NURSING MANAGEMENT OF

THE UNCONSCIOUS PATIENT

By Marie Kah
20th July 2018
Objectives
• Define terms related to neurological status
• Assess level of consciousness using the
Glasgow Coma Score
• Using the nursing process, critically manage an
unconscious patient
Definition of terms
• Consciousness- is the state of general
wakefulness and responsiveness to the
environment.
• Sleep- is the state of altered consciousness or
partial unconsciousness from which an
individual can be aroused.
• Unconsciousness- is the state of
unresponsiveness, where the patient is
unaware of the environment and no
purposeful response can be obtained.
• Unconsciousness- is the condition in which cerebral
function is depressed ranging from stupor to coma.
• Coma- is a clinical state of unconsciousness in which
the patient is unaware of self and environment, and
an individual cannot be awaken.
• Stupor- a state of semi-unconsciousness where the
patient does not move or speak, and makes no
response to stimuli.
• Glasgow Coma Score- is a quick practical and
standardized system for assessing the degree
of impaired consciousness.
• It is mainly used in adults.
• A score of ≤ 8 is generally indicative of coma.
Introduction
• Managing of the unconscious patient can be a
challenging experience and requires a
collaborative approach.
• Unconscious patients have no control over
themselves or their environment and thus are
dependent on the nurse.
• A nurse in the critical care unit or intensive
care unit needs to be abreast with appropriate
knowledge, skills and right attitude on how to
care for unconscious patients.
 The Glasgow Coma Score
• A tool used to evaluate 3 categories of
behaviour that reflect activities in the high
centre of the brain.
 Eye opening
 Verbal response
 Motor response
• The first score provides a baseline for future
scores.
• The lowest score the patient can achieve is 3,
indicating total unresponsiveness.
• The maximum score is 15, indicating an awake,
alert and fully responsive patient.
• A score < 15 is usually an indication there is a
cause for concern.
• By using the GCS it should be possible to detect
detioration before changes in vital signs occur.
Assisting with respiratory function
• Assessing respiratory pattern and rate
(maintaining a patent airway and promoting
adequate ventilation are nursing).
• The accumulation of secretions in the pharynx
presents a serious problem. Because the
patient cannot swallow and lacks pharyngeal
reflexes, these secretions must be removed to
eliminate the danger of aspiration.
• To maintain a patent airway, the patient is
nurse in recumbent position, to prevent the
occlusion of the airway from the tongue falling
back against the pharyngeal wall. This will also
facilitate drainage of secretions.
• Elevating the head of the bed to 30 degrees
helps prevent aspiration.
• Suctioning is performed to remove secretions
from the posterior pharynx and upper trachea.
• Chest physiotherapy and postural drainage
may be initiated to promote pulmonary
hygiene, unless contraindicated by the
patient’s underlying condition.
 Immobility
• An unconscious patient will be immobile.

• Special attention is given because they cannot

respond to external stimuli.

• Assessment includes 2 hourly turning to avoid

pressure, which can cause breakdown and
necrosis of the skin.
• Turning also provides kinaesthetic (sensation
of movement), proprioceptive (awareness of
position), and vestibular (equilibrium)
stimulation.
• Dragging the patient up in bed must be
avoided, because this creates a shearing force
and friction on the skin surface.
• Passive leg movements will encourage blood
flow back to the heart and also prevent
contractures.

• The use of extra pillows aids in the prevention

of footdrop and eliminates the pressure of
bedding on the toes.
• The heels of the feet should be assessed for
pressure areas.

• Administer anticoagulant as per order.

• Anticoagulants increase the velocity of blood

flow in the legs, the pelvic veins and the IVC.
 Eye care
• Some unconscious patients have their eyes
open and have inadequate or absent corneal
reflexes.
• The cornea is likely to become irritated or
scratched, leading to keratitis and corneal
ulcers.
• The eyes may be cleansed with cotton balls
moistened with sterile normal saline to
remove debris and discharge.
Assisting with cardio-vascular function

• Monitoring the CV function in unconscious

patients is of high importance.
• Monitor changes in vital signs that indicate
further detioration – TPR, B/P SaO₂
• Observe any change in colour e.g. pallor or
cyanosis.
• Observe signs of infection (tachycardia,
hypotension, pyrexia).
 Assisting with thermoregulation
• High fever in the unconscious patient may be
caused by infection of the respiratory or
urinary tract, drug reactions, or damage to the
hypothalamic temperature-regulating center.

• A slight elevation of temperature may be

caused by dehydration.
• If body temperature is elevated, tepid sponge,
reduce clothing and extra linens.

• Open windows and put the fan on to cool

down the room.
 Assisting with urinary and GI needs
• The unconscious patient is often incontinent or
has urinary retention.

• Insert a urinary catheter, monitor and record

urinary output.

• The patient is observed for fever and cloudy urine

because catheters are a major factor in causing
urinary tract infection.
• The area around the urethral orifice is
inspected for drainage.

• The urinary catheter is usually removed when

the patient has a stable cardiovascular system
and if no diuresis, sepsis, or voiding
dysfunction existed before the onset of coma.
• Monitor bowel action and record.
• Observe and report any signs of diarrhoea or
constipation.
• Immobility and lack of dietary fibre may cause
constipation.
• Monitor the number and consistency of
bowel movements and perform a rectal
examination for signs of faecal impaction.
• If constipation occur, laxatives administration will
prevent faecal impaction.

• The patient may require an enema.

• There is a risk of diarrhoea from infection, antibiotics,

and hyperosmolar fluids.

• Frequent loose stools may also occur with faecal

impaction.
 Assisting with nutrition and hydration
• Hydration status is assessed by examining tissue turgor
and mucous membranes, assessing intake and output
trends, and analyzing laboratory data.

• Administer I/V fluids as ordered. I/V solutions (and

blood transfusions) for patients with intracranial
conditions must be administered slowly.

• If given too rapidly, they may increase increase

intracranial pressure.
• The quantity of fluids administered may be restricted to
minimize the possibility of producing cerebral oedema.

• If the patient does not recover quickly and sufficiently

enough to take adequate fluids and calories by mouth, a
feeding tube will be inserted for the administration of
fluids and enteral feedings. Feed 3 hourly.

• Monitor and record fluid balance.

 Assisting with personal cleansing
• Personal cleansing is considered part of the
essence of care and needs to be carried out in
an uncompromising standard.

• Regular skin care including eyes, mouth,

catheter care as well as any invasive sites.
• The mouth is inspected for dryness,
inflammation, and crusting.

• Clean and rinsed carefully to remove secretions

and crusts and to keep the mucous membranes
moist.

• Apply vaseline on the lips to prevent drying,

cracking,and encrustations.
 Assisting with pain relief
• Monitor for signs of pain and discomfort.

• Frequent change of position (2 hourly).

• Administer analgesia as prescribed.

• Monitor the effectiveness of the interventions

given.
 Monitoring and managing potential
complications
• Pneumonia, aspiration, and respiratory
failure are potential complications because
the unconscious patient cannot protect the
airway or turn, cough, and take deep breaths.

• Vital signs and respiratory function are

monitored closely to detect any signs of
respiratory failure or distress.
• Total blood count and arterial blood gas
measurements are assessed to determine
whether there are adequate red blood cells to
carry oxygen and whether ventilation is
effective.
• Chest physiotherapy and suctioning are
initiated to prevent respiratory complications
such as pneumonia.
• If pneumonia develops, cultures are obtained to
identify the organism so that appropriate
antibiotics can be administered.
• Monitor closely for evidence of impaired skin
integrity, and strategies to prevent skin
breakdown and pressure sores.
• If pressure sores develop, care is taken to
prevent bacterial contamination , which may
lead to sepsis and septic shock.
 Psycho-social needs
• Explain all procedures even though the patient is
unconscious.
• Liaise with family members regarding the
patient’s condition.
• Communicating with the relatives can aide and
enhance the nurse-patient relationship by
fostering understanding and empathy.
• Discussion with family members can encourage
appropriate interactions and involvement in the
patient’s care.
THE END