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Nursing the unconscious patientNS309 Geraghty M (2005) Nursing the unconscious patient. Nursing Standard, 20,1, 54-64.Date of acceptance: July 18 2005.

Summary

Unconscious patients are nursed in a variety of clinical settings andtherefore it is necessary for all nurses to assess, plan and implementthe nursing care of this vulnerable patient group. This articlediscusses the nursing management of patients who are unconsciousand examines the priorities of patient care.

Author

Max Geraghty is senior staff nurse, Intensive Care Unit, NorthMiddlesex University Hospital, London,Email: max_geraghty@b)ueyonder,co.ul<

Keywords

Head injuries; Nursing: role; Patient assessment;Unconsciousness

These keywords are based on the subject headings from the BritishNursing Index, This article has been subject to double-blind review.For related articles and author guidelines visit our online archive atwww.nursing-standard.co.uk and search using the keywords.

Ajniand intended learning outcomes

The aim of rhis article is to explore tht- long-termcare needs of the unconscious patient and therelated nursing manageEiient. It will also discussthe emergency priorities tbat may arise. Afterreading this article you should be able to:

• Define consciousness and have anunderstanding of the related anatomy andphysiology.

• Discuss the various levels ofiinpairedconsciousness.

• List the causes of unconsciousness.

• Identify the needs of the unconscious patient.

• Prioritise patient care, recognising the skillsrequired for the assessment, planning andimplementation of nursing care.

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• Reflect on how the nursing skills needed tocare for the unconscious patient can be used toenhance practice in other areas of nursing.

Introduction

Nursing the unconscious patient can be achallenging experience. Unconscious patientshave no control over themselves or theirenvironment and thus are highly dependent onthe nurse. The skills required to care forunconscious patients are not specific to criticalcare and theatres as unconscious patients arenursed in a variety of clinical settings. Nursingsuch patients can be a source of anxiety fornurses. However, with a good knowledge base toinitiate the assessment, planning andimplementation of quality care, nursing patientswho are unconscious can prove highly rewarding,and the skills acquired can promote confidence inthe care of all patients.

Unconsciousness spans a broad spectrum(Hickey 20(}3a), from momentary loss ofconsciousness as seen with fainting, to prolongedcoma that may last Vv'eeks, months or even years.The causes of unconsciousness will dictate thelength of the coma and the prognosis. Yet theimmediate and ongoing needs of the unconsciouspatient are similar, whatever the underlying cause.

In your own words describe thefunction of the reticular activatingsystem and define consciousness.

Defining consciousness and aspects ofanatomy and physiology

To understand consciousness it is necessary tohave an appreciation of the complexity of therelated anatomy and physiology, as normalconscious behaviour is dependent on an intact

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and fully functioning brain (Pemherton 2000).Therefore, tbe manifestation of impaired orabsent consciousness points towards anunderlying brain dysfunction.

Consciousness is a function of the reticularformation (RF), which has its origins in thebrainstem (Barker 2002). The RF Is a network ofneurones that coiuiect with the spinal cord.,cerebellum, thalamus and hypothalamus. Allsensory pathways link into the RF (Fitzgeraldl996).Theretic-ularactivntingsystem(RAS)isafeature of the RF and is responsible for arousalfrom sleep and maintaining consciousness(Fitzgerald 1996). The RAS has a large numberof projections that are linked to the cerebralcortex (Pemberton 2000) and are concerned withthe arousal of the hrain during sleep andwakefulness (Fitzgerald l996)(Figure I).Awarenessis the result of the combined activityof the RF, RAS and higher cortical function. Thetwo main identified parts of the RAS are themesencephalon (upper pons and mid-brain) andthe thalamus. Signals from specific parts of thethalatnus initiate activity in specific parts of thecerebral cortex, as opposed to the diffuse flow ofimpulses from the mesencepbalon that causesgeneralised cerebral activity (Pemherton 2000).This process of selection prevents the cerebralcortex from receiving too much information atonce, thus possibly playing a part in directing anindividual's attention to specific mental activities(Hickey 2003b).

The arousal reaction is dependent on thestimulation of the RAS. The RAS receives inputsignals from a wide range of sources, including thesenses (Pemberton 2000). The RAS serves as apoint of convergence for signals from our externalenvironment and our internal thoughts andfeelings. For example, when an individual is in adeep sleep the RAS is in a dormant state. However,a loud noise or noxious stimulus will wake us. Ouremotional response and reasoning to such astimulus will 'modify' the RAS positively ornegatively as the RAS is also stimulated by thecerebral cortex (Pemberton 2000).

There are many pathways from the cerebralcortex thatconcern sensory and motor function,as welt as emotions and reasoning. Wheneverthese areas become excited impulses aretransmitted to the RAS, further increasing thelevel of activity, and in turn the RAS stimulatesthe cerebral cortex, thus increasing tbeexcitation of both regions. The number ofpathways that become activated is also relatedto the level of consciousness. If one pathway isactivated the degree of consciousness may beminimal, however, if many pathways areactivated simultaneously then this may result ina high level of consciousness. Consciousnessdemonstrates that the RAS is functioning and is

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capable of the screening and discrimination ofinformation (Pemberton 2000).

Consciousness can be defined as a state ofawareness of one's self and the environment(Barker 2002). A conscious person is capable ofresponding to sensory stimuli. Alternatively,coma isa total absence of awareness of one's selfand che environment. A person in a coma isunrousable and unresponsive to external stimuli.For example, when a person is asleep he or shecan be aroused by external stimuli, but tbis doesnot occur when a person is in a coma. Thissuggests tbat consciousness depends on whetherthe individual can be aroused to wakefulness.Fiowever, between the poles of consciousness andunconsciousness there is a continuum of differingstates of impaired consciousness.

Ijmeo"Think of a patient wi th impairedconsciousness you have nursed. Reflecton your experience and the underlyingcauses that led to impairment in that patient'sconsciousness. Describe the patient's physicaland emotional behaviour. What did you findchallenging about nursing this patient?

Impaired consciousness

There are acute and chronic states of impairedconsciousness. Acute states are potentiallyreversible, whereas chronic states indicateunderlying brain damage and hence areirreversible (Pemberton 2000). Acute states are

FIGURE 1

A mid-sagittal view of the reticular activating system andrelated structures

Thalamus

Mid-brain

Pons

Reticular formation

MedullaSensory input

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generally caused by metabolic upsets, such ashypoglycaeniia or drug intoxication, which alterhrain function.

A cioudingof consciousness suggestsinterference with the integrity of the RAS, with aresultant effect on the arousal response. This cancause unusual behaviour, ranging from irritabilityand confusion, to poor concentration anddrowsiness (Pemberton 2000). The changes canhe subtle at first and difficult to recognise.Delirium is similartocloudingof consciousness,although a person who is delirious may alsopresent with psychological manifestations, suchas illusions, hallucinations and delusions.

A shadow on the wall that takes the form of ananimal, or a noise that is misinterpreted as astranger coming to cause harm, are examples ofillusional states (Pemberton 2000).Hallucinations are defined as the sight or soundof something in the absence of any sensorystimuli, such as hearing voices or seeing objectsthat do not exist. Delusions are more persistentmisperceptions that are held to be real., howeverillogical they may seem (Hickey 2003b). Lethargyis characterised hy slow and sluggish speech,mental processes and motor activities. Theobtunded patient may be readily rousable but canonly respond verbally with a word or two, andcan only follow simple commands. Stupordescribes a state of near unrousability thatrequires vigorous or repeated stimulus to illicit aresponse (Hickey 2003b).

The categorisation of the different graduationsof coma is not universally accepted. The differencebetween each definition is the degree andpresentation of response to painful stimuli (Hickey2003b). However, terms such as semi-coma anddeep coma are still used in clinical practice.

Assessment of consciousness

A variety of scales have been devised to describepatients' level of consciousness (Barker 2002).However, the Glasgow Coma Scale (GCS)(Jennett and Teasdale 1977) is the mostuniversally accepted tool, which decreases thesubjectivity and confusion associated withassessing levels of consciousness (Hickey 2003b).The GCS has heen used as a prognostic deviceduring immediate assessment following a headinjury. The lower the score the poorer theprognosis. The GCS gives practitioners aninternationally accepted format that assistscommunication, minimises user interpretation,and rapidly detects change in the patient'scondition (Howarth 2004). National guidelines

indicate that the GCS should be used to assess allbrain-injured patients (National Institute forClinical Excellence (NICE) 2003).

The GCS forms a quick, objective and easilyinterpreted mode of neurological assessment,avoiding subjective terminology, such as "stupor'and 'semi-coma'. As it is the internationallyagreed common language in neurologicalassessment, it is essential that it is completedaccurately, and that any uncertainties arereported immediately (Hickey 2003b). The GCSmeasures the degree of consciousness under threedistinct categories, and each category is furthersubdivided and given a score as shown in Box 1(see also the version adapted by NICE 2003).

The regularity with which observations shouldbe undertaken is determined hy the severity of thepatient's condition (Cree 2003). Guidelines forthe head-injured patientaregeared towardsidentification of any potentially rapiddeterioration and suggest that observationsshould be undertaken every 30 minutes until the

The Glasgow Coma Scale

Eye opening (score)

Spontaneous(4)

To speech (3)

To pain (2)

No eye opening (1)

Verbal response

Orientated (5)

Confused (4)

Occasional words (3)

Incomprehensible sounds (2)

No response (1)

Best motor response

Obeys comniands (6)

Localising (5)

Normal flexion (4)

Abnormal flexion (3)

Extension to pain (2)

No response (1)

Each category is further subdivided andgiven a score:

15 = Maximum score for an alert individual

3 = Lowest possible score for tbe unconsciouspatient

Less than 8 = Cause for concern

(Jennett and Teasdale 1977)

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GCS reaches 15 or the patient's conditionstabilises (NICK 2003). After this, observationsshould continue hourly for four hours, returningto every 30 minutes if the patient's conditiondeteriorates. If the patient remains stable onhourly GCS assessment for four hours, theobservations can be reduced to every two hours(NICE 2003). Fiowever, these recommendationscannot be generalised and each patient needs tobe individually assessed. The GCS may bemisleading in patients who are hypoxic,haemodynamically shocked, fitting or post-ictal,showing little or no response. Therefore, it isimportant to re-evaluate patients once anyunderlying acute condition has been corrected(Dawson2000).

The accuracy of the GCS is dependent on theassessor using and interpreting it correctly. Thenurse must become familiar with the tool andstudies suggest that its use should be taught in detailto ensure accLiracy of rating by nurses (Heron etal2001). The reader should refer to the referencedliterature for more information and seek to gainpractical experience in the clinical environmentiShah 1999,Cree2003,Howarth2004).

Reflect on your experience of theGlasgow Coma Scale. How confidentdo you feel in using the tool in practice?What policies are available in your workplaceto assist and guide its application? Do theymeet the NICE (2003) guidelines?

Causes of unconsciousness

There are many different causes ofunconsciousness. Some examples are shown inBox 2; however, these are by no meansexhaustive. The causes of unconsciousness maydictate the length of the coma and the prognosis(Mallettand Dougherty 2000). Unconsciousnessoccurs when the RAS is damaged or inhibited,thus affecting the normal arousal mechanism(Pemherton 2000). Intrinsic factors that affect thenervous system directly can be seen as primarycauses. Secondary causes most often involveother body systems compromising metabolic andendocrine homeostasis. Unconsciousness may besudden, for example, following an acute headinjury, or it may be gradual, for example, with theonset of poisoning or a deranged metabolism, asin hypoxia or hypoglycaemia.

It is also important to remember thatunconsciousness may be induced, for example,the use of anaesthetics for surgical or medicalintervention. Another example of this is in criticalcare units, such as intensive care, where ananaesthetist will intervene and induce

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unconsciousness pharmacologically to allow foremergency intervention to stop a decline in apatient's condition.

Emergency priorities

The unconscious patient will require skilledemergency management. As a patient starts tobecome unconscious he or she loses control of hisor her ability to maintain a safe environment. Itcannot be stressed enough that the nurse has acrucial responsibility to anticipate, wherepossible, deterioration in a patient's condition(Nursing and Midwifery Council (NMC) 2004).Thus, in relation to consciousness, the nurse hasan essential role in the assessment of the centralnervous system using the GCS, monitoring vitalsigns, pupillary reaction and limb movements.Such skills will provide information thatcanallow for interventions to arrest a life-threateningdeterioration and potentially avert a decline tounconsciousness. The A (airway), B (breathing),C (circulation), D (disability) approach toresuscitation should be adopted, and themaintenance of a clear airway is the first priority(Colquhoun(?(<i/2004). Noisy snoring or harshbreathing sounds may be a sign that the airway isbeing compromised.

If the patient is still breathing spontaneouslyand does not require further resuscitation thenappropriate positioning of the patient, using therecovery position,will prevent vomit or anysecretion from obstructing the airway, potentiallycausingaspiration(Colquhoun£'M/2004). Theuse of an artificial airway, such as a Guedel, and theremoval of secretions through suction will ensurethat the airway remains patent (Pemberton 2000).

The unconscious patient is a medical emergency(Pemberton 2000). The nurse needs to work closely

Causes of unconsciousness

• Poisons and drugs: alcohol, general anaesthetics, overdose ofdrugs - legal and illicit, gases (carbon monoxide), heavy metals(lead poisoning).

• Vascular causes: post-cardiac arrest, ischaemia, haemorrhage{subarachnoid), acute hypovolaemia, for example, in trauma.

• Infections: sepsis, viral causes (human immunodeficiency virus),meningitis, protozoan infections (malaria), fungal (aspergillosis).

• Seizures: idiopathic or post-traumatic epilepsy, eclampsia.

• Metabolic disorders: hypoglycaemia, hypoxia, renal failure,

hepatic failure.

• Other causes: neoplasm - primary or secondary, trauma,degenerative disease.

Adapted from Mallett and Dougherty 2000)

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with the medical team to ensure that the rightpathways of medical management are appliedappropriately.The possible underlying cause willdictate immediate medical management which mayinclude: the administration of oxygen to maintaintissue perfusion; fluids to support cardiovascularfunction and correct metabolic derangement; andthe administration of intravenous (IV) medications,such as phenytoin in the presence of seizures. Thenurse skilled in phlebotomy will be required to takeblood for laboratory tests that will ascertain thepresence of drugs if overdose is suspected.

Physical examination can give many clues as tothe cause of unconsciousness. For example, abitten tongue may indicate an epileptic seizure, orneedie marks on the lower limbs or abdomencould be because the patient has insulin-dependent diabetes (Fuller 2004). A patient'smedical history is of vital importance and, if notalready known, friends and relatives can be ofassistancein this endeavour. Many people whohave life-threatening conditions that canprecipitate unconsciousness, such as epilepsy orallergies to penicillin, may be wearing braceletsthatinform medical practitioners (Fuller 2004).

Anyone accompanying an unconscious patientto hospital will require support and information.Witnessing the events leading to someone losingconsciousness can be very distressing. A nurse notinvolved in the immediate care of the patientshould be allocated to take responsibility forproviding this support (Pemberton 2000).

Ifthepatientdoes not regain immediateconsciousness then his or her ongoing needs willneed to be assessed. This may demand that thepatient be moved to an intensive care unit (ICU) toallow for critical management. Whether the patientis in a critical care bed or on rhe ward, the ongoingneeds and priorities remain unchanged.

Read the case example in Box 3. Listthe immediate nursing priorities.

Case study 1

Andrew is known to have insulin-dependent diabetes and is beingtreated for uncontrolled blood glucose levels on your unit I t isearly morning and breakfast has not yet been served. Andrew hasbeen to the bathroom to have a wash and is returning to his bedwhen he stumbles and falis to the ground. On immediateexamination he is seemingly conscious, but is pale, clamtny and notresponding coherently to guestions.

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The human body is designed for physical activityand movement; thus, physiological changes willoccur in the unconscious patient, which will beexacerbated by the length of immobility, cause ofimconsciousnessand the quality of care(Dougherty and Lister 2004). Thus, in addition tomanaging the underlying cause ofunconsciousness, the nurse should alsoimplement a framework of care that seeks toprevent further complications. To do this he orshe needs to understand the effects of prolongedimmobility on the main systems of the body.Effectsofprolonged immobility The morbidityof inimubiiity is directly associated with thelength of rime the patient is immobile and otherunderlying patient risk factors (Hickey 2003a),such as incontinence, poornutririon,hypotension, infection, obesity, old age and organfailure (Wunderlich 2002a, Hickey 2003a). Olderpatients in particular are vulnerable to thedetrimental effects of prolonged immobility.Physiological changes that occur over shortperiods of immobility are less severe andpotentially reversible. Prolonged periods result inincreased pathophysiological changes associatedwith increased morbidity and permanentdisabilities (Hickey 2003a). Thus, the effects ofimmobility give rise to many of the complicationsin the unconscious patient, hence the need fortheimplementation of a broad rangeof nursing skills.Respiratot7 function Maintaining a patentairway and promoting adequate ventilation arenursing priorities. Assessment of the mouth andteeth is also important. Dentures should beremoved and note made of any loose teeth orcrowns that may become dislodged andcompromise the airway. The inability to maintaina patent airway means that aspiration of fluids,from oral secretions, blood in the presence oftrauma, or vomit is a potential risk that may causefurther complications, for example, chestinfection. The insertion of a nasogastric tube inthe early stages of unconsciousness will allowremoval of gastric contents, thus reducing the riskofaspiration.

Oropharyngeal airways, such as the Guedelairway, have many benefits (Pemberton 2000).Tbey are easy to insert, prevent the tongue fromobstructing the airway, provide a passage thatallows the patient to breathe, and allows thenurse to remove secretions from the tracheathrough suctioning. A nasopharyngeal airwayalso allows the clearance of secretions usingsuction (Moore 2004), can be inserted if the useof an oropharyngeal airway is contraindicated,for example, in patients witb trauma to themandible or oral cavity. Suctioning should beundertakenwith care, following appropriate

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patient assessment to establish the need forintervention. Suctioning has associatedcontraindications and unwanted effects, forexample, a rise in intracranial pressure (Moore2004). The reader should refer to the article byMoore (2004) to gain a better understanding ofthis skill.

Positioning the patient is important and willfacilitate the drainage of secretions. The supineposition compromises the mechanics of breathingand lung volumes (Flickey 2003a). Tidal volumes- the volume of air that passes in and out of thelungs during normal quiet breathing-may not becompromised, depending on any underlyingrespiratory pathology, butgenerally lying flatcauses a reduction in the residua! volume andfunctional residual capacity of the lungs (Fiickey2003a). This can lead to partial or completecollapse of parts of the lung (atelectasis), as wellas poor ventilation, which can result in hypoxia.The accumulation of secretions over time cancontribute to the development of atelectasis andhypostatic pneumonia (Hickey 2003a). Correctpositioning of the unconscious patient alsominimises the risks associated with immobility interms of circulation and the musculoskeletalsystem (Wunderlich 2002b).

To maintain a patent airway the lateralrecumbent position is advised (Allan 2002) withthe head of the bed slightly tilted upwards, about10-30 degrees (Pemberton 2000) (Figure 2). It isimportant to recognise that such positioning isthe ideal and may be contraindicated by anunderlying condition, for example, a spinal or aniinderlyinghraininjury. Wherever there is a threatto the airway that cannot be resolved byrepositioningandtheclearance of secretions, theinsertion of an endotracheal tube will be necessary,to protect the airway from aspiration and theassociated risk of infection (Pemberton 2000). Ifunconsciousness is prolonged and an artificialairway is still required then a tracheostomy shouldbe considered (Hooper 1996).

The patient may require the administration ofoxygen therapy. Oxygen can be delivered usingdifferent types of equipment and humidificationis advised, where possible, to warm and moistenits delivery and to prevent drying of secretions(Dougherty and Lister 2004). Physiotherapy isimportant to encourage lung expansion, assist theremoval of secretions and help in the preventionof complications. Atelectasis and pneumonia arelong established consequences of prolongedbedrest (Hickey 2003a). The pooling ofsecretions leads to hypostatic pneumonia whichcreates an ideal environment for the growth ofbactt-ria (Flickey 2003b). The collapse of lungtissue and the effects of secretions will impairgaseous exchange.

Pulse oximetry will aid the ongoing

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monitoring of respiratory function. Oxygensaturation is a measure of the percentage ofhaemoglobin molecules that combine withoxygen. Pulse oximetry assists in monitoring theeffectiveness of oxygen therapy (Dougherty andLister 2004). Changes in the pattern of breathingmay indicate a developing respiratory failure, or adisorder of the respiratory control centre in thebrain (Dawson 2000). Close monitoring of thepatient's respiratory function is important andany changes should be reported.Cardiovascular function Monitoring thecardiovascular function in unconscious patientsis of high importance. Alterations in bloodpressure need to be viewed in relation to pulse

FIGURE 2

Positioning the unconscious patient

Attention is given to good body alignment, to helpprevent contractures, foot and wrist drop, musclestrain, joint injury and interference with circulationand chest expansion.

Care needs to be taken to ensure that the headand neck are aligned with the spine. The arm that isuppermost is flexed at the elbow and rested on apillow to prevent drag on the shoulder and wristdrop. The arm that is down is drawn slightlyforward from under the body, bent at the elbow tolie on the bed parallel with the neck and head, oracross the chest. The lower limb that is uppermostis flexed at the hip and knee, and supported by apillow with the other lower limb slightly flexed.

To avoid foot drop the feet are positioned at a 90degree angle to the leg with care taken to avoidany unnecessary pressure. A pillow at the foot ofthe bed can facilitate this position (Allan 2002,Wunderlich 2002b).

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rate, pulse quality and pulse pressure (Hickey2003a). For example, a low blood pressure in thepresence of a tachycardia with a pulse that feelsweak on palpation may indicate hypovolaemia.Change can be indicative of neurologicaldeterioration and such observations need to bebalanced with neurological assessment to obtaina more accurate evaluation. Hypotension is rarelycharacteristicofbraininiury alone, except in theterminal stages of herniation (Dawson 2000), andchanges in vital signs can be related to otherphysiological factors, for example,hypovolaemia, sepsis or cardiogenic shock.However, the effects of immobility can causechanges in cardiovascular function withincreased cardiac workload and central fluidshifts from the legs to the thorax and head(Dougherty and Lister 2004).

The risk of venous thromboembolism andpulmonary emboli from the effects of inimohilityis well recognised (Dougherty and Lister 2004).The use of antiembolic stockings should beconsidered once the risk of venousthromboembolism has been identified (Brync2002). Thrombus formation is caused by venousstasis, decreased vasotnotor tone, pressure on theblood vessels and a hypercoagulahle state(Hickey 2003a). Antiembolic stockings increasethe velocity of flow not only in the legs but also inthe pelvic veins and inferior vena cava,particularly when thigh-length stockings are used(Hayes etal2002). Liaison with thephysiotherapist will also be of benefit, as theintroduction ofpassive limb movements willencourage blood flow back to the heart as well ashaving positive musculoskeletal effects. Theadministration of an anticoagulant will alsoreduce the risks of venous thromboembolism(Casey 2003).

Nutrition and hydration Nutrition is afundamental human need and yetevidencesuggests that up to 40 per cent of hospital patientsremain malnourished (Pearce and Duncan 2002).The unconscious patient is dependent on thehealthcare team to deliver the correct nutritionalrequirements. Therefore, regular blood and urinetests to monitor electrolyte and metabolicchanges are essential to promote accurateassessment of each individual patient.

Obtaining a 24-hour urine collection isanimportant means of assessing the protein needs ofthe unconscious patient. Nitrogen is lost from thebody when protein is broken down. If nitrogenloss exceeds supply then catabolism (musclebreakdown) occurs. If uncorrected this willcompromise breathing by wasting respiratory

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and skeletal muscles (Woodrow 2004).Immobility also alters glucose-insulin

intolerance. An IV insulin sliding-scale regimenmay be required to maintain blood glucose levelswithin the normal range of 4-7mmol/l (Cowan1997). Close monitoring of glucose levels isessential to ensure that this range is maintained.Another example of altered metabolism is theincreased excretion of calcium from bones as aresult of reduced weight bearing and inactivity(Hickey 2003a).

The delivery of nutritional requirements is bestachieved enterally as the parenteral route has thedisadvantages of expense, increased risk ofinfection from IV cannulation, and gut atrophyand translocation of gut bacteria from non-use ofthe digestive tract (Woodrow 2004). Enteralfeeding can prevent this by averting atrophy ofthe villi that absorb nutrients and produceprotective mucus and immunoglobulins. Anyenteral feeding regimen should encompass a restperiod to allow for gastric acidity to return to itsnormal level (approximately pH 4.0)., thusreducing the risks of bacterial colonisation(Woodrow 2004).

Enteral feeding can be administered in avariety of ways and rhe most appropriate meansneeds to be decided following assessment of theunconscious patient. Nasogastric feeding is themost commonly used method and isrecommended for short-term feeding (less thanfour weeks) (Dougherty and Lister 2004). Finehore tubes should be used where possible as theyare associated with a lower incidence ofcomplications, such as rhinitis, oesophagealirritation and gastritis , than wide bore tubes(Payne-James e'fij/2001). It is important toremember that unconscious patients will not beable to communicate whether a feeding tube is inthe wrong place. Therefore, care must be taken toensure that it has been inserted correctly. A chestX-ray is required to confirm the position of theguide wire, to confirm that it has not beeninadvertently inserted into the lungs (Doughertyand Lister 2004).

Nasoduodenal, nasojejunal, percutaneousendoscopicgastrostomyorjejunostomy tubesmay be indicated if the patient's conditioncontraindicates direct gastric feeding, forexample, acute pancreatitis (Pearce and Duncan2002). A gastrostomy may be more appropriate ifenteral feeding is required for longer periods, thusremoving the risks associated with nasallyinserted tubes. Percutaneous endoscopicallyguided gastrostomy tubes are the most commonof this type (Payne-James e/13/2001).

Nutritional requirements may be affected byunderlying conditions that increase normalmetabolic demand or require further supplements,for example, sepsis, loss of fluids and electrolytes

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from diarrhoea or drainage, or tissue repairfollowing trauma (Woodrow 2004). Liaison withdieticians will assist in the ongoing assessment andplanning the patient's nutritional needs.

Water has many functions within the body thatare essential to maintaining health and sustaininglife, for example, giving form to body structuresand acting as a medium for nutrients andelectrolytes. Therefore, accurate fluid balanceshould be monitored and recorded to allow theidentification of potential fluid or electrolyteimbalances (Gobbi and Torrance 2000).Gastrointestinal function Bowel action is likelyto become irregular in the unconscious patient,thus monitoring and observation are important.Loose stool can be a result of poorly toleratedenteral feeding. Diarrhoea is caused when there ismore fluid entering the bowel than the bowel canabsorb during transit. Increased water in the gutor a decreased ability to absorb fluid can resuh indiarrhoea. Antibiotics can exacerbate this bydestroyinggut commensals (Woodrow 2004).

Constipation and faecal impaction are alsocommon in immobile, unconscious patients asnormal stimulants to peristalsis, such as physicalactivity, are absent. Constipation not onlycauses discomfort, but also increasesintra-abdominal pressure which will result in anunwanted rise in intracranial pressure and thepotential of further neurological impairment(Cree2003). Fnteral feeding will not stimulateperistalsis (Hickey 2003a). Consequently, theintroductionof a regular laxative is oftenrequired to assist evacuation of the bowelcontents (Pemberton 2000).

Monitoringbowelfunction with theuseof achart will help to assess the need for intervention.Fnteral laxatives on their own may not besufficient and the introduction of rectalpreparations such as suppositories and enemasmay be necessary. Manual evacuation (the digitalremoval of faecal matter) is an invasiveintervention that is now considered a nursingrole. However, it is not without risks. Forexample, stimulation of the vagus nerve in therectal wall can slow the patient's heart (Powelland Rigby 2000). There is minimal informationon this invasive procedure in the nursingliterature. However, Fader (1997) suggests thatmanual evacuation should only be undertakenwhen other methods of bowel evacuation havefailed. Nurses are accountable for their practiceand appropriate training should be undertakenbefore this procedure is carried out.Genitourinary function An unconscious patientwill be incontinent of urine. A urinary cathetershould be considered if the state ofunconsciousness is not resolved quickly. Thishelps to retain patient dignity, allows closemonitoring of urinary output and prevents skin

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breakdown. However, introduction of a urinarycatheter increases the risk of infection (Cetliffe1996). Bedrestalsoincreasesurinary stasis in therenal pelvis and urinary bladder furtherexacerbating the risk of urinary tract infection(Hickey 2003a). Alternatives to managingincontinence should be considered, for example,the use of a urinary sheath or incontinence pads.However, it is important that the benefits of theseinterventions are considered against theassociated risks of compromised skin integrityand poor fluid monitoring.Hygiene needs and skin care Attending to thehygiene needs of tbe unconscious patient shouldnever become ritualistic, and despite thepatient's perceived lack of awareness, dignityshould not be compromised. Personal hygiene isconsidered part of The Essence of Care(Department of Health (DH) 2001 a) and needsto be carried out to an uncompromisingstandard. Involving the family - whether toassist with hygiene practices or in helping to gainan understanding of the patient's personalhygiene requirements - can help to turn theroutine of bed bathing into an opportunity toreflect on the patient's individual needs.

The skin forms a protective barrier againstinfection and regulates body temperature. It alsoprovides some cushioning to bony prominences.Sustained pressure from immobilisation remainsthe most important cause of skin breakdown(Hickey 20()3a). Correct positioning, regularturning and use of a pressure-relieving mattresswill help to reduce these risks (Dougherty andLister 2004). Incontinence, perspiration, poornutrition, obesity and old age also contribute tothe formation of pressure ulcers. Therefore, anassessment tool, such as the Waterlow scale,should be used to aid early identification of therisks(Waterlow 1991,1998).

Care should be taken to examine the skinproperly, noting any areas which are red, dry orbroken. Following any washing procedure, it isimportant to ensure that the skin is dry as this willminimise the risk of loss of skin integrity.Fingernails and toenails also need to be assessedfor length and cleanliness, and ongoing care mayrequire consultation by a chiropodist. F^nsuringthat the skin is dry between the toes will help tominimise fungal infection. It is important toremember that chronic illnesses, such as diabetes,can increase the risk of ulceration in theextremities (Tyrrell 2002).

Minimum standards and methods of oralhygiene have been debated in the literature(Evans 2001). Research focusing on oralproblems associated with cancer suggests aminimum of four-hourly interventions to reducethe potential of infection from micro-organisms.Hourly interventions will help to moisten the

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membranesof patients who mouth breathe orrequire oxygen therapy (Krishnasamy 1995).The literature suggests that using a toothbrushand toothpaste is the most effective way ofremoving dental plaque but care should be takennot to damage the gingiva by using excessiveforce (Dougherty and Lister 2004).

The delicate surfaces and structures of the eyeare protected by tears that maintain moisture,however, the unconscious patient is at risk ofdrying of the eye. In assessing the eyes, observefor signs of irritation, corneal drying, abrasionsand oedema. Gentle cleaning with gauze and0.9% sodium chloride should be sufficient toprevent infection. Arrificial tears can also beapplied as drops to help moisten the eyes(Dougherty and Lister 2004).

Gentle cleaning of the nasal niucosa withgauze and water will help remove the build upof debris and maintain a moist environment. Ifa nasogastric tube is inserted attention shouldbe paid to the surrounding area as damage tothemucosa from pressure can occur (Bonomini2003). Gauze and water can also be used toclean around the aural canal, although caremust he taken not to push anything inside theear. The nurse should give proper attention tothe hygiene needs of the imconscioLis patient topromote comfort. In so doing the nurse shouldbe able to provide a clear rationale for all careprocedures.

Beatrice, wiio is 77 years old, is transferred to a medical wardfollowing a long admission on the intensive care unit (ICU).During her stay on the ICU she had a cardiac arrest whichresulted in her sustaining a hypoxic brain injury. For severalweeks her Glasgow Conia Scale (GCS) score has been stable at9. Her eyes open spontaneously giving a score of 4. She has atracheostomy tube in situ and makes no effort to communicateorally (1). She flexes her limbs in response to painful stimuli, butis unable to localise the source of the stimuli (4). She also has ageneralised weakness in her limbs with a more pronouncedhemiparesis on the right side of her body. Her vital signs - bloodpressure, heart rate, temperature and respiratory rate - arestable. She is expectorating copious secretions from hertracheostomy, and requires frequent suctioning to maintain apatent airway. She is obese and is at high risk of developingpressure ulcers. She has a urinary catheter in situ and has beentreated for a urinary tract infection while on the ICU. Beatrice isreceiving enteral feeding via a percutaneous endoscopicgastrostomy. Laxatives are prescribed to help maintain regularbowel function.

62 September 14 :: vol 20 no 1: : 2005

Read the case study in Box 4. Usinga nursing model familiar to your clinicalarea write a care plan that addressesBeatrice's needs. Try to be holistic in yourapproach. You may wish to refer to Box 5.

Communication The NHS Plan {DH 2001 b) callsfor tbe further development of communicationskills among healthcare professionals as the needfor effective communication is increasinglyrecognised. Communication between individualsis a hroad and varied experience. Active listeningis one of the most important communicationskills in the healthcare setting (Bailey andWilkinson 1998, McConnell 2001).

Although verbal communication with anunconscious patient is a one-sided experience, thenurse needs to be perceptive of the patient's non-verbal signals. Elliott and Wright (1999)concluded from their studies of nurse-patientcommunication that the nurse's level ofinteraction with patients is determined by the levelof the patient's responsiveness. They encouragehealthcare practitioners to maintain verbalcommunication with the unconscious patient.

Studies exploring the recollection of theunconscious patient following a return toconsciousness are predominantly concernedwith sedated critical care patients, for example.Green (1996). However, there is evidence thatpatients can recall with accuracy conversationsthat have taken place while unconscious(Pemberton 2000). Nurses should be verballyreassuring and explain all procedures tounconscious patients.

It is not only the content of what is said that isimportant but also how it is said. Tone of voiceconveys the emotion that is behind what is beingcommunicated. The nurse should be aware ofbetraying, through his or her tone of voice,feelings and opinions that may intimidate ordiminish the patient (Webb 1994).Non-verbal communication, such as facialexpression, eye contact, posture, personal spaceand bodily contacr, is important in socialinteraction. Non-verbal cues are often the firstelements of communication that help us to formimmediate impressions about someone (Webb1994). For patients with impaired consciousnesstouch, combined with kind and comfortingwords, can be a valuable means of providingreassurance. However, as with any aspect of care,this needs to he assessed individually as touch canalso be interpreted as invasive or threatening(Woodrow2000).

Understanding a patient's perception andinterpretation of his or her experience when

NURSING STANDARD

consciousness is impaired is not always possible.However, reported experiences describethreatening and frightening hallucinations. Thismay explain why patients with impairedconsciousness sometimes display inappropriatebehaviour such as fear and/or aggression(Woodrow 2000). Gauging appropriatecommunication requirements demands anunderstanding of the patient, hence the patient's

family can be a valuable resource in helping thenurse to become more informed about thepatient's life, his or her personality, and his or herwishes and desires. Communicating withrelatives can aid and enhance tbe nurse-patientrelationship by fostering understandingandempathy. A brief summary of the nursingmanagement of the unconscious patient isprovided m Box 5.

Nursing management of the unconscious patient

Neurological status: Regular Glasgow Coma Scale assessment should be recorded, including pupil and limb assessment.Increase or decrease the frequency of observations as indicated by the patient's condition.

Respiratory function: Position tbe patient in the lateral recumbent position to prevent the occlusion of the airway fromthe tongue falling back against the pharyngeal wall. Elevate the head of bed to 30 degrees to facilitate the drainage ofsecretions from the mouth. Avoid feeding orally. Remove excess oral secretions with suction to avoid aspiration. Considerthe use of an oral or nasopharyngeal airway, to maintain patency of the ainway and to aid removal of secretions. Monitorand record respiratory function, including oxygen saturations, respiratory rate, depth and regularity.

Cardiovascular function: Monitor heart rate and rhythm, blood pressure and temperature. Be av^are of any changes invital signs that indicate further neurological deterioration. Observe tbe patient for any changes in colour, for example,pallor or cyatiosis, including the peripheries. Observe for signs of infection, including pyrexia, tachycardia and hypotension.

Immobility: Reposition the patient regularly following assessment of pressure areas and respiratory function. AssessWaterlow score and monitor skin integrity. Consider the use of anti-embolism stockings and anticoagulants for venousthromboembolism prophylaxis.

Pain: Observe for signs of pain or discomfort. Aim to alleviate, consider repositioning the patient or administeringanalgesia as prescribed. Monitor the effectiveness of any intervention.

Renal function: Insert a urinary catheter to avoid urinary stasis. Monitor urine output hourly.

Nutrition and hydration: Consider enteral feeding to provide nutritional support. Monitor and record fluid balance andadminister intravenous fluids as prescribed.

Gastrointestinal needs: Monitor and record bowel functiofi, observing for and reporting diarrhoea or constipation.Consider the use of laxatives to prevent faecal impaction.

Hygiene needs: Regular skin care including eye, mouth and catheter care, as well as care of any invasive sites.

Psychosocial needs: Ensure all procedures are explained to the patient Liaise with family members regarding theliatient's condition and encourage appropriate interaction and involvement in care.

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NURSING STANDARD September 14 :: vol 20 no 1:: 2005 63

learning zone neurological care

Reflect on what you have learnt aboutthe nursing management of unconsciouspatients. Discuss how such skills could beused to enhance the general nursing care ofconscious patients in your clinical area.

Conclusion

The unconscious patient places a demand onresources, notably time and staff. Juggling suchdemands while ensuring that a safe and caringenvironment is maintained are managerialchallenges. Completion of a risk assessment may

help to highlight any potential compromise tothe maintenance of a safe environment.

Depending on the underlying condition, theunconscious patient may never fully recover ormay die from complicating factors. This can bedemoralising for the nurse, especially after along period of committed nursing care.However, the patient may recover fully whichcan be a rewarding and uplifting experience.Fitherway, a committed focus on maintaining ahigh standard of care and promoting dignitythroughout, regardless of the outcome, remainparamount NS

Now that you have completed thisarticle, you might like to write a practice^profile. Guidelines to help you are on page 68.

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