Care of Unconscious Patient

 Definition of Unconsciousness

The brain requires a constant supply of oxygenated blood and glucose to function.
Interruption of this supply will cause loss of consciousness within a few seconds
and permanent brain damage in minutes.

 Assessment:

 Nurses frequently need to monitor the conscious level as impairments may

complicate the existing condition and may cause complications and further
deterioration.
 Glasgow Coma Scale: The Glasgow Coma Scale is a neurological scale –
Gives a reliable, objective record of the level of consciousness (LOC) of a
person, for initial as well as continuing assessment.
o The nurse observes and describes three aspects of the patient’s behavior:
1. Eye opening
2. Verbal response
3. Motor response.
o Interpretation of Glasgow Coma Scale.
o Highest score is 15/15 – Good orientation
o Lowest score is 3/15 - Deep coma. 
Physical Assessment
 Voluntary movement – Strength and asymmetry in the upper extremities.
 Deep tendon Reflexes – biceps, triceps and patella.
 Pupillary light reflex (pupil size).
 Corneal blink reflex.
 Gag swallowing reflex.
Procedure:

Steps of Procedure Yes No

1. Maintenance of Effective Airway 

- An adequate airway must be maintained at all times.

Position the patient in the lateral. Recumbent position to
prevent the occlusion of the airway from the tongue
falling back against the pharyngeal wall. 
- Elevate the head of bed to 30 degrees to facilitate the
drainage of secretions from the mouth. Remove excess
oral secretions with suction to avoid aspiration. 
- Change positions from side-to-side every 2 hourly to
prevent pooling of mucous and secretions in the lungs. 
- Consider the use of an oral or nasopharyngeal airway, to
maintain patency of the airway and to aid removal of
secretions. Monitor and record respiratory function,
including oxygen saturations, respiratory rate, depth and
regularity. 
- Apply suction to remove excess secretions and mucus
collected in the nose, mouth and the respiratory passage. 
- If necessary, insert oral airway for easy breathing. Loosen
the garments to allow free movements of the chest and
abdomen. 
- The patient may require the administration of oxygen
therapy. Physiotherapy is important to encourage lung
expansion, assist the removal of secretions and help in the
prevention of complications.
- The inability to maintain a patent airway means that
aspiration of fluids, from oral secretions, blood in the
presence of trauma, or vomit is a potential risk that may
cause further complications, for example, chest infection.
- The insertion of a nasogastric tube in the early stages of
unconsciousness will allow removal of gastric contents,
thus reducing the risk of aspiration. 
2. Maintenance of fluid & electrolyte balance and
nutrition

- The diet must contain an adequate supply of all nutrients

required for life. Nutrition may be supplied by
intravenous fluids or gastric tube feeding. 
- Monitor Intake and output chart accurately and record.
Obtaining a 24-hour urine collection is an important
means of assessing the protein needs of the unconscious
patient. 
- Monitor heart rate and rhythm, blood pressure and
temperature. Be aware of any changes in vital signs that
indicate further neurological deterioration. Observe the
patient for any changes in color, for example, pallor or
cyanosis, including the peripheries. Observe for signs of
infection, including pyrexia, tachycardia and
hypotension. 
- Administer prescribed intravenous fluids with electrolytes
and vitamins. Fluids are maintained by IV therapy. Keep
accurate records of IV intake and urine output and
observe the patient for signs of dehydration or fluid
overload. 
- Do not over load the stomach. Give 200 - 250 ml of fluid
every 3 hours. When the fluid volume is given at a time is
reduced, the frequency should be increased. 

3. Maintenance of personal hygiene and care of pressure

areas

- Sponging is performed as frequently as necessary. The

unconscious patient should be given a complete bath
every other day. The patient's face and perineal area
should be bathed daily. 
- Change positions from side-to-side every 2 hourly to
relieve pressure on pressure areas and to prevent pooling
of mucous and secretions in the lungs. The bed linen must
be kept wrinkle free and dry Side railing on both sides is
helpful to protect the patient.
- Keep skin dry, clean and free of moisture to prevent bed
sore. Apply back care every 4 hourly. Precautions must
 be taken to prevent the development of pressure sores.
Utilize a protective mattress such as a flotation mattress,
alternating pressure mattress, or eggcrate mattress. 
- Provide oral hygiene with prescribed solution 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. 
- Clean ear with swab and dry carefully especially behind
the ears. Check eyes frequently for signs of irritation or
infection. Use only cleansing solutions and eye drops
ordered by the physician. 
- Gentle cleaning of the nasal mucosa with gauze and water
will help remove the buildup of debris and maintain a
moist environment. If a nasogastric tube is inserted
attention should be paid to the surrounding area as
damage to the mucosa from pressure can occur.
- Keep the patient's room at a comfortable temperature.
Check the patient's skin temperature by feeling the
extremities for warmth or coolness. 

4. Promoting Elimination 

- The bowel should be evacuated regularly to prevent

impaction of stool. Palpate the abdomen for distension.
Auscultate bowel sounds. 
- If the patient is observed for any sign of urinary
incontinence retention and constipation, report to the
physician. 
- An unconscious patient will be incontinent of urine. A
urinary catheter should be considered if the state of
unconsciousness is not resolved quickly. This helps to
retain patient dignity, allows close monitoring of urinary
output and prevent skin breakdown. 
- Keep accurate record of bowel movements. Note time,
amount, color, and consistency. 
- A liquid stool softener may be ordered by the physician to
prevent constipation or impaction. It is generally
administered once per day. 
- If the patient has retention of urine, apply gentle pressure
 over the bladder region. It will help in partially emptying
the bladder. 
- The bladder should be emptied regularly to prevent
infection or stone formation. Adequate fluids should be
given to prevent dehydration. Keep accurate intake and
output records. 
- If the patient is constipated, a glycerin suppository or
enema is advised according to doctor's prescription. 

5. Maintaining Mobility 

- Provide a foot rest (pillow or sand bags) to maintain the

position of the feet at right angles to the legs. Give
adequate support to the limbs and heal when moving or
turning. 
- Provide passive exercise to the limbs at least 4 times
daily. Flexion and extension of all the joints and ankles,
knee, hip, wrist, elbow, shoulder, etc. 
- Check daily for the development of thrombophlebitis by
applying pressure on the calf muscles below the knee
joints. 
- 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.