care of Unconscious Patient-
Maintaining patient's airway.
Protecting the patient from falling off the bed.
Maintaining fluid balance and managing nutritional needs.
Maintaining skin integrity.
Preventing urinary retention.
Incontinence care.
Providing sensory stimulation.
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care of unconscious patient (2).pptx
1. CARE OF UNCONSCIOUS PATIENT
PRESENTED BY-
SAYMA KHAN
NURSING TUTOR/CI
ERA'S COLLEGE OF NURSING
2. 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.
3. 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
6. 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
7. 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
9. 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
10. • 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
11. 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
13. 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.
14. 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
15. • 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.
16.
17. 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.
18. • 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
19.
20. • 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
21. • 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
22. • 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.
23. This Photo by Unknown author is licensed under CC BY-NC.