The document discusses the assessment and management of unconscious patients. It defines unconsciousness as a state of reduced awareness and responsiveness. Causes can include head injuries, tumors, overdoses, infections, and more. Levels of consciousness are assessed using scales like the Glasgow Coma Scale. Nursing priorities for unconscious patients include airway maintenance, skin care, range of motion exercises to prevent contractures, and careful monitoring for any changes in condition.

1. ASSESSMENT AND MANAGEMENT OF
UNCONSCIOUSNESS CLIENT.
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2.  Unconsciousness this is a state in which the patient is
unaware of what is going on around him and is unable to
make purposeful movement.
 Unconsciousness can be brief lasting a few minutes or
sustained lasting an hour or longer ( lasting more than
6hrs = coma).
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3.  Unconsciousness is a state in which a person has
reduced awareness of his or her surroundings, is
without deliberate thoughts, and is less than
normally responsive to stimuli such as light and
sound.
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4.  Head injury
 Brain tumour
 Drug overdose.
 Hypoglycaemia
 Asphyxia
 Alcohol intoxication
 Meningitis
 Epilepsy
 CVA/STROKE
 Hypovolaemic shock.
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5.  Conscious (alert)--the patient responds immediately, fully,
visual, auditory, and other stimuli. The patient is aware of
himself, aware of the place and aware of the time.
 Semi- conscious- patient can be roused with difficult they
may respond to some stimuli.
 Stupor- partial unconsciousness where the patient
responds to stimuli by opening eyes , moving limbs.
 Comatose-- is a state of complete unconsciousness.
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6.  History taking
 Physical Assessment
 Neurological assessment
 Assess level of unconsciosness
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7.  Glasgow Coma Scale is the tool used to
assess level of consciousness.
 It evaluates three categories of behaviour
that reflect activities in the high centre of the
brain.
 Eye Opening
 Verbal Response
 Motor Response
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8.  The first score provides a base line for future
scorings.
 The lowest score the patient can achieve is 3
indicating total unresponsiveness.
 The maximum score is 15 indicating an awake,
alert and fully responsive patient.
A Score Less than 15 is usually an indication that
there is a cause for concern.
Note: The accuracy of the GCS is dependent on the
assessor using and interpreting it correctly.
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10. Conscious
 Normal, alert oriented to self, place, and mind
 Opens eyes spontaneously, responds to stimuli appropriately.
Confused
 impaired or slowed thinking,disoriented
 Delirious
 Disoriented, restless, attention deficit , possible incidence of
hallucinations and delusions
Somnolent
 Excessive drowsiness
 responds-to verbal stimuli although slow and inappropriate
Obtunded
 Decreased alertness, slowed motor responses; sleepiness
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11. Stuporous
 Sleep-like state; can be aroused only by
vigorous and repeated noxious stimuli ;
 little or no activity;
 responsiveness only to pain
Comatose- Unarousable and unresponsive,
 no gag reflex or pupillary response to light
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12.  The basic principle to remember is that the
unconscious patient is completely dependent on the
nurse for all of his needs.
 Any omissions in basic nursing care or any failure to
protect the unconscious patient in his helpless state
may inhibit recovery or greatly prolong his
convalescence because of complications that might
have been prevented.
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13.  Always assume that the patient can hear, even
though he makes no response.
 Always address the patient by name and tell him
what you are going to do.
 Refrain from any conversation about the patient's
condition while in the patient's presence.
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14.  Ineffective breathing pattern
 Altered tissue perfusion
 Ineffective thermoregulation
 Risk for injury
 Impaired physical mobility
 Altered nutrition
 Urinary and Bowel incontinence
 Risk for impaired skin integrity
 Ineffective family coping.
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15.  Maintain effective breathing pattern
 Maintain Temp., Pulse, B/P, within normal range.
 Consume adequate balance diet
 Maintain safety
 Maintain regular pattern of bowel and urine
 Maintain skin integrity
 Family indicate understanding of diagnosis.
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16.  Regularly observe and record the patient's vital signs and
level of consciousness using a coma scale.
 (1) Report changes in vital signs to the team leader or
physician.
 (2) Note changes in response to stimuli.
 (3) Note the return of protective reflexes such as blinking the
eyelids or swallowing saliva.
 (4). Keep the patient's room at a comfortable temperature .
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17.  Maintaining a patient airway and promoting
adequate ventilation are nursing priorities.
 Maintain a patent airway by proper positioning of
the patient.
 Whenever possible, position the patient on his
side with the chin extended. This prevents the
tongue from obstructing the airway.
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18.  This lateral recumbent position is often referred to as the
"coma position."
 It is the safest position for a patient who is left
unattended.
b. Suction the mouth, pharynx, and trachea as often as
necessary to prevent aspiration of secretions.
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20. Reposition the patient from side-to-side to prevent pooling
of mucous and secretions in the lungs.
d. Administer oxygen as ordered.
e. Always have suction available to prevent aspiration
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21. A patient who is unconscious is normally fed and
medicated by NGT feed.
 (1) Keep accurate records of all intake. (Feeding
formula, water, liquid medications.)
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22. When feeding an unconscious patient via NGT, it is best
to place the patient in a sitting position (Fowler's or semi-
Fowlers) and support with pillows.
 (a) This permits gravity to help move the feeding or
medication.
 b. Fluids are maintained by IV therapy.
 (1) Keep accurate records of IV intake and urine output.
 (2) Observe the patient for signs of dehydration or fluid
overload and aspiration of vomitus.
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23.  a. The unconscious patient should be given a
complete bath every day. (This prevents drying
of the skin.)
 (1) Change the bed linen if damp or soiled
 (2) The skin should be lubricated with
moisturizing lotion after bathing.
 (3) The nails should be kept short, as many
patients will scratch themselves.
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24.  (2) Observe the skin for evidence of skin breakdown.
 Skin care should be provided each time the patient is
turned.
 (1) Examine the skin for areas of irritation or
breakdown.
 (2) Apply lotion, prn.
 (3) Gently massage the skin to stimulate circulation.
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25.  b. Provide oral hygiene at least twice per shift. Include
the tongue, all tooth surfaces, and all soft tissue areas.
The unconscious patient is often a mouth breather. This
causes saliva to dry and adhere to the mouth and tooth
surfaces.
 (1) Always have suction apparatus immediately available
when giving mouth care to the unconscious patient.
 (2) Apply petrolatum to the lips to prevent drying.
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26.  c. Keep the nostrils free of crusted secretions. Prevent
drying with a light coat of lotion, petrolatum, or water-
soluble lubricant.
 d. Check the eyes frequently for signs of irritation or
infection. Neglect can result in permanent damage to the
cornea since the normal blink reflex and tear-washing
mechanisms may be absent. Use only cleansing
solutions and eye drops ordered by the physician.
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27. The bowel should be evacuated regularly to prevent
impaction of stool.
(1) Keep accurate record of bowel movements.
(2) Administer stool softener/suppositories as
needed/alt days
( 3) Provide catheter care at least once per shift to
prevent infection in catheterized patients
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28. When positioning the unconscious patient, pay particular
attention to maintaining proper body alignment.
(1) Limbs must be supported in a position of function. Do
not allow flaccid limbs to rest unsupported.
(2) Change the patient's position every 2-4 hours.
(3) Utilize a foot board at the end of the bed to decrease
the possibility of foot drop.
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29.  When joints are not exercised in their full range of
motion each day, the muscles will gradually shrink,
forming what is known as a contracture. Passive
exercises must be provided for the unconscious
patient to prevent contractures.
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30.  Exercises with a range of motion (ROM) are performed
under the direction of the physical therapist.
 It is a nursing care responsibility to maintain the patient's
range of motion.
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