nursing care

1. DR MANAS NAYAK(DA,MD,IDCCM)
CHIEF CONSULTANT,CRITICAL CARE MEDICINE,
SBM HOSPITAL,CUTTACK
NURSING CARE OF AN
UNCONSCIOUS PATIENT
drmanasnayakscb@gmail.com,
9861538756
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2. Discussion Points
 Definition of Unconsciousness.
 Etiology of Unconsciousness.
 Pathophysiology of unconsciousness
Signs and Symptoms.
 Diagnostic testing, and treatment options.
 Nursing management of Unconscious patients
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3. BASICS
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4. RAS (Reticular Activating
System)
The reticular activating system, or RAS, is a
piece of the brain that starts close to the top
of the spinal column and extends upwards
around two inches.
It has a diameter slightly larger than a pencil.
All of your senses are wired directly to this
bundle of neurons that's about the size of
your little finger.
Often, the RAS is compared to a filter or a
nightclub bouncer that works for your brain.
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5. While it may be a fairly small part of your brain, the
RAS has a very important role: it's the gatekeeper
of information that is let into the conscious mind.
It makes sure your brain doesn't have to deal with
more information than it can handle. Thus, the
reticular activating system plays a big role in the
sensory information you perceive daily.
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6. damage in minute
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 s.
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7. CONSCIOUSNESS
A state of awareness of yourself and your
surroundings
Ability to perceive sensory stimuli and respond
appropriately to them
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8. UNCONSCIOUSNESS
Abnormal state - patient is unarousable
and unresponsive. Coma is a deepest
state of unconsciousness.
Unconsciousness is a symptom rather than a
disease.
Degrees of unconsciousness that vary in length
and severity:
Brief – fainting
Prolonged – deep coma
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9. Etiology
STRUCTURAL OR
SURGICAL
Trauma
Epidural /
Subdural
hematoma
Brain contusion
Hydrocephalus
Stroke
Tumor
METABOLIC OR
MEDICAL
Cardiac arrest
Hypotension due to any
Hypoxia,Asphyxia
Infection
Meningitis
Encephalitis
Hypo/hyperglycemia
Heptic
encephalopathy
Hyponatremia
Drug /alcohol
overdose
Poisoning
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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)
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UNCONSCIOUSNESS

11. Signs and Symptoms
The person will be unresponsive (does not
respond to activity, touch, sound, or other
stimulation).
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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)
Respiratory changes
Abnormal pupil reactions
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13. 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)
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14. Diagnostic test:
X-ray -SKULL
MRI (magnetic resonance imaging) : tumors,
vascular abnormalities, IC bleed
CT (computerized tomography) : cerebral edema,
infarctions, hydrocephalus, midline shift
Lumbar puncture : cerebral meningitis, CSF
evaluation
PET (positron emission tomography)
EEG: electric activity of cerebral cortex
Blood test like CBC, LFT, RFT, ABG etc.
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15. Medical management
The goal of medical management are to preserve
brain function and prevent further damage.
Ventilator support
Oxygen therapy
Management of blood pressure
Management of fluid balance
Management of seizures : anti epileptic ,
sedatives, paralytic agents
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16. 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 prophylaxis
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17. Surgery if necessary
Craniotomy : Skull/bone flap is kept in the
abdomen
Cranioplasty
Burr-hole
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18. 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
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19. Assessment :
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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 is 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:
1. Eye opening
2. Verbal response.
3. Motor response.

20. 20

21. 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
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22. 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’.
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23. 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.
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.
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24. Physical Assessment
Voluntary movement – Strength and
asymmetry in the upper extremities
Deep tendon Reflexes – biceps, triceps
and patella
Pupillary light reflex (pupil size)
Corneal blink reflex
Gag swallowing reflex
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25. 25

26. 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
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27. 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
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28. Oronasopharyngeal suction 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
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29. Ineffective cerebral tissue
perfusion
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.
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30. 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.
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31. Risk for increased ICP.
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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.
m Breath sound must be assessed every 2

32. 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
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33. 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 edema.
Over hydration and intravenous fluids with
glucose are always avoided in comatose patients
as cerebral oedema may follow.
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34. 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
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35. 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.
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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.

36. PROPER POSITIONING
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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
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37. 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.
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38. 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.
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39. 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
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40. 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.
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41. 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.
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42. Imbalanced nutrition
Diet prescribed nutrition based on individuals
requirements specifically to meet energy needs,
tissue repair, replace fluid loss to maintain basic
life functions
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43. METHODS
TPN (Total parenteral nutrition)
TPN is considered for prolonged unconsciousness.
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.
Enteral feeding via Nasogastric, nasojejunal OR
PEG tube .
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44. 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.
Over sedation should be avoided – as it impedes
the assessment of the level of consciousness and
impairs respiration.
Assess the Need for restrain.
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45. 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.
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46. 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.
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47. 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
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48. 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
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49. 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.
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50. THANK U