Conditions

1. UNCONSCIOUSNESS

2. CONSCIOUSNESS - consciousness is defined as a state
of awareness of self, time and of environment, as well as
a state of responsiveness to that environment or
adaptation to the external stimuli.

3. Unconsciousness - is a condition in which the
patient is unresponsive and unaware of
environmental stimuli. It can be brief, lasting for few
seconds, hours, days or longer.

4. Causes and Risk Factors of
Unconsciousness
• Head injury (traumatic
brain injury)
• Skull fracture
• Brain hypoxia (e.g., due
to a brain infarction or
cardiac arrest)
• Extremes of body
temperature
• Cardiac arrest
• Blood loss
• Cerebrovascular accident
• Epilepsy
• Hypoglycaemia
• Hyperglycaemia
• Drug overdose
• Encephalitis
• Meningitis
• Fluid and electrolyte
imbalance

5. • Hypothermia
• Poisonous substances and fumes (that depress the activity
of the central nervous system)
• Pathophysiology of Unconsciousness
• Impairment of consciousness indicates dysfunction
• reticular activating system (RAS). RAS is a piece of the
brain that starts closing to the top of the spinal column an
extends upwards around 2 inches. RAS has a large
number projections that are basically linked to the
cerebral cortex .

6. • Confessional State Confusion state is a state in which
the patient cannot take into account all elements of
his/her immediate environment, implying an element
of sensorial clouding.
• Apathy and drowsiness are often prominent and
accompanied by disorientation primarily for time, less
often for place and rarely for self.

7. • Mild confusion states are common, especially in
elderly patients exposed to hospital or trauma of major
surgery. Precipitating factors are: metabolic
encephalopathy due to systemic organ failure,
especially of kidneys or liver, excessive medication,
nutritional insufficiency or systemic infection with
fever.
• A severely confused person is usually unable to carry
out more than a few simple commands.

8. • Delirium is characterized by a fluctuating disturbance in
consciousness and change in cognition that develop over a
period of time. It is generally accompanied by increased
morbidity and subsequent functional decline. The signs and
symptoms of delirium include disorientation which is
sometimes total and inclusive of absence of self-regulation.
Other characteristic findings are irritability, perceptual
delusions, visual hallucinations and usually intermittent
impairment of arousal, but there may be sustained insomnia.
• Obtundation is characterized by reduced alertness and
hypersomnia (a state of excess of sleep). When awakened from
an obtunded state, the patient remains drowsy and confused

9. • Stupor is unresponsiveness from which the patient can
only be aroused by vigorous repeated painful stimuli.
There is no response to verbal stimuli and the response to
pain becomes progressively less as the level of stupor
deepens.
• The patient is unable to localize the site of the painful
stimuli. The mental and physical activity is reduced to a
minimum. The patient can open his eyes and does not
appear to be unconscious. Deep tendon reflexes are
usually intact, but there may be evidence of muscle
twitching.

10. Coma The patient who appears to be asleep and at the
same time incapable of responding, is in a state of coma.
Coma may vary in degree from light to medium to deep.
In deepest stage, no reaction of any type is obtainable
from the patient. Corneal, pupillary, pharyngeal, tendon
and plantar reflexes are absent. Coma may last few days
to few weeks. After this, patients gradually come out of
the coma, some of them may progress to a vegetative
state and some may die.

11. GLASGOW COMA SCALE
• Level of consciousness is assessed through Glasgow
coma scale
• Client's response is rated from 3 to 15. Less than 3
indicates unconsciousness due to neurological
impairment.

13. NURSING CARE OF UNCONSCIOUS
PATIENT
• Unconscious comatose clients are completely dependent on others
because their consciousness and protective reflexes are impaired.
Therefore, they require aggressive nursing intervention. Nurses
are responsible for meeting basic needs and pre- venting the
complications associated with unconsciousness.
• For the effective care, nurse should perform frequent assessment
of comatose client, plan the care and implement the care.
• Assess vital signs (temperature, pulse, blood pressure respiration)
of the patient 4 hourly or as required to plan the care, prevent
complications and manage early signs of any deviation in normal
functioning.
• .

14. Priority Wise Nursing Care of Unconscious
Patient Ineffective airway clearance related to upper airway
obstruction by tongue and soft tissue.
Nursing care for maintaining patent airway:
• Assess respiratory rate pattern, lung sound, hypoxia and cyanosis, presence of
secretion because of inability to clear respiratory secretions to plan the care.
• Elevating the head end of the bed to 30 degrees to prevent aspiration
• Positioning the patient in lateral or semi-prone position to prevent aspiration
• Insert airway if tongue is paralyzed or obstructing the airway Suction airway
intermittently to prevent accumulation of secretion in posterior pharynx and
upper trachea and prevent aspiration.
•
• Administer humidified oxygen before suction in and prevent hypoxia.
• Initiate chest physiotherapy and postural drainage promote pulmonary hygiene

15. • Prepare client for endotracheal intubation or
tracheostomy and connect to mechanical ventilation
as needed to maintain respiration, efficient removal of
tracheobronchial secretion, protect from aspiration
and maintain oxygen level.
• Increase amount of fluid administered; at least 2.5 L a
day to loosen airway secretion and promoting easy
removal.
• Auscultate chest at least every 8 hours to detect
adventitious breath sound or absent breath sound.
Monitor arterial blood gas (ABG) measurement to
detect complications of respiration.

16. Risk of injury related to unconscious state Nursing
care for protecting the client from injury:
• Assess the risk factors for injury: Lack of side rails,
seizures, invasive lines and equipment, restraints and
tight dressing.
• Keep side rails up and bed in lowest position
whenever the client is not receiving any direct care to
prevent fall.
• Observe seizure precaution for clients with history of
seizure episodes.

17. • Use padded side rails to prevent injury during seizure activity.
Keep client's nails short to prevent scratching. Use caution
when moving the client, give adequate support to limbs and
head to prevent dislocation.
• Always turn the client toward the nurse to prevent fall. Protect
from external sources of heat such as hot water bags.
• Unconscious client cannot voice pain. Release restraints every
2 hours. It helps in providing range of motion exercise and
prevent complications of immobility.
• Avoid restraints as far as possible. Allow one family member
to be with the client. Keep bed and bedding free from
moisture, dust and debris to prevent skin excoriation.
• Avoid speaking negatively about the client or his conditions.
The last sense to go is the sense of hearing for psychological
integrity.

18. Risk of fluid volume deficit related to inability to ingest food,
dehydration from osmotic diuretics. Nursing care for
maintaining optimum fluid volume state:
• Assess hydration status by examination of skin turgor,
mucus membrane, intake and output changes and
analyzing laboratory data electrolytes, creatinine and
blood urea nitrogen (BUN).
• Hydrate the client with use of intravenous (IV) fluids
as prescribed to meet fluid needs.
• Avoid over hydrating the client with IV fluids or
blood transfusion because excessive or rapid
administration of fluid may lead to cerebral edema
and increased intracranial pressure (ICP).

19. • Administer fluids slowly to prevent injury to veins.
Continue fluid administration with use of Ryle's
tubeto allow long-term fluid administration.
• Administer corticosteroids and diuretics in suspected
cerebral edema to maintain normal volume of fluids.
• Maintain intake and output and do
properdocumentation to detect abnormality.
• Evaluate peripheral pulse and blood pressure at
regular intervals to measure circulatory adequacy.

20. Imbalanced nutrition less than body requirement related to
inability to eat or swallow as evidenced by weight and other
nutritional parameter less than normal.
• Nursing care for maintaining nutritional status: Assess
nutritional status through skin and mucus membrane.
• Administer IV fluids to meet nutritional mucous. Administer
fluid diet in the form of juices, shake, soup, water, milk and
protein lactose through Ryle's tube feeding, as unconscious
patient cannot take oral feed.
• Increase the quantity as prescribed because metabolic need
increases due to immunodeficiency, protein wasting and lung
tissue catabolism.
• Provide high calorie, high protein and vitamin-rich liquid diet.
Initiate total parenteral nutrition if the client cannot tolerate
Ryle's tube feed, or according to need.

21. Ineffective thermoregulation due to damage to hypo-
thalamus center as evidenced by persistent elevation of
body temperature, warm and dry skin.
• To maintain body temperature: Regularly assess the
temperature.
• Look for possible site of infection.
• Control persistent elevation of temperature with use of
antipyretics, cooling blankets, adequate fluid intake, tepid
sponge, cold compress and good ventilation of room.
• Fever increases metabolic demand of brain, decreases
circulation and oxygenation resulting in cerebral deterioration.
• Control shivering in fever with use of blanket, warm
environment and heat application. Prevent infection by using
aseptic technique during procedure.
•

22. Altered oral mucous membrane related to mouth
breathing, absence of pharyngeal reflex, inability to
ingest fluids as evidenced by dryness, inflammation,
crusting and halitosis.
• To maintain oral hygiene: Assess oral mucous membrane
regularly. Inspect mouth every 8 hourly using flash light
and tongue depressor to detect problems in early stage.
• If denture is present, remove them to prevent choking
and other complication.
• Provide oral care. Cleanse mouth carefully with
appropriate solution (potassium permanganate, Listerine)
every 2-4 hours to prevent halitosis and infection.
• Provide oral care after suctioning to clean oral cavity
adequately. Apply thin coat of petroleum jelly after oral
care to moisten the lips and prevent drying and cracking.

23. • Risk of impaired corneal integrity related to
absence of corneal blink reflex and dryness of eyes.
• To maintain eyes integrity: Assess signs of impaired
corneal integrity (corneal drying, irritation, ulceration).
• Look for presence of corneal blink responses to plan
the care. Protect eyes with shield.
• If eyes remain open for long period, corneal ulceration
will develop.
• Apply eye patches when indicated to ensure that eyes
remain closed.
• Make sure the client's eyes are not rubbing against
anything such as bedding or clothing.
•

24. • Inspect the condition of eyes with flashlight at regular
intervals to detect corneal irritation at early stage.
• Irrigate eyes with sterile saline or prescribed solution
as ordered. Removal of discharge and debris prevents
inflammation.
• Provide regular eye care with proper sterile technique
to prevent eye infection and clean the eyes.
• Instill prescribed ophthalmic ointment in each eye to
prevent corneal ulceration.
• Instill artificial tears as prescribed to keep eyes moist
and prevent dryness of eyes.

25. • Self-care deficit (bathing, feeding, grooming and toileting) related
to unconscious state.
• To maintain hygiene: Assess self-care needs to perform self-care
activities.
• To maintain skin hygiene or skin integrity: Perform bed bath daily or
as required (upon soiling of bed with stool, urine, sweat or dirt).
Clean skin prevents bacterial growth and promote overall well- being.
• Regularly change the position. Provide passive exercise. Provide a
range of motion exercises to prevent contracture. Avoid vigorous
massage of bony prominences (vigorous massage causes skin
excoriation over bony prominences).
• Provide high calorie, high protein, vitamin rich diet with more
amount of fluid.
• Adequate nutrition prevents pressure sore formation. Prevention of
contracture and joint deformity and Keep the body in the anatomical
position with the muscle wasting: use of devices like foot rest,
trochanter rolls, sandbags, rolled cloth, water filled gloves. Body
alignment helps to prevent joint deformity and contracture.
• Give protein-rich diet. It helps to maintain positive nitrogen balance.

26. • Perform range of motion exercises every 4 hourly after
removing the support devices. Passive exercise helps to
strengthen the weak muscles, loosens spastic muscles,
promotes joint flexibility and increases overall well-being
of the client.
• Prevention of deep vein thrombosis: Elevate lower
extremities above the heart level intermittently for 20
minutes.
• It increases venous return, thus preventing thrombus
formation. Perform passive range of motion exercise toe
very 4 hourly.
• Use elastic stockings as required. Extremities Monitor the
presence of redness, swelling and increased temperature of
legs.
• Prevention of hypostatic pneumonia/aspiration pneumonia:
Pulmonary congestion occurs due to the stagnation of
blood in the dependent portions of the lungs in persons who
are ill and lie in the same position for long periods.

27. • Aspiration pneumonia is an inflammation (usually due to an
infection) of lungs and bronchial tubes by inhaling materials
such as vomitus, food, or liquid.
• Suction the airway at regular interval, unconscious client is
unable to remove oral and airway secretion and
accumulation of secretion leads to pneumonia.
• Change position 2 hourly, prevent pooling of secretion in
the lungs and thus hydrostatic pneumonia is prevented.
• Initiate chest physiotherapy and postural drainage unless
contraindicated. Feed the client in a head elevated.
• Aspirate Ryle's tube before feeding.
• Watch for regurgitation and vomiting. Keep head turned to
one side. Give fluids to loosen airway secretions to facilitate
easy removal.

28. Prevention of constipation: Provide adequate fluid. Increased
fluids are required for softening the feces. Administer stool
softener and enema to bowel evacuation.
• Change position every 2 hourly. increases bowel movement.
Impaired sensory stimulation related to improper neural
functioning Providing sensory stimulation: Provided at proper
time to avoid sensory deprivation.
• Efforts are made to maintain the sense of daily rhythm by
keeping the usual day and night patterns for activity and sleep.
• Maintain the same schedule each day. Orient the client to the
day, date and time accordingly.
• Touch and talk in reassuring voice. Proper communication
should be done. Always address the client by name and explain
the procedure each time. Interrupted family process related to
chronic illness of family members as evidenced by anger, grief
and non- participation in client care.

29. • Assess family's response toward the client's illness, severe
anxiety, denial, anger, remorse, grief, usual use of coping
mechanism, role of client in the family, communication
pattern, social support available, financial status and
relationship between family members provide baseline data
about family and helps in planning the care to help them
accordingly.
• Develop a supportive and trusting relationship with the family
or significant others to develop good interpersonal
relationship. Provide information and frequent updates on
client's condition and progress. It helps to alleviate anxiety.
Family needs should be maintained.
• Family support should be given. Involve family in routine
care. Teach procedure that they can perform at home.
Demonstrate and teach methods of sensory stimulation to be
used frequently.

30. • This intervention helps family to understand that client is having
internal awareness of what is going on around, though he is not
responding to stimuli, it helps them to better cope with client's
condition and reduces their anxiety to a greater extent and
increases their participation in client's care.
• Educate them about the needs of client, care of client, treatment
plan, prognosis of treatment and don't provide any false
assurance. Teach them to report unusual restlessness in the client.
It indicates cerebral hypoxia or metabolic imbalance.
• Help the family members to verbalize their doubts and cope with
the situation. Enlist help of social worker, home health agency,
or other resources to assist family with financial concern and
need for medical equipment in home.