Presentation on Nursing care of unconscious patient.ppt

Nursing care of unconscious patient

1. NURSING CARE OF AN
UNCONSCIOUS PATIENT

2. AIM:
At the end of the presentation the group will be
able to provide comprehensive nursing care to an
unconscious patient.

3. OBJECTIVES :
THE GROUP IS ABLE TO :
Define Unconsciousness.
List the etiology of unconsciousness.
Identify the pathophysiology of unconsciousness
and describe its signs and symptoms.
Identify diagnostic testing, and treatment
options.
Describe the nursing management of
Unconscious patients.

4. ANATOMY

5. Widespread damage to both cerebral hemispheres due to
disruption of the reticular activating system in the upper
brain stem.

6. The brain requires a constant supply of oxygenated blood
and glucose to function. Interruption of this function will
cause loss of consciousness within few seconds and
permanent brain damage in minutes.

7. CONSCIOUSNESS
•A state of awareness of yourself and your surroundings
•Ability to perceive sensory stimuli and respond appropriately to
them

8. UNCONSCIOUSNESS
•Abnormal state - client is unarousable and unresponsive.
Coma is a deepest state of unconcsiousness.
•Unconcsiousness is a symtom rather than a disease.
Degrees of unconsciousness that vary in length and severity:
•Brief – fainting
•Prolonged – deep coma

9. Etiology
STRUCTURAL OR SURGICAL
UNCONSCIOUSNESS
Trauma
Epidural / Subdural
hematoma
Brain contusion
Hydrocephalus
Stroke
Tumor
METABOLIC OR MEDICAL
UNCONSCIOUSNESS
Infection
Meningitis
Encephalitis
Hypo/hyperglycemia
Heptic encephalopathy
Hyponatremia
Drug /alcohol overdose
Poisoning /intoxication

10. Pathophysiology
Damage to the brain and skull
Inflammation, edema and haemorrhage
Increased ICP
Diffused damage to the cerebral tissues
Blocks the signal to the RAS (Reticular activating system)
UNCONSCIOUSNESS

11. Signs and Symptoms
The person will be unresponsive (does not respond to
activity, touch, sound, or other stimulation).

12. An unconscious person:
Is unaware of his surroundings and does not respond to sound
Makes no purposeful movements
Does not respond to questions or to touch
Confusion
Drowsiness
Inability to speak or move parts of his or her body
Loss of bowel or bladder control (incontinence)
Stupor

13. Respiratory changes (cheyne stroke respiration, cluster
breathing, ataxic breathing, hyperventilation)
Abnormal pupil reactions

14. Effects of Altered LOC or Coma:
1.Full recovery with no Long term residual effects
2.Recovery with residual damage (learning deficits,
emotional difficulties, impaired judgement)
3.Persistent vegetative state (cerebral death or brain death)

15. Diagnostic test:
X-ray
MRI (magnetic resonance imaging) : tumors, vascular
abnormalities, IC bleed
CT (computerized tomography) : cerebral edema,
infarctions, hydrocephalus, midline shift
Lumbar puncture : cerebral meningitis, CSF evaluation

16. PET (positron emission tomography)
EEG: electric activity of cerebral cortex
Blood test like CBC, LFT, RFT, ABG etc.
In addition to these imaging techniques, a variety of
neurological and behavioral tests are used to diagnose brain
injury.

17. Medical management
The goal of medical management are to
preserve brain function and prevent
further damage.
•Ventilatory support
•Oxygen therapy
•Management of blood pressure
•Management of fluid balance
•Management of seizures : anti epileptic
(fosphenytoin), sedatives, paralytic agents

18. •Treating Increased ICP : mannitol,
corticosteroids
•Management of temperature regulation
(fever): ice packs, tepid
sponging,Antipyretics,NSAIDS
•Management of elimination : laxatives
and high fibre diet
•Management of nutrition: TPN and RT
feeds
•DVT prophylaxsis

19. Surgery if necessary
•Craniotomy : Skull/bone flap is kept in the
abdomen
•Cranioplasty
•Burr-hole

20. Nursing Management
GOALS OF NURSING CARE
•Maintain adequate cerebral perfusion
•Remain normothermic
•Be free from pain, discomfort, and
infection
•Attain maximal cognitive, motor and
sensory function

21. Assessment :
Nurses frequently need to monitor the conscious level as
impairments may complicate the existing condition and may cause
complications and further deterioration.
GLASGOW COMA SCALE.
The Glasgow Coma Scale : 
The Glasgow Coma Scale A neurological scale – Gives a reliable,
objective record of the level of consciousness (LOC) of a person,
for initial as well as continuing assessment.
The nurse observes and describes three aspects of the patients
behavior:
Eye opening
Verbal response
Motor response.

22. Eye opening response Spontaneous 4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdraws 4
Flexion 3
Extension 2
None 1
Total  3 to 15
13-15 minor brain injury 9-12 is moderate 3-8 is
severe

23. Interpretation of Glasgow Coma Scale.
 Highest score is 15/15 – Good orientation
 Lowest score is 3/15 - Deep coma. Considered brain dead if
client dependant on a ventilator
GCS ≤ 8 – Severe brain injury
GCS 9 – 12 - Moderate brain injury
GCS ≥ 13 – Mild brain injury.

24. Limitations of
GCS scoring.
Eye opening:
If severe facial/eye swelling/ptosis is present one cannot test eye
responses.
The patient who is in deep coma with flaccid eye muscles will
show no response to stimulation. However if the eyelids are
drawn back the eyes may remain open. This is very different from
spontaneous eye opening and must be recorded as ‘none’.

25. Verbal Response:
The verbal response may be compromised by the presence of
an endotracheal/ tracheostomy tube.
Hearing defect/ speech defect may alter patient’s response.
Written instructions may be used.

26. Motor Response:
Asymmetrical responses(focal deficit): Best motor
response should be recorded. e.g. if patient localizes
pain on his left side but flexes to pain on his right side,
localizing response is recorded.
Explain the use of pain stimuli to the relatives.
Pain infliction may result in bruising.

27. Physical Assessment
Voluntary movement –
Strength and asymmetry
in the upper extremities
Deep tendon Reflexes –
biceps, triceps and patella
Posture – Decerebrating
and Decorticating

29. Pupillary light reflex (pupil size)
Corneal blink reflex
Gag swallowing reflex

30. Potential nursing diagnosis :
Ineffective airway clearance
Ineffective cerebral tissue perfusion
Risk for increased ICP
Imbalanced fluid volume
Impaired skin integrity
Self care deficit
Imbalanced nutrition
Incontinence : bowel and /or bladder
Risk for aspiration
Risk for contractures
Altered family process

31. Maintaining a patent airway
•The breath sounds must be assessed every 2 hourly.
•ABG results must be interpreted to determine the degree of oxygenation
provided by the ventilators or oxygen.
•Assess for cough and swallow reflexes
•Use an oral artificial airway to maintain patency
•Tracheostomy or endotracheal intubation and mechanical
ventilation maybe necessary
PREVENTING AIRWAY OBSTRUCTION
•Position on alternate sides 2-4 hrs to prevent secretions
accumulating in the airways on one side. Maintain the neck in a
neutral position

32. •Oronasopharyngeal suction equipment may be necessary to
aspirate secretions.
•If facial palsy or hemi paralysis is present the affected side must be kept
the uppermost.
•Chest percussion and postural drainage may be prescribed to
assist in the removal of tenacious sections
•Dentures are removed
•Nasal and oral care is provided to keep the upper airway free of
accumulated secretions debris
•Monitoring neurological signs at intervals determined by their
condition
•Document these results and compare with previous assessments

33. Assess the GCS, SPO2 level and ABG of the patient.
Monitor the vital signs of the patients (increased
temperature)
Head elevation of 30 degrees, neutral position
maintained to facilitate venous drainage.
Reduce agitation .(Sedation.)
Reduce cerebral edema (Corticosteroids, osmotic or
loop diuretics.) Generally peaks within 72 hrs after
trauma and subsides gradually.
Ineffective cerebral tissue perfusion

34. Schedule care so that harsh activity [suctioning
bathing, turning] are not grouped together, with breaks
between care for recovery. Talk softly and limit touch
and stimulation.
Administer laxatives, antitussives and antiemetics
as ordered
Manage temperature with antipyretics and
cooling measures. Prevent seizure with ordered
dilantin.
Administer mannitol 25-50 g IV bolus if ICP >20, as
prescribed.

35. Risk for increased ICP.
Assess the GCS score, assess signs of increased ICP .
Head elevation of 30 degrees, neutral position
maintained to facilitate venous drainage and prevent
aspiration.
Pre-oxygenation before suctioning should be
mandatory , and each pass of the catheter limited to 10
seconds, with appropriate sedation to limit the rise in ICP.
Insertion of an oral airway to suction the secretions.
The breath sounds must be assessed every 2 hourly
As fluid intake is restricted and glucose is avoided to
control cerebral oedema and intravenous infusion cannot be
considered as a nutritional support.

36. Signs of increased ICP :
Restlessness
 headache
pupillary changes: ASSESS every hourly
respiratory irregularity
widening pulse pressure, hypertension and
bradycardia. (CUSHING’S TRIAD)
NORMAL ICP : 5 TO 15 mm of Hg

37. Imbalanced fluid and electrolyte
Intake-Output chart should be meticulously maintained.
Daily weight should be taken.
Assess and document symptoms that may indicate fluid
volume overload or deficit.
Diuretics may be prescribed to correct fluid overload and
reduce oedema.
Overhydration and intravenous fluids with glucose
are always avoided in comatose patients as cerebral
oedema may follow.

38. Impaired skin integrity
The nurse should provide intervention for all self-care needs
including bathing, hair care, skin and nail care.
Frequent back care should be given.
Comfort devices should be used.
Positions should be changed.
Special mattresses or airbeds to be used.
Adequate nutritional and hydration status should be
maintained.
Patient’s nails should be kept trimmed.
Cornea should be kept moist by instilling methyl cellulose
0.5% to 1%.

39. Protective eye shields can be applied or the eyelids
closed with adhesive strips if the corneal reflex is
absent. These measures prevent corneal abrasions and
irritation.
Inspect the oral cavity.
Keep the lips coated with a water-soluble lubricant
to prevent encrustation, drying, cracking. Inspect the
paralyzed cheek.
Frequent oral hygiene every 4 hourly.
Nasal passages may get occluded so they may be cleaned
with a cotton tipped applicator.

40. PROPER POSITIONING
Lateral position on a pillow to maintain head in a neutral position
Upper arm positioned on a pillow to maintain shoulder
alignment
Upper leg supported on a pillow to maintain alignment of
the hip
Change position to lie on alternate sides every 2-4hrs
For hemiplegia – position on the affected side for brief periods,
taking care to prevent injury to soft tissue and nerves, oedema or
disruption of the blood supply
Maintaining correct positioning enables secretions to drain from the
client’s mouth, the tongue does not obstruct the airway and postural
deformities are prevented.

42. Self care deficit
Attending to the hygiene needs of the unconscious
patient should never become ritualistic, and despite the
patient's perceived lack of awareness, dignity should not be
compromised.
Involving the family in self care needs.
Incontinence, perspiration, poor nutrition, obesity
and old age also contribute to the formation of
pressure ulcers.
Care should be taken to examine the skin properly, noting
any areas which are red, dry or broken.
Fingernails and toenails also need to be assessed
Chronic illnesses, such as diabetes needs more attention

43. Bathing:
Minimum two nurses should bathe an unconscious patient as
turning the patient may block the airway.
Proper assessment of the condition of the skin must be done
when giving a bed bath.
Hair care should not be neglected.

44. Oral Hygiene:
A chlorhexidine based solution is used.
Airway should be removed when providing oral
care. It should be cleaned and then reinserted.
If the patient has an endotracheal tube the tube should
be fixed alternately on each side.
Minimum of four-hourly oral care to reduce the
potential of infection from micro-organisms.
Also not to damage the gingiva by using excessive force.

45. Eye Care:
In assessing the eyes, observe for signs of irritation,
corneal drying, abrasions and oedema.
Gentle cleaning with gauze and 0.9% sodium chloride
should be sufficient to prevent infection.
Artificial tears can also be applied as drops to help
moisten the eyes.
Corneal damage can result if the eyes remain open for a
longer time.
Tape can be used to close the eyes.

46. Nasal Care:
Cleaning of the nasal mucosa with gauze and water
Nasogastric tube placement damage to the nasal mucosa
Ear Care:
Clean around the aural canal, although care must be taken
not to push anything inside the ear.

47. Imbalanced nutrition
•Diet prescribed nutrition based on individuals requirements
specifically to meet energy needs, tissue repair, replace fluid
loss to maintain basic life functions

48. •METHODS
•TPN (Total parenteral nutrition)
•Enteral feeding via Nasogastric, nasojejunal OR PEG tube
Intravenous fluids are administered for comatose patients.
As fluid intake is restricted and glucose is avoided to control
cerebral oedema and intravenous infusion cannot be considered
as a nutritional support.
•Total paraentral nutrition, i.e. TPN is considered for prolonged
unconsciousness.
•Naso-gastric feedings are given.

50. Risk for injury
Side rails must be kept whenever the patient is not
receiving direct care.
Seizure precautions must be taken.
Adequate support to limbs and head must be given
when moving or turning an unconscious patient. Protect
from external sources of heat.
Oversedation should be avoided – as it impedes the
assessment of the level of consciousness and impairs
respiration.
Assess the Need for restrain.

51. Impaired bowel/ bladder functions
Assess for constipation and bladder distention.
Auscutate bowel sounds.
Stool softeners or laxatives may be given.
Bladder catheterization may be done.
Meticulous catheter care must be provided under
aseptic techniques.
Monitor the urine output and colour.
Initiate bladder training as soon as consciousness has
regained.

52. Risk for contractures
Maintain the extremities in functional positions by
providing proper support.
Remove the support devices every four hours for
passive exercises and skin care.
Foot support should be provided.

53. Sensory stimulation
•Brain needs sensory input
• Widely believed that hearing is the last sense to go
•Talk, explain to the patient what is going on
•Upon waking many clients remember….. and will accurately
recall events and processes that happened while they were
“sleeping”. (unconscious)
•Some have reported they longed for someone to talk to them
and not about them.

54. •Nurses must:
•Show respect
•Encourage family to contribute to the care of their loved ones
•Afford the privacy both the client and family deserve
•Encourage stimulation by:
•Massage
•Combing/washing hair
•Playing music/radio/CD/TV
•Reading a book
•Bring in perfumed flowers
•Update them with family news

55. Altered family process
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.

56. Any
Questions ?
????????