Fundamentals of nursing. unconsciousness

ROYALTY TELEVISION

1. FUNDAMENTALS OF NURSING ASSESSMENT AND MANAGEMENT OF UNCONSCIOUSNESS CLIENT. 2/23/2021 JONES H.M -MBA/DMS 1

2. Unconsciousness this is a state in which the patient is unaware of what is going on around him and is unable to make purposeful movement. Unconsciousness can be brief lasting a few minutes or sustained lasting an hour or longer ( lasting more than 6hrs = coma). UNCONSCIOUSNESS 2/23/2021 JONES H.M -MBA/DMS 2

3. Unconsciousness is a state in which a person has reduced awareness of his or her surroundings, is without deliberate thoughts, and is less than normally responsive to stimuli such as light and sound. 2/23/2021 JONES H.M -MBA/DMS 3

4. Head injury Brain tumour Drug overdose. Hypoglycaemia Asphyxia Alcohol intoxication Meningitis Epilepsy CVA/STROKE Hypovolaemic shock. Causes of unconsciousness 2/23/2021 JONES H.M -MBA/DMS 4

5. Conscious (alert)--the patient responds immediately, fully, visual, auditory, and other stimuli. The patient is aware of himself, aware of the place and aware of the time. Semi- conscious- patient can be roused with difficult they may respond to some stimuli. Stupor- partial unconsciousness where the patient responds to stimuli by opening eyes , moving limbs. Comatose-- is a state of complete unconsciousness. LEVELS OF CONSCIOUSNESS 2/23/2021 JONES H.M -MBA/DMS 5

6. History taking Physical Assessment Neurological assessment Assess level of unconsciosness Assessment of unconscious client 2/23/2021 JONES H.M -MBA/DMS 6

7. Glasgow Coma Scale is the tool used to assess level of consciousness. It evaluates three categories of behaviour that reflect activities in the high centre of the brain. Eye Opening Verbal Response Motor Response ASSESSING LEVEL OF CONSCIOUSNESS 2/23/2021 JONES H.M -MBA/DMS 7

8. The first score provides a base line for future scorings. The lowest score the patient can achieve is 3 indicating total unresponsiveness. The maximum score is 15 indicating an awake, alert and fully responsive patient. A Score Less than 15 is usually an indication that there is a cause for concern. Note: The accuracy of the GCS is dependent on the assessor using and interpreting it correctly. 2/23/2021 JONES H.M -MBA/DMS 8

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10. Conscious Normal, alert oriented to self, place, and mind Opens eyes spontaneously, responds to stimuli appropriately. Confused impaired or slowed thinking,disoriented Delirious Disoriented, restless, attention deficit , possible incidence of hallucinations and delusions Somnolent Excessive drowsiness responds-to verbal stimuli although slow and inappropriate Obtunded Decreased alertness, slowed motor responses; sleepiness LEVELS OF UNCONSCIOUSNESS 2/23/2021 JONES H.M -MBA/DMS 10

11. Stuporous Sleep-like state; can be aroused only by vigorous and repeated noxious stimuli ; little or no activity; responsiveness only to pain Comatose - Unarousable and unresponsive, no gag reflex or pupillary response to light 2/23/2021 JONES H.M -MBA/DMS 11

12. The basic principle to remember is that the unconscious patient is completely dependent on the nurse for all of his needs. Any omissions in basic nursing care or any failure to protect the unconscious patient in his helpless state may inhibit recovery or greatly prolong his convalescence because of complications that might have been prevented. CARE OF THE UNCONSCIOUS 2/23/2021 JONES H.M -MBA/DMS 12

13. 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 from any conversation about the patient's condition while in the patient's presence. General nursing considerations: 2/23/2021 JONES H.M -MBA/DMS 13

14. Ineffective breathing pattern Altered tissue perfusion Ineffective thermoregulation Risk for injury Impaired physical mobility Altered nutrition Urinary and Bowel incontinence Risk for impaired skin integrity Ineffective family coping. Nursing Diagnosis 2/23/2021 JONES H.M -MBA/DMS 14

15. Maintain effective breathing pattern Maintain Temp., Pulse, B/P, within normal range. Consume adequate balance diet Maintain safety Maintain regular pattern of bowel and urine Maintain skin integrity Family indicate understanding of diagnosis. PLANNING 2/23/2021 JONES H.M -MBA/DMS 15

16. Regularly observe and record the patient's vital signs and level of consciousness using a coma scale. (1) Report changes in vital signs to the team leader or physician. (2) Note changes in response to stimuli. (3) Note the return of protective reflexes such as blinking the eyelids or swallowing saliva. (4). Keep the patient's room at a comfortable temperature . INTERVENTIONS 2/23/2021 JONES H.M -MBA/DMS 16

17. Maintaining a patient airway and promoting adequate ventilation are nursing priorities. 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. AIRWAY AND BREATHING 2/23/2021 JONES H.M -MBA/DMS 17

18. This lateral recumbent position is often referred to as the "coma position." It is the safest position for a patient who is left unattended. b. Suction the mouth, pharynx, and trachea as often as necessary to prevent aspiration of secretions. 2/23/2021 JONES H.M -MBA/DMS 18

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20. Reposition the patient from side-to-side to prevent pooling of mucous and secretions in the lungs. d. Administer oxygen as ordered. e. Always have suction available to prevent aspiration 2/23/2021 JONES H.M -MBA/DMS 20

21. A patient who is unconscious is normally fed and medicated by NGT feed. (1) Keep accurate records of all intake. (Feeding formula, water, liquid medications.) NUTRITIONAL NEEDS 2/23/2021 JONES H.M -MBA/DMS 21

22. When feeding an unconscious patient via NGT, it is best to place the patient in a sitting position (Fowler's or semi-Fowlers) and support with pillows. (a) This permits gravity to help move the feeding or medication. b. Fluids are maintained by IV therapy. (1) Keep accurate records of IV intake and urine output. (2) Observe the patient for signs of dehydration or fluid overload and aspiration of vomitus. 2/23/2021 JONES H.M -MBA/DMS 22

23. a. The unconscious patient should be given a complete bath every day. (This prevents drying of the skin.) (1) Change the bed linen if damp or soiled (2) The skin should be lubricated with moisturizing lotion after bathing. (3) The nails should be kept short, as many patients will scratch themselves. SKIN CARE 2/23/2021 JONES H.M -MBA/DMS 23

24. (2) Observe the skin for evidence of skin breakdown. Skin care should be provided each time the patient is turned. (1) Examine the skin for areas of irritation or breakdown. (2) Apply lotion, prn. (3) Gently massage the skin to stimulate circulation. 2/23/2021 JONES H.M -MBA/DMS 24

25. b. Provide oral hygiene at least twice per shift. Include the tongue, all tooth surfaces, and all soft tissue areas. The unconscious patient is often a mouth breather. This causes saliva to dry and adhere to the mouth and tooth surfaces. (1) Always have suction apparatus immediately available when giving mouth care to the unconscious patient. (2) Apply petrolatum to the lips to prevent drying. 2/23/2021 JONES H.M -MBA/DMS 25

26. c. Keep the nostrils free of crusted secretions. Prevent drying with a light coat of lotion, petrolatum, or water-soluble lubricant. d. 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. 2/23/2021 JONES H.M -MBA/DMS 26

27. The bowel should be evacuated regularly to prevent impaction of stool. Keep accurate record of bowel movements. (2) Administer stool softener/suppositories as needed/alt days ( 3) Provide catheter care at least once per shift to prevent infection in catheterized patients ELIMINATION 2/23/2021 JONES H.M -MBA/DMS 27

28. When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. Limbs must be supported in a position of function. Do not allow flaccid limbs to rest unsupported. (2) Change the patient's position every 2-4 hours. (3) Utilize a foot board at the end of the bed to decrease the possibility of foot drop. POSITIONING 2/23/2021 JONES H.M -MBA/DMS 28

29. When joints are not exercised in their full range of motion each day, the muscles will gradually shrink, forming what is known as a contracture. Passive exercises must be provided for the unconscious patient to prevent contractures. EXERCISE 2/23/2021 JONES H.M -MBA/DMS 29

30. Exercises with a range of motion (ROM) are performed under the direction of the physical therapist. It is a nursing care responsibility to maintain the patient's range of motion. 2/23/2021 JONES H.M -MBA/DMS 30

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