NURSING CARE OF UNCONSCIOUS PATIENTS
· Consciousness is defined as the state of being aware of physical events or mental concepts.
· Conscious patients are awake and responsive to their surroundings
· Unconsciousness means that the patient is unaware of what is going on around him and is unable to make purposeful movement.
· The basic principle to remember is that the unconscious patient is completely dependent on others for all of his needs
· A manifestation of altered consciousness implies an underlying brain dysfunction. Its onset may be sudden, for example following an acute head injury, or it may occur more gradually, such as in hypoglycaemia.
- Always know that the patient can hear, even though he makes no response.
- Always address the patient by name and tell him what you are going to do.
- Refrain from any conversation about the patient's condition while in the patient's presence.
- Note changes in response to stimuli.
- Note the return of protective reflexes such as blinking the eyelids or swallowing saliva.
- Keep the patient's room at a comfortable temperature.
- Carry out the ABCDE survey:
• Regularly observe and record the patient's vital signs and level of consciousness using GCS - Glasgow Coma Scale
The lower the score the poorer the prognosis.
Observations should be undertaken every 30 minutes until the GCS reaches 15 or the patient's condition stabilizes. After this observations should continue hourly for four hours (NICE )
• AVPU Scale for faster assessment of the victim's consciousness level. In AVPU, the patient is given a letter score (A, V, P, U) based on the following elements:
A (Alert) — the patient is able to maintain spontaneous eye opening, verbal response and coordinated motor functions.
V (Voice) — the patient is able to respond when spoken to (such as actual speech or grunt).
P (Pain) — the patient responds when pain stimulus is applied (such as withdrawing limb from pain or extension/flexion or extremities).
U (Unresponsive) — the patient does not show any response to voice or pain.
• Pupillary reaction
• Cranial nerve assessment
• Cerebellar -balance & co-ordination
Airway and breathing:
• Maintain a patent airway by proper positioning of the patient. Whenever possible, position the patient on his side with the chin extended. This prevents the tongue from obstructing the airway.
• This lateral recumbent position with the head of the bed slightly raised upwards, about 10-30 degrees is the safest position for a patient
Reposition the patient from side-to-side to prevent pooling of mucous and secretions in the lungs.
• Administer oxygen as ordered- to maintain tissue perfusion
• Suction the mouth, pharynx, and trachea as often as necessary to prevent aspiration of secretions.
• Physiotherapy is important to encourage lung expansion, assist the removal of secretions
• Dentures should be removed and note made of any loose teeth that may become dislodged and compromise the airway.
The insertion of nasogastric tube will allow removal of gastric contents, thus reducing the risk of aspiration.
• Oropharyngeal airways provide a passage that allows the patient to breathe, and allows the nurse to remove secretions from the trachea through suctioning
· Monitoring the cardiovascular function in unconscious patients is of high importance
· Monitor vital signs as changes in vital signs can be related to other physiological factors, for example, hypovolaemia, sepsis or cardiogenic shock.
· Antiembolic stockings increase the velocity of flow in the legs thus improving venous return
· A patient who is unconscious is normally fed and medicated by gavage.
· Always observe the patient carefully when administering anything by gavage,
· Do not leave the patient unattended while gavage feeding.
· Keep accurate records of all intakes. (Feeding formula, water, liquid medications.)
· Fluids are maintained by IV therapy.
· When NG feeding an unconscious patient, it is best to place the patient in a sitting position (Fowler's or semi-Fowlers) and support with pillows. This permits gravity to help move the feeding or medication. The chance of aspiration of feed into the airway is reduced.
· Observe the patient for signs of dehydration or fluid overload.
Hygiene & skin care
· The unconscious patient should be given a complete bath every other day.(This prevents drying of the skin.) The patient's face and perineal area should be bathed daily.
· The skin should be lubricated with moisturizing lotion after bathing.
· The nails should be kept short
· Provide oral hygiene at least twice per shift.
· Apply petroleum to the lips to prevent drying.
· Keep the nostrils free of crusted secretions. Prevent drying with a light coat of lotion, petroleum, or water-soluble lubricant.
· If the patient is incontinent, the perineal area must be washed and dried thoroughly after each incident.
· Check the eyes frequently for signs of irritation or infection. Neglect can result in permanent damage to the cornea since the normal blink reflex and tear-washing mechanisms may be absent. Use only cleansing solutions and eye drops ordered by the physician. One such solution, methyl cellulose (referred to as "artificial tears") may be ordered for instillation at frequent intervals to prevent irritation.
· Change the bed linen if damp or soiled.
· Observe the skin for evidence of skin breakdown.
· Skin care should be provided each time the patient is turned.
· Examine the skin for areas of irritation or breakdown.
· Apply lotion.
· Gently massage the skin to stimulate circulation
· The bowel should be evacuated regularly to prevent impaction of stool.
· Keep accurate record of bowel movements. Note time, amount, color, and consistency.
· A liquid stool softener may be ordered by the physician to prevent constipation or impaction, It is generally administered once per day.
· If enemas are ordered, use proper technique to ensure effective administration
· The bladder should be emptied regularly- mostly by catheterization .
· Keep accurate intake and output records.
· Provide catheter care at least once per shift to prevent infection in catheterized patients
· When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. The unconscious patient cannot tell you that he is uncomfortable or is experiencing pressure on a body part.
· Limbs must be supported in a position of function. Do not allow flaccid Limbs to rest unsupported.
· When turning the patient, maintain alignment and do not allow the arms to be caught under the torso.
· Change the patient's position to a new weight-bearing surface every two hours. This decreases the likelihood of complications eg. Pressure ulcers
· Utilize a foot board at the end of the bed to decrease the possibility of foot drop.
· Passive exercises must be provided for the unconscious patient to prevent contractures.
· Utilize a protective mattress such as a water mattress.
· Change the patient's position at least every two hours.
· Unless contraindicated, get the patient out of bed and into a cushioned, supportive chair.
· Protect the patient from injury.