CARE OF UNCONSCIOUS CLIENT

A Report by: DONELIE KAY T. ASANZA

Consciousness
Implies awareness and attention to one's surroundings and to oneself Maintained by impulses mediated via Grey Matter in the Reticular Activating System (R.A.S.)

Unconsciousness
Unconsciousness is different from normal sleep in that unconscious subjects are not usually arousable and quite often, there is loss of or interference with basic protective reflexes such as: Maintenance of free airway Coughing and swallowing Withdrawal from noxious stimuli etc.

Causes Of Unconsciousness Include:

1. Shock 7. Hysteria 2. Asphyxia 8. Infantile 3. Poisoning Convulsions 4. Head Injury 9. Hypothermia or 5. Cerebrovascular Hyperthermia Accidents- (Stroke) 10.)diabetes 6. Epilepsy Mellitus Hypo/Hyper 11.Fainting/Syncop e, Vasovagal Attacks 12. Heart Attacks 13. others E.G. Meningo Encephalitis, Fluids And Electrolyte Disorders

ASSESSMEN T

A. Decorticate posturing- flexion of upper extremities, internal rotation of the lower extremities & plantar flexion of the feet B. Decerebrate posturing- extension and outward rotation of upper extremities & plantar flexion of the feet

NURSING DIAGNOSIS

Ineffective airway clearance related to Altered LOC Risk of Injury related to decreased LOC Deficient fluid volume related to inability to take fluids by mouth Impaired oral mucous membrane r/t mouth breathing, absence of pharyngeal reflex and altered fluid intake Impaired tissue integrity of cornea r/t diminished or absent corneal reflex

Ineffective thermoregulation r/t damage to hypothalamic center Impaired urinary elimination (incontinence or retention) r/t impairment in neurologic sensing and control Bowel incontinence r/t impairment in neurologic sensing and control and also r/t changes in nutritional delivery methods Disturbed sensory perception r/t neurologic impairment Interrupted family processes r/t health crisis

Collaborative Problems/ Potential Complications

Respiratory distress or failure Pneumonia Aspiration Pressure Ulcer Deep Vein Thrombosis Contractures

NURSING CARE OBJECTIVES

Maintenance of clear airway Protection from injury Attainment of fluid volume balance Achievement of intact oral mucous membrane Maintenance of normal skin integrity Absence of corneal irritation

Attainment of effective thermoregulation Effective urinary elimination Bowel continence Accurate perception of environmental stimuli Maintenance of intact family or support system Absence of complications

NURSING INTERVENTIONS

Maintaining the Airway

1. Elevate the head of bed to at least 30 degrees to prevent aspiration. 2. Position the patient in a lateral or semiprone position to facilitate drainage of secretions. 3. Suction nasopharyngeal secretions as necessary. Hyperoxygenate the client before and after suctioning. 4. Chest physiotherapy and postural drainage may be initiated as ordered. 5. Auscultate the chest at least every 8 hours to detect adventitious breath sounds or absence of breath sounds. 6. If in mechanical ventilation, maintain the patency of the endotracheal tube or tracheostomy. 7. Continously monitor arterial blood gas measurements and vital signs.

Protecting the Patient

1. Keep the side rails padded at all times. 2. Prevent injury from invasive lines and equipment and other potential sources of injury should be identified such as restraints, tight dressings, environmental irritants,etc. 3. Provide privacy and speak to the patient while doing nursing activities. 4. Do not speak negatively about the patients condition or prognosis while in front of him/her.

Maintaining Fluid Balance and Managing Nutritional Needs

1. Assess patients hydration status. 2. Administer the required IV Fluids. BE CAUTIOUS in the regulation rate. 3. Assist in the insertion of gastrostomy tube.

Providing Mouth Care

1. Inspect patients mouth for dryness, inflammation and crusting. 2. Cleanse and rinse patients mouth carefully to remove secretions and crust. 3. Apply a thin coating of petrolatum on patients lips. 4. If the patient has an endotracheal tube, move the tube to the opposite side of the mouth daily to prevent ulceration of the mouth and lips.

Maintaining Skin and Joint Integrity

1. Regularly turn the patient to avoid pressure. 2. Carefully reposition to prevent ischemic necrosis over pressure areas. 3. Maintain correct body position. 4. Do passive exercise of the extremities to prevent contractures. 5. Use splints and foam boots to prevent foot drop and pressure ulcers in the toes. 6. Use of trochanter rolls to support hip joints is also important. 7. Specialty beds such as fluidized or low-air loss beds may be used to decrease pressure on bony prominences.

Preserving Corneal Integrity

1. Cleanse the eyes with moistened cotton balls with normal saline to remove debris and discharge. 2. If artificial tears are prescribed, they may be instilled every 2 hours. 3. Apply cold compress (if periorbital edema is present). Care must be exerted to avoid contact with the cornea. 4. Eye patches should be used cautiously.

Maintaining Body Temperature

1. Assess patients body temp by rectal or tympanic and NEVER BY MOUTH. 2. Adjust room temperature. 3. Remove all bedding over the patient. 4. Administer acetaminophen as prescribed. 5. Give cool sponge bath and allow an electric fan to blow over the patient. 6. Frequent temperature monitoring is indicated to assess patients response to therapy and prevent excessive decrease in temperature and shivering.

Preventing Urinary Retention

1. Palpate the bladder or scan at intervals to assess for urinary retention. 2. If the patient is not voiding, an indwelling urinary catheter is inserted and connected to a closed drainage system. 3. Observe for fever and cloudy urine. 4. An external urinary catheter (condom catheter) for male or absorbent pads for female can be used for unconscious patients who can urinate spontaneously although involuntary .

Promoting Bowel Function

1. Assess for distention of the abdomen by abdominal girth using a tape measure and auscultating for bowel sounds. 2. Monitor the number and consistency of bowel movements. 3. Perform a rectal examination for fecal impaction. 4. Administer stool softeners as prescribed through tube feedings. 5. A glycerin suppository may be indicated to facilitate bowel emptying. 6. Patient may also require enema every other day to empty the lower colon.

Providing Sensory Stimulation

1. Communicate to the patient and encourage family members to do so. 2. Avoid making negative comments in the patients presence. 3. Orient the patient to time and place at least every 8 hours. 4. Suggest activities such as reading patients favorite book and playing his favorite music to family members. 5. After the patient regained consciousness, orient the patient to his/her environment by videotaped family and social events.

Monitoring and Managing Potential Complications

1. Closely monitor for vital signs and respiratory function. 2. Chest physiotherapy and suctioning is initiated to prevent respiratory complications such as pneumonia. 3. Monitor for signs and symptoms of DVT. Measures to prevent DVT must be initiated.