care of unconscious patient (2).pptx

CARE OF UNCONSCIOUS PATIENT
PRESENTED BY-
SAYMA KHAN
NURSING TUTOR/CI
ERA'S COLLEGE OF NURSING

INTRODUCTION
• CONSCIOUSNESS IS A STATE OF BEING
WAKEFUL AND AWARE OF SELF
ENVIROMENT AND TIME.
UNCONSCIOUSNESS CAN BE BRIEF,
LASTING FOR FEW SECONDS TO AN HOUR
OR SO, OR SUSTAINED, LASTING FOR
FEW HOURS OR LONGER.

LEVEL ON UNCONSCIOUSNESS
1.ALERTNESS, ORIENTED: Open eys spontaneously, responds to
stimuli appropriately
2.LETHRGY, SLEEPY: Slow to respond but appropriate response, open
eyes to stimuli orented.
3.STUPOR - Aroused by and open eyes to painful stimuli, never fully
awake, confused, unclear conversation.
4.SEMI-COMA STAGE: moves in response to painful stimuli, no
convesation, protective blinking/swallowing, pupillary reflex present
5.COMA: Unresponsive expect to severe pain, no protective reflexes,
fixed pupils, no voluntary movement

ASSESSMENT OF
UNCONSCIOUS PATIENT
•HISTORY TAKING
•PHYSICAL ASSESSMENT
•LABTEST & PROCEDURE

PHYSICAL ASSESSMENT
GLASSGOW COMA SCALE IS USED TO ASSESS THE LEVEL
OF CONSCIOUSNESS

CONT...
• THE CLIENT'S RESPPONSE ARE RATED ON A
SCALE FROM 3 TO 15. A SCORE OF 3 INDICATED
SEVERE NEUROLOGIC IMPAIREMENT. A SCORE
OF 15 INDICATES THAT THE CLIENT IS FULLY
RESPONSIVE. A SCORE LESS THAN 7 REQUIRE
FREQUENT ASSESSMENT

LAB TEST AND PROCEDURE
• X RAY
• MRI
• CT
• LUMBAR PUNCTURE
• PET (POSITRON EMISSION TOMOGRAPHY)
• EEG (ELECTRICAL ACTIVITY OF CEREBRAL
CORTEX)
• BLOOD TEST LIKE CBC, LFT, RFT, ABG ETC

COMPLICATIONS OF IMMOBOLITY
• SKIN- PRESSURE SORE, LACERATION
• RESPIRATORY- HYPOSTATIC PNEUMONIA, PULMONARY,
EMBOLISM
• CV COMPLICATION- DVT, POSTURAL
HYPOTENSION, THROMBO EMBOLISM
• GI SYSTEM- PARALYTIC ILIUS, CONSTIPARTION, DISTENSION,
• PSYCHOLOICAL- ANXIETY, DEPRESSION
• NERULOGICAL- FOOT DROP

MEDICAL MANAGEMENT
THE GOAL OF MEDICAL MANAGEMENT ARE TO
PRESERVE BRAIN FUNCTION AND PREVENT FURTHER
DAMAGE
• VENTILATOR SUPPORT
• MANAGEMENT OF BLOOD PRESSURE
• MANAGEMENT OF FLUID BALANCE
• MANAGEMENT OF SEIZURES

• TREATING INCREASED ICP: MANINTOL
CORTICOSTERIODS
• MANAGEMENT OF TEMPERATURE REGULATION: ICE
PACKS, SPONGING
• MANAGEMENT OF ELEMINATION: LAXATIVES
• MANAGEMENT OF NUTRITION: TPN AND RT FEEDS
• DVT PROPHYLAXIS

NURSING MANAGEMENT
• MAINTAINING PATIENT AIRWAY-
ABC MANAGEMENT
ABG RESULTS MUST BE INTREPRETED TO DETERMINE THE DEGREE
OF OXYGENATION PROVIDED BY THE VENTILATORS OF OXYGEN
ASSESS FOR COUGH AND SWALLOW REFLEXES
USE AN ARTIFICAL AIRWAY TO MAINTAIN PATENCY
PREVENTING AIRWAY OBSTRUCTION
TRACHEOSTOMY OR ENDO-TRACHEAL INTUBATION AND
MECHANICAL VENTLATION MAY BE NECESSARY

• SUCTIONING
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.
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 and document result.
• Ineffective cerebral tissue perfusion
Assess the GCS, SPO2 level and ABG of the patient.
Monitor vital signs of the patient.

Head elevation of 30 degrees, neutral position maintained to
facilitate venous drainage.
Reduce agitation(sedation)
Reduce cerebral edema. Generally peaks within 72 hours after
trauma and subsides gradually.
Talk softly and limit touch stimulation.
Administer laxatives and antiemetic as ordered
Manage temperature with antipyretic and cooling measure.
Administer mannintol 25-50 g iv bolus if icp increased

• POSITIONING
Head elevation of 30 degrees, neutral position
maintained to facilitate venous drainage ad prevent
aspiration.
Preoxygen before suctioning should be mandatory.
Change the position of patient every 2 hourly in right
semi lateral or left semi lateral position.
Special mattresses or airbed should be used.

ROUTINE CARE OF PATIENT-
• FLUID AND ELECTROLYTE BALANCE-
Intake output chart should be meticulously maintained.
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 edema may
follow.

• CARE OF SKIN-
The nurse should provide intervation for all self care needs
including bathing, hair care, skin and nail care.
Frequent back care should be given.
Protective eye shield can be applied or the eyelids closed with
adhesive strips if the cornea reflex is absent. These
measures prevent corneal abrasions and irritation.
Inspect the oral cavity.
Ferequent oral care should be given

• NUTRITIONAL NEED
Total parenteral nutrition.
Energy feeding via N.G tube
Intavenous fluid are administered for comatose
patient.
• RISK FOR INJURY-
Side rails must be kept whenever the patient is not
receiving direct care.
Seizure precautions must be taken
Assess the need for restrain

• IMPAIRED BOWEL/BLADDER FUNCTION
Assess for constipation and bladder distension
Auscultate bowel sounds
Stool softeners or laxative may be given
Catheter care must be provided under aseptic
techniques.
Monitor the urine output and colour.
Initiate bladder training as soon as consciouness has
regained

• IMPAIRED FAMILY PROCESS
Include 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.
Clarifications and questions should be encouraged.

This Photo by Unknown author is licensed under CC BY-NC.

care of unconscious patient (2).pptx

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