain all procedures before

preform Allow family member to stay with

client.

Other aspects of care Provide opportunity to practice

religious activities Use therapeutic touch during care Speak to the client in smooth

manner Explain every procedure before

perform Encourage family members to talk

to the client Orientate the client to the date,

time, place & person

QUESTIONS?

THANK YOU!