Upload
deepani-nanayakkara
View
294
Download
0
Embed Size (px)
Citation preview
CARE OF THE UNCONSCIOUS CLIENT
A Simple Guide For Student NursesH. Deepani
RN, BN, Nursing TutorSchool of Nursing
ColomboSri Lanka
Unconsciusness
A condition in which there is a depression of cerebral function ranging from stupor to coma.
Level of consciousness 1. Alert open eyes spontaneously responds all stimuli appropriately
2. Drowsy /lethargy/sleepy Slow to respond but appropriate Oriented
3. Stupor/ confused Aroused by painful stimuli Unclear conversation
4. Semiconscious Moves in painful stimuli Never fully awake No verbal response Blinking/ swallowing reflexes present
5. Coma/ unconscious Unresponsive No voluntary movement No reflexes
Causes
1. CEREBRAL Head injury Cerebral heamorrhage Tumors Abscess CVA Diseases -meningitis, encephalitis
,cerebral malaria, toxaemia
2. METABOLIC DISEASES Hepatic coma Renal failure Diabetic coma-hyperglycaemic
hypoglycaemic Diabetic ketoacidosis Dehydration
3.POISONING Drug over dosage Snake bites Pesticides Alcohol4. SEPTICAEMIA
Signs No response to external stimuli No reflex action Changes in vital signs(BP ,pulse,
respiration, temperature) Changes in pupil size and reaction Decreased sphincter action
Fecal incontinenceConstipationUrinary incontinenceRetention of urine
Signs of dehydration Changes in skin Abnormal involuntary
movementsDecorticationsdecerebration
contd…
Complications Head –lice/pressure soreEye – corneal ulcersMouth – parotitis, cracked lips, dry lips
Lungs – pneumoniaMalnutritionFoot dropWrist drop
Pressure ulcersJoint contracturesMuscle wastingDehydrationUrinary tract infections
Nursing assessment
1. Neurological -GCS2. Physical 3. Investigations
1. Glasgow Coma Scale (GCS) Assess neurological function by using Glasgow Coma Scale (GCS) Parameters
eye openingVerbal responseMotor responsePupil size & reactionVital signs
Score range - 3 to 15 3- death /unconscious 15- conscious &alert
GCS contd…
1.
2. Best verbal response Oriented 5 confused 4inappropriate speech 3incomprehensible sound
2
no verbal response 1
PARAMETER FINDINGS SCOREEye opening spontaneous 4
to speech 3To pain 2 no eye opening
1
contd…Best motor response obeys command 6
localizes pain 5
withdraws from pain 4
Abnormal flexion(decorticate posture)
3
abnormal extension (decerebrate posture)
2
No motor response 1
Physical assessment1. Vital signs2. Eyes3. Facial symmetry4. Reflex actions-
swallowing Blinking Tendon reflexes5. Neck- stiffness
Motor responseMonoplegiaParaplegiaHemiplegiaQuadriplegiaDecerebration Decortication
Skin - pressure ulcers Fecal or urinary incontinence Edema
Investigations CT Scan MRI Scan Lumber Puncture -CSF analysis EEG Monitoring of ICP Blood sugar Blood urea S.E. urine and other investigations
Nursing diagnoses Ineffective airway clearance r/t
accumulation of secretion Ineffective cerebral tissue perfusion r/t
pathological changes of the brain Risk for injury r/t unconsciousness Risk for fluid volume deficit r/t inability to
ingest fluid Ineffective thermoregulation r/t
pathological changes in the brain Risk for corneal tissue injury r/t absence
of corneal reflex
Altered oral mucous membrane r/t absence of pharyngeal reflex
Risk for altered nutrition less than body requirement r/t inability to eat and swallow
Impaired urinary elimination Impaired bowel elimination Impaired physical mobility Self care deficit : bathing, grooming r/t
unconsciousness Risk for complications: pressure sore,
contractures, hypostatic pneumonia, r/t immobility
objectives of care To maintain air way patency To maintain optimal cerebral perfusion To prevent injury To maintain fluid balance To maintain thermoregulation To prevent corneal tissue injury To maintain intact oral mucous
membrane To maintain balanced optimal nutrition
To maintain normal urinary elimination
To maintain normal bowel elimination
To maintain normal physical activity To improve self care To prevent complications
Nursing interventions
1. To maintain airway patency Assess respiratory status (RR/ SaO2/
chest movement/lung sounds/ cyanosis) Place in lateral or semi prone position Insert oro-pharingeal airway to avoid
tongue falling back Suck out oral and nasal secretions Administer humidified oxygen Provide chest physiotherapy Monitor ABG (Arterial Blood Gas)
Prepare for endotracheal intubation if respiration inadequate
Provide artificial ventilation with ventilator
Provide special care for the ventilated patient
2. To maintain optimal cerebral perfusion
Assess GCS and vital signs at regular intervals Monitor ICP (if available) Keep the head and neck aligned Keep head of bed elevated 30 degrees Administer O2 to prevent hypoxic brain injury Check ABG to assess CO2 level Take measures to prevent ↑ICP
-give analgesics before suctioning of airway-give osmotic diuretics & dexamethazone-give stool softeners to prevent straining- give mild sedation if patient is restless
3. To prevent injury Assess risk factors which can cause
injuries Keep side rails up and keep them padded Observe for convulsive attacks Avoid over sedation Keep client nails short Use light restraints if restless Allow a family member to stay with the
client Keep the bed linen clean, dry and wrinkle
free
4. To maintain fluid balance Assess hydration status Monitor intake and output hourly Give IV fluid initially as ordered Initiate NG feed as soon as possible Provide diuretics and
dexamethazone as ordered if cerebral edema suspected
5. To maintain thermoregulation Assess body temperature 4houly Assess all possible sites for infection
(urine, wound, lung, IV sites) Send specimen from all possible
sites(urine, wound swab, phlegm, blood, CSF)for culture & ABST (septic screen)
Take measures to reduce fever (loosen cloth, open doors windows, tepid bath, antipyretics)
Give antibiotics a/c to culture report Give adequate fluid
6. To prevent corneal injury Asses eye for dryness, redness or any
abnormalities Remove contact lenses if worn Clean eyes at regular intervals Instill artificial tears as prescribed Instill eye drops and ointments as
prescribed Use aseptic techniques while giving eye
care Cover eyes with sterile eye patches Prepare for tarsorrhaphy if indicated
7. To maintain intact oral mucous membrane
Asses for dryness, cracks of lips, white or reddened patches , coated tongue etc
Remove dentures if worn Give mouth care every 2-4 hourly Apply glycerin to lips Put crushed Nystatin tablet or anti
fungal solutions for oral thrush as ordered
Clean nostrils to avoid congestion Move endotracheal tube to the other
side of the mouth daily
8. To maintain balanced optimal nutrition
Assess bowel sounds Give NG feeds every 3-4 hourly if
bowel sounds present Give high calorie, high protein and
vitamin rich diet in the liquid form Start TPN if the client cannot
tolerate NG feed Assess signs of any complications
during NG feed & TPN
9. To maintain normal urinary elimination
Asses for any abnormalities of urination Insert an indwelling catheter if retention
of urine present Give catheter care to prevent catheter
related infections Send urine sample for culture & ABST to
asses presence of organisms Apply a condom catheter if incontinence
is present Provide adequate fluid intake
9. To maintain normal bowel elimination
Assess patient for constipation, incontinence or any abnormalities
For constipation Give fruit juice, vegetable soup & juice
through NG tube to facilitate stool softening
Insert suppositories as orderedFor incontinence Wear incontinent pad or diapers Provide perineal care soon the bowel
opened Keep the perineal area clean and dry
10. To maintain normal physical activity
Asses all joints for any deformities and muscle wasting
Provide passive exercise for all joints at every possible times
Turn pt every two hourly Use supportive devices to prevent
deformities Teach and encourage family members to do
the exercises frequently Refer to the physiotherapy unit for special
physiotherapy needs When recovering encourage active exercises
11. To improve self care Provide bed bath daily Provide pressure point care Provide mouth care 2-4 hourly Comb hair as needed Provide perineal care twice a day Change cloth every day and whenever
needed Perform hair wash twice a week Cut nails short Shave beard and mustache of male client
daily Teach family members about performing
hygienic care
12. To prevent complicationsPressure sores Keep skin clean & dry Turn pt 2hourly Provide pressure point care Use supportive devices to avoid
pressure on bony prominences
Joint contractures, foot drop & wrist drop
Provide exercises to all joints Use supportive devices (foot
board, splints) to maintain body alignment
Give high protein diet to promote tissue growth
Deep Vein Thrombosis(DVT) Elevate lower limb above heart level
intermittently Provide passive ROM exercise every
4hourly Use elastic stockings to lower limbs Monitor and compare temperature of both
legs Check Posterior Tibial & Dorsalis Pedis
pulse regularly Monitor for pain ,swelling, redness of the
legs Give S/C heparin if prescribed
Pneumonia Suck out secretions at regular
intervals & whenever necessary Change positions 2 hourly Give chest physiotherapy & use
postural drainage to remove secretions
Keep in head elevated position while feeding
Keep the head tuned to a side always to facilitate drainage of oral secretions
Provide emotional support Reassure client and family Explain all procedures before
preform Allow family member to stay with
client.
Other aspects of care Provide opportunity to practice
religious activities Use therapeutic touch during care Speak to the client in smooth
manner Explain every procedure before
perform Encourage family members to talk
to the client Orientate the client to the date,
time, place & person
QUESTIONS?
THANK YOU!