Unconsciousness: Abnormal state of complete or partial unawareness of self and environment
· 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
· 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
· 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.
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