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CARE OF THE UNCONSCIOUS

PATIENT

OBJECTIVES
• At The End of The Session, The student should
be able to:
• Define consciousness and have an
understanding of the related anatomy and
physiology.
• Discuss the various levels of impaired
consciousness.
• List the causes of unconsciousness.

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OBJECTIVES
• Identify the needs of the unconscious patient.
• Prioritize patient care, recognizing the skills
required for the assessment, planning and
implementation of nursing care.
• Reflect on how the nursing skills needed to care
for the unconscious patient can be used to
enhance practice in other areas of nursing.

Nervous System
The Nervous System is:
• Responsible for coordinating body functions;
• Responding to changes, stimuli in the internal
and external environments
▫ Brain; Spinal cord; Peripheral nerves
• Basic Structure
▫ Neuron: Sensory; Motor

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Neuronal Anatomy

Three Characteristic –
Excitability (generate)
Conductivity (transmit)
Influence (other cells to transmit nerve impulses)

Glial Cells

Provide support, nourishment, and protection to neurons

Nervous System
• The Nervous System is divided in to two
Anatomic Divisions
▫ Central Nervous System (CNS)
 brain, spinal cord, cranial nerves I and II
▫ Peripheral Nervous System (PNS)
 cranial nerves III to XII, spinal nerves, and
the peripheral components of the autonomic
nervous system (ANS)

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Neurotransmitters
• Communicate messages from one neuron to
another,
• One neuron to a specific target tissue
• Stored in the synaptic vesicles of neurons
• Potentiate, terminate or modulate a specific action
• Can be excitatory or inhibitory
• Many neurologic disorders are due, at least in part,
to an imbalance in neurotransmitters (Parkinson’s,
myasthenia gravis)

Neurotransmitters
• List of major neurotransmitters
▫ Acetylcholine (major transmitter of the parasympathetic
nervous system)
▫ Serotonin
▫ Dopamine
▫ Norepinephrine (major transmitter of the sympathetic
nervous system)
▫ Gamma-aminobutyric acid (GABA)
▫ Enkephalin, Endorphin

(Chapter 60 – Table 60-1 pg 1832)

Nervous System

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Central Nervous System

• Brain
▫ Higher level – Cerebrum,
▫ Lower level – Cerebellum, Brain stem: Midbrain;
Pons; Medulla oblongata,

• Spinal cord; Cauda equina

▫ Protection
 Skull
 Membranes (meninges): Pia mater, Arachnoid, Dura
mater (PAD)

Brain Structure

The Cerebrum
• The cerebrum or cerebral cortex is the largest part
of the human brain, associated with higher brain
function such as thought and action.
• It has a highly folded surface or cortex
• The cerebral cortex is divided into four sections,
called “lobes”:
 the frontal lobe,  occipital lobe,

 parietal lobe  temporal lobe.

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The Cerebrum
• Frontal Lobe - associated with reasoning, planning,
parts of speech, movement, emotions, and problem
solving

• Parietal Lobe - associated with movement,

orientation, recognition, perception of stimuli

• Occipital Lobe - associated with visual processing

• Temporal Lobe - associated with perception and

recognition of auditory stimuli, memory, and speech

Lower Level Brain

• The Cerebellum
▫ similar to the cerebrum (it has two hemispheres and a
cortex).
▫ the cerebellum is responsible for the regulation and
coordination of movement, posture, and balance.
• The Limbic System
▫ referred to as the "emotional brain", is found buried
within the cerebrum.
▫ This system contains the
 thalamus – which has sensory and motor functions. Almost
all sensory information enters this structure . Axons from
every sensory system (except olfaction) synapse here as the
last relay site before the information reaches the cerebral
cortex.

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Lower Level Brain

▫ Limbic system cont’d
 hypothalamus - (part of diencephalon) involved in
functions including homeostasis, emotion, thirst, hunger,
circadian rhythms, and control of the autonomic nervous
system. It also controls the pituitary.
 amygdala – (part of the telencephalon, located in the
temporal lobe) involved in memory, emotion, and fear.
 hippocampus - This part of the brain is important for
learning and memory . . . for converting short term
memory to more permanent memory, and for recalling
spatial relationships in the world about us

Lower Level Brain

• Brain Stem:
▫ Lies beneath the limbic system and comprises of
ascending and descending nerve fibres going to
and from the cerebrum and cerebellum.
▫ It contains the centre for sneezing, coughing,
hiccupping, vomiting, sucking and swallowing. It
is responsible for basic vital life functions such as
breathing, heartbeat, and blood pressure.

Lower Level Brain

• Brain Stem:
▫ The brain stem is made of the midbrain, pons, and medulla
 Midbrain - It is involved in functions such as vision, hearing,
eye movement, and body movement (including voluntary
movement)
 Pons - It is involved in motor control and sensory analysis. It
also plays an important role in the level of consciousness and
sleep.
 Medulla - Caudal part of the brain. It is responsible for
maintaining vital body functions, such as breathing and heart
rate.
▫ The reticular formation is located in the brain stem, the
reticular activating system is part of the formation and
regulates arousal and components of consciousness.

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The Reticular Formation

• The reticular formation is
a nerve network of nuclei
clusters found in the
central core of the brain
stem.

• It extends from the

medulla up to the
thalamus and
hypothalamus.

The Reticular Formation

• Its functions can be classified into 4 categories:
▫ motor control (physical movements or activities such as walking
or running)
▫ sensory control (all the senses including pain)
▫ visceral control (encompasses breathing, heart rate and blood
pressure)
▫ control of consciousness (alertness, sleeping, and various
conscious states)
• Individuals who have difficulties with pain,
alertness, or physical coordination might have
damage to their reticular formation.

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Cerebrospinal Fluid
• Cerebrospinal fluid (CSF)
is a clear, colourless
liquid that bathes the
brain and spinal cord.

• It is formed in the
choroid plexus and
circulates throughout the
ventricles before seeping
into the subarachnoid
space that surrounds the
brain and spinal cord.

Cerebrospinal Fluid
• Function:
▫ Cushion the brain within the skull and serve as a
shock absorber for the central nervous system,
▫ Circulates nutrients and chemicals filtered from
the blood
▫ Removes waste products from the brain.
▫ Can be tested for bacteria or immunoglobulins in
diagnosing many diseases of the nervous system,
including Multiple Sclerosis.
▫ Normal CSF contains a minimal number of white
blood cells and no red blood cells.

Brain Ventricles
• The ventricles of the brain are a communicating
network of cavities filled with cerebrospinal fluid
(CSF) and located within the brain parenchyma.
• There are four ventricles:
▫ 2 lateral ventricles, the third ventricle, (the
cerebral aqueduct) and the fourth ventricle
• The choroid plexuses produce CSF, which fills
the ventricles and subarachnoid space, following
a cycle of constant production and re-
absorption.

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Brain Ventricles

Cerebral Circulation
• The brain’s blood supply originates from the
base of the brain. It arises from the internal
carotid arteries (anterior circulation) and the
vertebral arteries (posterior circulation)

• The internal carotid arteries provide blood flow

to the anterior and middle portions of the
cerebrum. The vertebral arteries join to form the
basilar artery and provide blood flow to the
brainstem, cerebellum, and posterior cerebrum.

Cerebral Circulation
• The circle of Willis is
formed by communicating
arteries that join the
basilar and two internal
carotid arteries.

• Because these two arteries

form a circle, if one of the
main arteries is occluded,
the distal smaller arteries
that it supplies can receive
blood from the other
arteries (collateral
circulation).
Circle of Willis

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Blood Brain Barrier

• The blood-brain barrier (BBB) protects the neural
tissue from variations in blood composition and
toxins.

• The endothelial cells forming the blood-brain

barrier are highly specialized to allow precise control
over the substances that enter or leave the brain.

• This protective function can be altered by trauma,

cerebral edema, and cerebral hypoxemia.

Meninges
• This is three membranes that envelopes the
brain and spinal cord with the predominant
function of protection.

• Each layer is a separate membrane:

▫ Pia mater-vascular layer that protects the blood
vessels passes through the brain and spinal cord.
▫ Arachnoid –a thin layer of connective tissue the
space between this layer and the pia mater is the
subarchnoid space where the cerebrospinal fluid
flows.

Meninges
▫ Dura Mater
 Outer dura mater - membrane (periosteum) of cranial
bones
 Inner dura mater – forms the folds that separate the two
cerebral hemispheres, the cerebral hemispheres from the
posterior fossa (cerebellum and brain stem)
▫ The anchor the spinal cord.

▫ Two spaces formed by the meninges are commonly

accessed by physicians.
 Subarachnoid space – for diagnostic studies (L3 & L4)
 Epidural space – delivery of medication

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Peripheral Nervous System

• Cranial Nerves: 12 pairs
▫ I: Olfactory nerve
▫ II: Optic nerve
▫ III: Oculomotor nerve
▫ IV: Trochlear nerve
▫ V: Trigeminal nerve
▫ VI: Abducens nerve
▫ VII: Facial nerve
▫ VIII: Vestibulocochlear
▫ IX: Glossopharyngeal nerve
▫ X: Vagus nerve
▫ XI: Accessory nerve
▫ XII: Hypoglossal nerve

NB.
These cranial nerves some are only
sensory, some only motor, and some
both. Unlike spinal nerves.

Peripheral Nervous System

Peripheral Nervous System

• Spinal Nerves
▫ 31 pairs (Both sensory & motor)
 8 cervical,
 12 thoracic,
 5 lumbar
 5 sacral,
 1 coccygeal
▫ Two roots
 Dorsal (afferent – sensory)
 Ventral (efferent – motor)
▫ Dermatome distribution

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Dermatomes

Peripheral Nervous System

• Autonomic Nervous System
▫ Sympathetic nervous system
 Expenditure of energy
 Catecholamines: Epinephrine; Norepinephrine;
Dopamine
▫ Parasympathetic nervous system
 Conservation of energy
 Acetylcholine

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Normal Intracranial Pressure

• Intracranial pressure (ICP) is the
hydrostatic force measured in the brain CSF
compartment.

• A balance among the three components (brain

tissue, blood, CSF) maintains the ICP.

• Normal ICP ranges from 5 to 15 mmHg

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Normal Intracranial Pressure

• Factors influences ICP include:
▫ (1) arterial pressure; (2) venous pressure;
(3) intraabdominal and intrathoracic pressure; (4)
posture;
(5) temperature; and (6) blood gases, particularly
carbon dioxide levels.

• The degree of their influence on ICP is based on

the brain adaptation abilities.

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Increased Intracranial Pressure

• The skull is a closed box with three essential
components:
▫ Brain tissue (84%)
▫ Blood (4%)
▫ CSF (12%
• As volume in the compartment increases pressure
increases.
• A significant increase without compensation 
Increased Intracranial Pressure

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Increased Intracranial Pressure

• Pathophysiology and ▫ Factors increasing edema
Etiology  Hypercapnia
 Cerebral Acidosis
▫ A Mass
 Systemic Hypertension
 Brain tumors  Impaired Auto-regulation
 Hematoma  Hypoxia
 Abscess

▫ Cerebral Edema
 Head trauma
 Infectious
 Inflammatory disorders

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Increased Intracranial Pressure

• Signs and Symptoms
▫ Decreasing LOC
▫ Headache
▫ Vomiting (without nausea)
▫ Ocular Changes
 Papilledema (edema of the optic disc)

• Late signs: Cushing’s triad; Cheyne-Stokes respirations

▫ Changes in vital signs
 Cushing traid ((systolic hypertension with a widening
pulse pressure, bradycardia with a full and bounding
pulse, and irregular respirations)

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Monro-Kellie Doctrine
• If one of the three components in the cranial vault,
(brain tissue, blood, CSF), increases in volume, at
least one of the other two must decrease in volume, or
the pressure increases.
• It causes displacement of the brain, this causes
restriction of blood flow to the brain, decreasing
oxygen delivery and waste removal.
• Cells within the brain become anoxic and cannot
metabolize properly, producing ischemia, infarction,
irreversible brain damage, and, eventually, brain
death

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Increased Intracranial Pressure

Complications
• Complications of increased ICP include:
▫ Brain stem herniation,
 Results from an excessive increase in ICP in which the
pressure builds in the cranial vault and the brain tissue
presses down on the brain stem.
▫ Diabetes Insipidus,
 Result of decreased secretion of antidiuretic hormone
(ADH).
▫ Syndrome of inappropriate antidiuretic hormone
(SIADH).
 Result of increased secretion of ADH.

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Intracranial Herniations

• Sustained increases in ICP

result in brainstem
compression and herniation of
the brain from one
compartment to another.
• Herniation of brain tissue can
cause a potentially reversible
process to become irreversible.

Major types of intracranial herniations

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Increased Intracranial Pressure

• Diagnostic Findings
▫ CT; MRI; Lumbar puncture; Cerebral
angiography; Skull radiography
▫ Lab Studies including CBC, coagulation profile,
electrolytes, serum creatinine, ABGs, ammonia
level, drug and toxicology screen, CSF analysis for
protein, cells, glucose
• Medical and Surgical Management
▫ Immediate goal: Decrease ICP by relieving cause
▫ Goals
 Maintain BP
 Prevent hypoxia
 Ensure cerebral perfusion

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Increased Intracranial Pressure

• Drug Therapy
▫ Osmotic diuretic – Mannitol (Osmitrol 25%)
▫ Hypertonic saline solution
▫ Corticosteroids (e.g., dexamethasone [Decadron]) are
used to treat vasogenic edema surrounding tumors and
abscesses.
▫ Antipyretics (for fever or other fever reducing strategies
to maintain temp 36° to 37° C)
▫ Barbiturates decrease cerebral metabolism, causing a
decrease in ICP and a reduction in cerebral edema

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Increased Intracranial Pressure

• Nursing Management
• Nursing diagnoses for the patient with increased
ICP include, but are not limited to, the following:
▫ Decreased intracranial adaptive capacity related
to decreased cerebral perfusion or increased ICP
▫ Risk for ineffective cerebral tissue perfusion
related to reduction of venous and/or arterial
blood flow and cerebral edema
▫ Risk for disuse syndrome related to altered LOC,
immobility, and altered nutritional intake

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Increased Intracranial Pressure

• Nursing Interventions are aimed at achieving these
overall goals for the patient with increased ICP:
1. Maintain a patent airway;
2. Have ICP within normal limits;
3. Have normal fluid, electrolyte, and nutritional
balance; and
4. Prevent complications secondary to immobility and
decreased LOC.

Consciousness

Controls sweating,
blood pressure,
digestion and Alertness

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WHAT IS CONSCIOUSNESSS
• Complete awareness of self and environment
with appropriate responsiveness to stimuli
(Watson,1979).

• Consciousness is a function of the reticular

formation (RF), which has its origins in the
brainstem (Barker 2002). The RF is a network of
neurons that connect with the spinal cord,
cerebellum, thalamus and hypothalamus.

WHAT IS CONSCIOUSNESS
• All sensory pathways link into the RF (Fitzgerald
1996). The reticular activating system (RAS) is a
feature of the RF and is responsible for arousal from
sleep and maintaining consciousness (Fitzgerald
1996).

• The RAS has a large number of projections that are

linked to the cerebral cortex (Pemberton 2000) and
are concerned with the arousal of the brain during
sleep and wakefulness (Fitzgerald 1996)

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WHAT IS UNCONSCIOUSNESS
• Interruption of impulses from the Reticular
Activating System or failure of the cerebral
cortical neurons to respond to incoming
impulses, produces a loss of consciousness.

INTRACRANIAL CAUSES OF IMPAIRED

CONSCIOUSNESS
• Head Injuries

• Depressed Skull Fracture

• Cerebral Vascular Disease

• Aneurysm

• Thrombosis And Embolism

INTRACRANIAL CAUSES OF IMPAIRED

CONSCIOUSNESS
• Compressions of Brain Tissues (Lesions,
Abscess, Hematoma, Elevated Intracranial
Pressure)

• Infections: e.g Meningitis, Viral Encephalitis

• Epilepsy

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EXTRACRANIAL OR SYSTEMIC CAUSES

• Metabolic Diseases (Hypoglycemia, Diabetic
Ketoacidosis, Renal And Hepatic Failure).
• Diseases That Interfere With O2 Supply To The
Brain (Cardiac Failure, Shock, Respiratory
Insufficiency).
• Infections
• Intoxication And Poisoning (Alcohol, Narcotics,
Barbiturates, Carbon Monoxide
• Hypothermia

IMPAIRED CONSCIOUSNESS

• There are acute and chronic states of impaired

consciousness. Acute states are potentially
reversible, whereas chronic states indicate
underlying brain damage and hence are
irreversible (Pemberton 2000).

• Acute states are generally caused by metabolic

upsets, such as hypoglycaemia or drug
intoxication, which alter brain function.

ASSESSMENT
• ABC (Airway, Breathing, Circulation)
• DEF (Diagnosis, Evaluation, Further
Management)
• Neurological Observations: GCS, Pupillary
Response,

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ASSESSMENT
• Glasgow Coma Scale (GCS) is
a neurological scale which aims to give a reliable
and objective way of recording the conscious
state of a person for initial as well as subsequent
assessment.
• A patient is assessed against the criteria of the
scale, and the resulting points give a patient
score between 3 (indicating deep
unconsciousness) and 15 (consciousness).

Decorticate posturing
• Decorticate posturing indicates that there may be
damage to areas including the cerebral hemispheres,
the internal capsule, and the thalamus. It may also
indicate damage to the midbrain.
• While decorticate posturing is still an ominous sign
of severe brain damage, decerebrate posturing is
usually indicative of more severe damage as the
rubrospinal tract and hence, the red nucleus, is also
involved indicating lesion lower in the brainstem.

Decorticate posturing

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Decorticate posturing
• Decorticate posturing is also called decorticate
response, decorticate rigidity, flexor posturing,
or, colloquially, mummy baby.
• Patients with decorticate posturing present with
the arms flexed, or bent inward on the chest, the
hands are clenched into fists, and the legs
extended and feet turned inward.
• A person displaying decorticate posturing in
response to pain gets a score of three (3) in the
motor section of the Glasgow Coma Scale.

Decerebrate Posturing
• Decerebrate posturing is also called decerebrate
response, decerebrate rigidity, or extensor
posturing. It describes the involuntary extension of
the upper extremities in response to external
stimuli.
• In decerebrate posturing, the head is arched back,
the arms are extended by the sides, and the legs are
extended. A hallmark of decerebrate posturing is
extended elbows. The arms and legs are extended
and rotated internally. The patient is rigid, with the
teeth clenched. The signs can be on just one side of
the body or on both sides, and it may be just in the
arms and may be intermittent.

Decerebrate Posturing

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Decerebrate Posturing
• A person displaying decerebrate posturing in
response to pain gets a score of two (2) in the
motor section of the Glasgow Coma Scale.
• Decerebrate posturing indicates brain stem
damage, specifically damage below the level of
the red nucleus (e.g. mid-collicular lesion). It is
exhibited by people with lesions or compression
in the midbrain and lesions in the cerebellum.

ASSESSMENT

ASSESSMENT
Interpretation of the scale is vital.
• Generally, brain injury is classified as:
▫ Severe, with GCS < 8–9
▫ Moderate, GCS 8 or 9–12
▫ Minor, GCS ≥ 13.
• Generally when a patient is in a decline of their
GCS score, the nurse or medical staff should
assess the cranial nerves and determine which of
the twelve have been affected.

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Pupillary Response
• Under normal conditions, the pupils of both eyes
respond identically to a light stimulus,
regardless of which eye is being stimulated.
Light entering one eye produces a constriction of
the pupil of that eye, the direct response, as
well as a constriction of the pupil of the
unstimulated eye, the consensual response.

Pupillary Response

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Patient 1
• Mr. Patrick opens his eyes and look at the person who is
examining him.
• He speak normally and answer questions appropriately
• He is able to follow commands like, “show me two fingers.”

Score Mr. Patrick:

E – _____
V – _____
M - _____

THIS PATIENT HAS A GLASGOW COMA SCORE OF ______.

Patient 2
• Mrs. Grey eyes are closed, even if someone calls her loudly.
She opens her eyes when pinched.
• She said “Don’t!” or "Stop!" when pinched, but does not speak
any whole sentences and does not answer any questions
• She does not follow commands, but if someone pinches her,
she will quickly push his or her hand away.

Score Mrs. Grey

E – _____
V – _____
M - _____

THIS PATIENT HAS A GLASGOW COMA SCORE OF ______.

Patient 3
• Ms. Chase eyes are closed, even if someone pinches her.
• She makes no sound, even if someone pinches her.
• She does not follow commands. She will not move, even
if someone pinches her.
Score Ms. Chase
E – _____
V – _____
M - _____

THIS PATIENT HAS A GLASGOW COMA SCORE OF _____.

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Patient 4
• Mr. Simpson eyes remain closed, even if someone pinches
him.
• He groans in response to being pinched, but will not say any
recognizable words.
• He does not follow commands, but if someone pinches him,
you will try to push his or her hand away.

Score Mr. Simpson

E – _____
V – _____
M - _____

THIS PATIENT HAS A GLASGOW COMA SCORE OF ______.

Next - Cranial Nerve Testing

Cranial Nerves: 12 pairs

• I: Olfactory nerve • VIII: Vestibulocochlear
• II: Optic nerve • IX: Glossopharyngeal nerve
• III: Oculomotor nerve • X: Vagus nerve
• IV: Trochlear nerve • XI: Accessory nerve
• V: Trigeminal nerve • XII: Hypoglossal nerve
• VI: Abducens nerve
• VII: Facial nerve
NB.
These cranial nerves some are only
sensory, some only motor, and some both.
Unlike spinal nerves.

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ASSESSMENT
• Respiratory
• Circulatory
• Integument
• Gastrointestinal
• Musculoskeletal
• Elimination

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MANAGEMENT

• Airway • Diagnosis

• Breathing • Evaluation

• Circulation • Further management

MANAGEMENT
• OXYGEN AND TRANSPORT:- AIRWAY
▫ Oropharyngeal Airway / Endotracheal tube /
Nasopharyngeal airway
▫ Positioning:- Recovery, lateral recumbent with the
head of the bed slightly tilted upwards, about 10-
30 degrees (Pemberton 2000).
 It is important to recognize that such positioning is
the ideal and may be contraindicated by an
underlying condition, for example, a spinal or an
underlying brain injury.

MANAGEMENT
• OXYGEN AND TRANSPORT:-
▫ Suctioning
▫ Breathing
▫ Level of Consciousness (GCS)
▫ Pupillary Response, Eye Care, Gag Reflex
▫ Respirations (Rate, Rhythm, Depth)
▫ Chest Excursions
▫ Chest Auscultation

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MANAGEMENT
• OXYGEN AND TRANSPORT:-
▫ Circulatory (Capillary Refill, B/P, HR, O2)
▫ Saturation
▫ Intravenous Fluids

MANAGEMENT
• SAFETY AND PROTECTION:-
▫ Integument
▫ Skin (Colour, Temperature, Dryness / Coldness /
Moisture.
▫ Discoloration of Pressure Areas Blueness or
Cyanosis of Extremities

MANAGEMENT
• SAFETY AND PROTECTION:-
▫ Musculoskletal
▫ Passive ROM
▫ Positioning (Lateral, Semi-prone (Prevention of
Contractures, Foot Drop, Proper Alignment
▫ Hourly Turns
▫ Cotsides

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MANAGEMENT
• SAFETY AND PROTECTION:-
▫ Hygiene Needs (Mouth Care, Q2hrly, Lip
Moisture)
▫ Removal of Dentures
▫ Nasal Care
▫ Keep Eyes Close
▫ Catheter Care (Once Per Shift)

MANAGEMENT
• NUTRITION:-
▫ Intravenous Fluids With Additives
▫ Nasogastric Feeds
▫ Gastrostomy Feeds
▫ Total Parental Nutrition

MANAGEMENT
• ELIMINATION:-
▫ Q1hly Emptying of Drainage (Expect At Least 30
mls Urine Every Hour)
▫ Correct Charting of Output

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MANAGEMENT
• PSYCHOLOGICAL:-
▫ Maintainance of Patient’s Dignity
▫ Guard Conversations
▫ Undate Family (Answer Questions, Reassure)

Case Study 2
• Beatrice, a 77 years old, is transferred to a medical ward following a long
admission on the intensive care unit (ICU). During her stay on the ICU
she had a cardiac arrest which resulted in her sustaining a hypoxic brain
injury. For several weeks her Glasgow Coma Scale (GCS) score has been
stable at 9/15. Her eyes open spontaneously giving a score of 4. She has a
tracheostomy tube in situ and makes no effort to communicate orally (1).
She flexes her limbs in response to painful stimuli, but is unable to
localise the source of the stimuli (4). She also has a generalised weakness
in her limbs with a more pronounced hemiparesis on the right side of
her body.
• Her vital signs - blood pressure, heart rate, temperature and respiratory
rate - are stable. She is expectorating copious secretions from her
tracheostomy, and requires frequent suctioning to maintain a patent
airway. She is obese and is at high risk of developing pressure ulcers. She
has a urinary catheter in situ and has been treated for a urinary tract
infection while on the ICU. Beatrice is receiving enteral feeding via a
percutaneous endoscopic gastrostomy. Laxatives are prescribed to help
maintain regular bowel function.

Nursing Diagnosis
• Ineffective airway clearance related to altered level
of consciousness
• Risk for injury related to decreased level of
consciousness.
• Risk for impaired skin integrity related to
immobility
• Impaired urinary elimination related to impairment
in sensing and control.
• Disturbed sensory perception related to neurologic
impairment.
• Interrupted family process related to health crisis.
• Risk for impaired nutritional status.

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THE END
QUESTIONS

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