Care of patient with Unconsciousness...for First Year Nursing Students. Thanks

2. Abhishek A. Joshi
Nursing Tutor
GCON. Bhavnagar

3. KNOWLEDGE
IS
HAVING
A RIGHT ANSWER
&
INTELLIGENCE
IS
ASKING
THE WRITE QUESTION…

4.  Introduction of Unconsciousness
 Pathophysiology
 Causes
 Assessment
 Nursing Care/Management

5.  Consciousness is a state of being wakeful of Time, Place
and person (individual).
 Unconsciousness is a term used widely to denote a state
of unresponsive of an individual or external stimuli.
 Unconsciousness is defined as “A state in which the
cerebral functions are decreased and the individual is
unresponsive to sensory stimuli.”
 Other definition of unconsciousness is “ A state in which
patient doesn’t oriented of Time, place and person as
well as external environment.”

6. Underlying Cause
due to neurologic
dysfunction
Disruption in the
cells of Nervous
system
Faulty impulse
transmission from
brain to other parts
of the body
Impaired LOC (Level of
Consciousness)

7. 1. Head injury.
2. Hemorrhage.
3. Cerebral thrombosis.
4. Diabetes mellitus.
5. Renal failure.
6. Poisons drugs.
7. Alcohol, Anesthesia.
8. Carbon monoxide gas.
9. Asphyxia, Epilepsy etc.

8. 1. Alertness, oriented: opens eyes spontaneously,
responds to stimuli appropriately.
2. Lethargy, sleepy: slow to respond but appropriate
response: opens eyes to stimuli, oriented.
3. Stupor: Aroused by and opens eyes to painful stimuli:
never fully awake: confused: unclear conversation.
4. Semi-coma stage: Moves in response to painful stimuli:
no conversation, protective blinking/swallowing:
pupillary reflex present.
5. Coma: Unresponsive except to severe pain: no
protective reflexes: fixed pupils: no voluntary
movements

9. • For the care to be effective, a nurse should
perform frequent, systematic and objective
assessment on the comatose client.
• During the first few hours of coma
neurological assessment is to be done as
often as every 15 minutes.

10.  Collect pertinent information regarding
present illness, past illness/surgeries,
personal history, nutritional history,
socioeconomic and environmental status as
these data help in determining the causes for
coma.

11. LEVEL OF CONSCIOUSNESS:-
Glasgow coma scale is used to assess the
level of consciousness as given below:-

12. S. NO. TEST SCORE
1 Eye opening - Spontaneous
- To speech
- To pain
- No response
4
3
2
1
2 Verbal response - Oriented
- Confused
- Inappropriate words
- Incomprehensive
sound
- No response
5
4
3
2
1
3 Motor response - Obeys commands
- Localizes
- Withdraws
- Flexes
- Extends
- No response
6
5
4
3
2
1

13. • Thus, the client’s responses are rated on a
scale from 3 to 15.
• A score of 3 indicates severe neurologic
impairment.
• A score of 15 indicates that the client is fully
responsive.
• A score less than 7 requires frequent
assessment.

14.  Pattern of respiration
 Eyes: - pupil size, reflecting to light, eye
movement, corneal reflex.
 Facial symmetry
 Swallowing reflex
 Neck
 Motor responses and all reflexes.

15. 1. POSITION: -
Commonly give prone, lateral, or sim’s
position as per according to patient’s
condition.
2. AIRWAY: -
Maintain patient’s airway, keep patient’s jaw
forward, loose patient’s clothes, and suction
frequently, provide sufficient ventilation.

16.  Level of consciousness.
 Reaction to vocal stimulation.
 Size of pupils, reaction of light on pupil etc are
observed and must be chart every half hour.
 Recording vital signs every two hourly.
 Charting and recording of blood pressure
 If patient having muscular spasm so which area
affected that also note and record
 Maintain urine analysis.
 Chart in diabetes mellitus and renal failure
patient.

17.  Observed the patient and provide personal
hygiene care to the patient.
 As per requirement give sponge bath.
 Take care of pressure points.
 Give passive exercise to limbs, so that can prevent
stiffening of joints, muscular contraction and
venous static.
 To prevent dryness of mouth and tongue give
frequent mouth care

18.  Provide eye care because it prevents discharge
from lid margin and prevent dry conjunctiva
and also prevent corneal ulcer so that instill
eye drops as per Doctor’s order.
 Change position frequently.

19.  Keep patient on water bed mattress.
 Bed linen keeps dry if moist then immediately
change bed linens.
 Use bed cradle for cut off weight of bed
clothes.
 Keep pillow between knee and ankle
prominence.
 Change patient’s position every hourly.
 Massage every two hourly on pressure areas.

20.  If redness or injury so inform
immediately.
 Use foot rest for to prevent foot
drops.
 Use pillow or foot board at the
bottom side to prevent weight of
bed clothes on the feet.
 Passive physiotherapy so that
keeps ankle and feet in good
condition.

21.  Apply splint on hands to prevent wrist drops
and keep in correct position.
 Back care every two hourly and apply Telkom
powder.
 Keep skin clean, dry and free of pressure and
use pressure relieving devices like air
cushion, air/water mattress.
 Avoid dragging and pulling the client while
changing position, avoid vigorous massage of
bony prominences

22.  Provide high calorie, high
protein, vitamin rich diet and
more amounts of fluids such
as porridge, soup, juice etc.
 Give I.V or gastric tube
feeding according to the
nutritional status and
requirement.

23.  Observe for retention of urine and constipation.
Give glycerin suppository and stool softness or
enema as per order of physician.
 Continuous catheterization to prevent urinary
problems.
 Accurate recording of fluid balance, if
necessary give I.V. fluids.
 Give gentle pressure on bladder part that helps
to empty bladder in retention of urine.

24.  Assess family response towards
the client’s illness-
severe anxiety, anger, denial,
grief, reconciliation then usual
use of coping mechanisms, role of
client in the family,
communication pattern, social
support available, financial status,
relationship between family
members etc.

25.  Develop a supportive and trusting
relationship with the family or
significant others.
 Provide information and frequent
updates on client’s condition and
progress.
 Involve family in routine care;
teach procedures that they can
perform at home.

26.  Demonstrate and teach methods
of sensory stimulations to be used
frequently: -
1, Use physical touch and reassuring voice.
2, Talk in a meaningful way even when client
does not seem to response.
3, Orient person periodically to person, place
and time.

27.  Teach family to recognize and
report unusual restlessness of
the client.
 Enlist help of social workers,
home health agency or other
resources.

28.  Neurological status remains at baseline or
improved.
 Maintains clear airway, cough up secretion.
 Absence of signs of dehydration.
 Intact, pink mucous membrane.
 No skin breakdown.
 Core temperature within normal level.
 Bowel movement on regular basis.

29. 29
Dr Shashwat Jani. 9909944160.