Care of unconscious patient

Fundamentals of Nursing- Unconciousness- Assessment and nursing management of patient

1. CARE OF UNCONSCIOUS PATIENT PREPARED BY MS. JANNET REENA PURANI

2. INTRODUCTION Unconsciousness is an abnormal state in which a person is not alert and not fully responsive to his/her surroundings. Levels of unconsciousness range from drowsiness to collapse and may range in severity from fainting to coma.

3. TERMINOLOGIES Consciousness  is a state of being wakeful and aware of self, environment and time Unconsciousness  is an abnormal state resulting from disturbance of sensory perception to the extent that the patient is not aware of what is happening around him. Loss of Consciousness  is apparent in patient who is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. A person who is unconscious and unable to respond to the spoken words can often hear what is spoken.

4. Levels of Unconsciousness 1. Alert : Normal consciousness 2. Automatism : Aware of surroundings   May be unable to remember actions later Possible abnormal mood, may show defects of memory and judgement 3. Confusion : Loss of ability to speak and think in a logical coherent fashion Responds to simple orders May be disorientated for time and space

5. Levels of Unconsciousness ( Contd ) 4.  Delirium/Acute confusion with agitation : Characterized by restlessness and possible violence Not capable to rational thought May be troublesome and not comply with simple orders 5. Stupor : Quite and uncommunicative Remains conscious but sits or lies with a glazed expression Does not respond to orders Bladder and rectal incontinence occur More serious than the previous wild stage

6. Levels of Unconsciousness ( Contd ) 6. Semi-coma : A twilight stage Patients often pass fitfully into unconsciousness May be aroused to the  stuporosed  state by vigorous stimulation 7. Coma : Patient deeply unconscious  Can not be roused and does not wake up with vigorous stimulation

7. CAUSES OF UNCONSCIOUSNESS Injury to the head by a fall or blow Skull Fracture Asphyxia, Fainting Extreme body temperature Diabetic coma due to Hyperglycemia Insulin shock due to Hypoglycemia Substance abuse and alcohol abuse Straining during bowel movement Coughing hard Cardiac Arrest Blood Loss Cerebrovascular Accident Epilepsy and Infantile convulsions Drug overdose Hypothermia Poisonous substances and fumes Breathing quickly (hyperventilating )

8. SIGNS AND SYMPTOMS The person will be unresponsive to activity, touch, sound or other stimulation. Inability to speak or move his/her body. Drowsy and/or disoriented; he/she may come in and out of consciousness. Confused and incoherent. In a coma; he/she may be completely motionless. Loss of bowel or bladder control (incontinence) Stupor Abnormal pupil reactions

9. Assessment of Unconscious Patient History Physical assessment Glasgow coma scale Assessment of LOC Evaluation of mental status. Cranial nerve functioning. Reflexes. Motor and sensory functioning. Scanning, imaging, tomography, EEG.

10. Diagnostic Tests X-ray MRI (magnetic resonance imaging) : tumors , vascular abnormalities, IC bleed CT (computerized tomography) : cerebral edema , infarctions, hydrocephalus Lumbar puncture : cerebral meningitis, CSF evaluation PET (positron emission tomography) EEG: electric activity of cerebral cortex Blood test like CBC, LFT, RFT, ABG etc.

11. FIRSTAID MANAGEMENT Unlike when a person is asleep, someone who is unconscious cannot cough, clear his/her throat, or turn his/her head if in distress. When unconscious, a person is in danger of choking, making it very important to keep the airway clear while awaiting medical care.

12. CONTD.. 1.Check the person's airway, breathing, and circulation. 2.If you do not think there is a spinal injury, put the person in the recovery position: Position the person lying face up. Turn the person's face toward you. Take the person's arm that is closest to you, and place it to his/her side, tucking it under the buttock. Take the person's other arm, and place it across his/her chest. Cross the person's ankles by placing his/her far leg over the near leg. Supporting the person's head with one hand, pull his/her clothing at the hip, rolling toward you. The person will be on his/her stomach, facing you. Bend one arm up and one arm down, to support the upper and lower body. Tilt the person's head back to allow air to move freely in and out of the mouth. If you do think there is a possible spinal injury, leave the person as you found him/her (as long as breathing continues). If the person vomits or bleeds out of his/her mouth, roll his/her entire body at one time to the side. Be sure to support the person's neck and back to keep the head and body in the same position while you roll him/her. 3.Keep the person warm until emergency medical help arrives.

13. CONTD.. The following should be avoided in the case of loss of consciousness: Do not give an unconscious person anything by mouth; even if he/she regains consciousness, do not give anything until consulting a physician. Do not attempt to wake an unconscious person by slapping or shaking him/her or by putting cold water on the person. Do not put a pillow under the head of an unconscious person, as this could block his/her airway.

14. Nursing Care Of Unconscious Patient Nursing Diagnosis Ineffective airway clearance related to altered level of consciousness Risk for injury related to decreased level of consciousness. Risk for impaired skin integrity related to immobility Impaired urinary elimination related to impairment in sensing and control. Disturbed sensory perception related to neurologic impairment. Interrupted family process related to health crisis. Risk for impaired nutritional status.

15. 1. Maintaining Patent Airway Elevating the head end of the bed to 30 degree prevents aspiration. Positioning the patient in lateral or semi prone position. Suctioning to remove secretions. Chest physiotherapy. Auscultate in every 8 hours. Care of Endo tracheal tube or tracheostomy.

16. 2. Protecting The Client Padded side rails Restrains. Take care to avoid any injury. Talk with the client in-between the procedures. Speak positively to enhance the self esteem and confidence of the patient. 

17. 3.Maintaining fluid balance and managing nutritional needs Assess the hydration status. More amount of liquid. Start IV line. Provide Liquid diet. Care of NG tube .

18. 4.Maintaining skin integrity Regular changing in position.  Passive exercises.  Back massage. Use splints or foam boots to prevent foot drop.  Special beds to prevent pressure on bony prominences.

19. 5.Preventing Urinary Retention Palpate for a full bladder.  Insert an indwelling catheter. Condom catheter for male and absorbent pads for females in case of incontinence.  Inducing stimulation to urinate.

20. 6. Providing Sensory Stimulation Provided at proper time to avoid sensory deprivation. Effort are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep. Maintain the same schedule each day. Orient the client to the day, date, and time accordingly. Touch and talk. Proper communication. Always address the client by name, and explain the procedure each time.

21. 7. Family Needs Include the family members in patient’s care. Communicate frequently with the family members. The family members should be allowed to stay with the patient when and where it is possible. Use external support systems like professional counsellors, religious clergy etc. Clarifications and questions should be encouraged.

22. Potential Complications Respiratory distress Pneumonia Aspiration Pressure ulcer

23. Complications of immobility Skin: - Pressure sore, laceration. Respiratory: - Hypostatic pneumonia, pulmonary. Embolism. C.V. complications: - DVT, postural hypotension, thrombo embolism. G.I. system: - Paralytic ilius , constipation, distention. Urological: - UTI, stone. Muskulo skeleton: - Contracture, osteoporosis, dystrophy, weakness. Neurological: - Foot drop. Psychological: - Anxiety, depression