Unconsciousness
Unconsciousness:
Abnormal state of complete or partial unawareness of self and environment
Causes
·
Traumatic
brain injury
·
Brain
hypoxia (e.g., due to a brain infarction or cardiac arrest)
·
Severe
poisoning with drugs that depress the activity of the central nervous system
(e.g., alcohol and other hypnotic or sedative drugs).
Symptoms & Signs
·
Unresponsiveness
(does not awaken when spoken to, touched, or otherwise stimulated)
·
Unconsciousness
may be brief and temporary fainting or prolonged
·
Disorientation
·
Light-headedness
·
Palpitations
·
Headache
·
Drowsiness
·
Stupor
Assessment
·
Perform
a complete assessment
·
Neurologic
system - mental status, cranial nerve function, reflexes, and motor and sensory
function, GIasgow Coma Scale
Complications of
unconsciousness
·
Respiratory
failure, pneumonia and aspiration.
·
Pressure
ulcers, venous stasis, musculoskeletal deterioration, and disturbed
gastrointestinal functioning due to immobility
Management
·
The
goals of care are-
·
Maintenance
of a clear airway
·
Protection
from injury
·
Attainment
of fluid volume balance.
·
Achievement
of intact oral mucous membranes
·
Maintenance
of normal skin integrity
·
Absence
of corneal irritation,
·
Attainment
of effective thermoregulation, and effective urinary and bowel
elimination.
·
Compensate
for the absence of cough, swallowing, blink reflexes.
Nursing Interventions
1. Maintaining
the airway:
·
Establish
an adequate airway and ensure ventilation.
·
Elevating
the head of the bed to 30 degrees helps prevent aspiration.
·
Persistent
suctioning
·
Oral
care
2. Protecting the patient
·
Padded
side rails are provided and raised at all times.
·
Care
should be taken to prevent injury from invasive lines and equipment, and other
potential sources of injury should be identified
3. Maintaining
fluid balance and managing nutritional needs:
·
Assess
hydration status, intake and output.
·
NG
tube Feeding or IV fluids
4. Providing
mouth care
·
The
mouth is inspected for dryness, inflammation, and crusting.
·
Frequent
mouth wash
5. Maintaining
skin and joint integrity
·
Change
position Q2H
·
Passive
exercise of the extremities to prevent contractures.
·
Prevent
foot drops by splits
6.
Preserving corneal integrity
·
Clean
with cotton balls moistened with sterile normal saline to remove debris and
discharge.
7.
Achieving thermoregulation
·
Assess
for the body temperature
·
Cover
the exposed parts
8. Promoting
bowel function
·
Monitors
the number and consistency of bowel movements.
·
Fiber
rich diet and stool softeners
9. Preventing
urinary retention
·
Check
for urinary retention
·
Indwelling
urinary catheter
10. Providing
sensory stimulation
·
Sensory
stimulation is provided at the appropriate time to help overcome the profound
sensory deprivation
11. Monitoring
and managing potential complications
12. Meeting
families' needs
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