care of unconscious patient.pptx

care of unconscious patient for bsc. nursing 1st year nursing foundation

1. VIDYAKIRANA GROUP OF INSTITUTION SUBJECT- NURSING FOUNDATION TOPIC- CARE OF UNCOUNSCIOUS PATIENT PRESSENTED BY – MRS. SULEKHA DESHMUKH

2. INTRODUCTION CONSCIOUSNESS- a state of awareness of yourself and your surroundings Ability to perceive sensory stimuli and respond appropriately to them.

3. UNCONSCIOUSNESS- in the state of not being awake and not aware of things around you, especially as the result of a head injury

4. Cause of unconsciousness Surgical unconsciousness ------ Trauma [ a state of great shock or sadness] Epidural hematoma [ blood occurs between the dura mater and the skull ] Hydrocephalus [ water on the brain] Stroke [interruption of blood supply] Tumor

5. Medical unconsciousness---- poisoning Infection Meningitis Encephalitis Hypo/ hyperglycemia Hyponatremia[ maintain a balance of body fluid, muscles and nerves] Drug / alcohol overdose

6. Sign and symptoms of unconscious patient The person will be unresponsive [ dose not respond to activity, touch, sound, or other stimulation Unaware of his/ her surrounding and dose not respond to sound No movement Dose not respond to question or to touch Drowsiness [ a state of being sleep ]

7. Inability to speak or move parts of his /her body Loss of bowel or bladder control Stupor

8. General nursing consideration Always assume 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 [ to stop yourself doing something] from any conversation about the patients condition while in the patient’s presence.

9. Conn…. Regularly observe and record the patient’s vital signs and level of consciousness 1- always take a rectal temperature 2-Report change in vital signs to the professional nurse 3- note change in response to stimuli

10. 4- Note the return of protective reflexes such as blinking the eyelids or swallowing saliva 5- keep the patient room at a comfortable temperature, adjust the room temperature if patient’s skin is too warm or too cool.

11. Care of the patient A - AIRWAY AND BREATHING- maintain a patent airway by proper positioning of the patient. Whenever possible, position the patient on his/her side with the chin extended , this prevent the tongue from obstructing the airway This is lateral recumbent position is often referred to as the ‘coma position’

12. B – suction the mouth, pharynx and trachea as often as necessary to prevent aspiration of secretion C – Reposition the patient from side to side to prevent pooling[collection] of mucous aspiration of secretion D- administer oxygen as ordered

13. Nutritional Need

14. A patient who is unconscious is normally feed by gavage Always observe the patient care fully when administering anything by gavage Do not leave the patient unattended while gavage feeding Keep accurate records of all intake [ feeding formula,

15. Conn… Water, liquid medications] When gavage feeding an unconscious patient. It is best to place the patient in a sitting position [ fowlers or semi – fowlers ] and support with pillows. fluids are maintained by intra venous therapy Keep accurate records of intra venous intake and urine output

16. Conn.. Observe the patient for signs of dehydration or fluid overload. [ is a condition where you have too much fluid volume in your body like blood and water, people with heart and kidney condition often experience fluid overload[ hypervolemia ]

17. Skin care

18. 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 nail should be kept short.

19. Provide oral hygiene at least twice per shift include the tongue, all tooth surfaces and all soft tissue area Apply petroleum to the lips to prevent dryness. Keep the nostrils free of secretion. Check the eyes frequently for signs of irritation or infection, neglect can result in permanent damage to the cornea.

20. Use only cleansing solutions and eye drops ordered by the physician. If the patient incontinent, the perineal area must be washed and dried thoroughly after each incident. Change the bed linen if dame or soiled. Observe the skin for evidence of skin breakdown. Gently massage the skin to stimulate circulation.

21. ELIMINATION – excreting waste product from the body

22. 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

23. If enemas are ordered, use proper technique to ensure effective administration. The bladder should be emptied regularly to prevent infection or stone formation Adequate fluid should be given to prevent dehydration

24. Keep accurate intake and output records Report low urine output to professional nurse. Provide catheter care at least once per shift to prevent infection in catheterized patients.

25. POSITIONINING -- when positioning the unconscious patient pay particular attention to maintain proper body alignment . The unconscious patient cannot tell you that he is uncomfortable or is experiencing pressure on a body part. When turning the patient maintain alignment and do not allow the arms to be caught under the torso.

26. Change the patient position every two hours this decrease the likelihood of complication such as pressure ulcer . Utilize a food board at the end of the bed to decease the possibility of food drop.

27. When joints are not exercised in their full range of motion each day, the muscles will gradually shrink. Passive exercise must be provided for the unconscious patient to prevent contraction. Exercise with a range of motion are performed under the direction of the physical therapist Nursing personnel must be proficient in ROM exercise

28. Physical therapy personnel will not always be available It is a nursing care responsibility to maintain the patient’s range of motion.

29. CARE OF PRESSURE SORES Utilize a protective mattress such as a flotation mattress [encourage blood circulation, help relieve backaches] alternating pressure mattress [ relieve from pressure and improve blood flow] or eggcrate mattress [ provide additional support on spine, hip and shoulder when lying down]. Change the patient position at least every two hours.

30. flotation mattress eggcrate mattress alternating pressure mattress

31. Protect the patient from injury Keep side rails up. Pad the rails with pillow or folded blankets Keep sharp objective out of the bed Use draw sheets for easier turning Keep suction equipment available at the bedside for emergencies

32. RESTRAINS – use restrains only with physician’s order Use mitten restrains to prevent the patient from pulling at catheter, iv set and his hair . Take precaution to prevent restrain from becoming restricting do not cut off circulation , do not irritate the skin.