2-22. GENERAL

a. Unconsciousness means that the patient is unaware of what is going on around him and is unable to make purposeful movement. The basic principle to remember is that the unconscious patient is completely dependent on others for all of his needs. Any omissions in basic nursing care or any failure to protect the unconscious patient in his helpless state may inhibit recovery or greatly prolong his convalescence because of complications that might have been prevented.

b. The most common causes of prolonged unconsciousness include:

(1) Cerebrovascular accident (CVA).

(2) Head injury.

(3) Brain tumor.

(4) Drug overdose.

c. General nursing considerations:

(1) Always assume that the patient can hear, even though he makes no response.

(2) Always address the patient by name and tell him what you are going to do.

(3) Refrain from any conversation about the patient’s condition while in the patient’s presence.

d. Regularly observe and record the patient’s vital signs and level of consciousness.

(1) Always take a rectal temperature.

(2) Report changes in vital signs to the professional nurse.

(3) Note changes in response to stimuli.

(4) Note the return of protective reflexes such as blinking the eyelids or swallowing saliva.

e. Keep the patient’s room at a comfortable temperature. Check the patient’s skin temperature by feeling the extremities for warmth or coolness. Adjust the room temperature if the patient’s skin is too warm or too cool.

2-23. AIRWAY AND BREATHING

a. Maintain a patent airway by proper positioning of the patient. Whenever possible, position the patient on his side with the chin extended. This prevents the tongue from obstructing the airway.

(1) This lateral recumbent position is often referred to as the “coma position.”

(2) It is the safest position for a patient who is left unattended.

b. Suction the mouth, pharynx, and trachea as often as necessary to prevent aspiration of secretions.

c. Reposition the patient from side-to-side to prevent pooling of mucous and secretions in the lungs.

d. Administer oxygen as ordered.

e. Always have suction available to prevent aspiration of vomitus.

2-24. NUTRITIONAL NEEDS

a. A patient who is unconscious is normally fed and medicated by gavage.

(1) Always observe the patient carefully when administering anything by gavage.

(2) Do not leave the patient unattended while gavage feeding.

(3) Keep accurate records of all intake. (Feeding formula, water, liquid medications.)

(4) When gavage feeding an unconscious patient, it is best to place the patient in a sitting position (Fowler’s or semi-Fowlers) and support with pillows.

(a) This permits gravity to help move the feeding or medication.

(b) The chance of aspiration of feeding into the airway is reduced.

b. Fluids are maintained by IV therapy.

(1) Keep accurate records of IV intake and urine output.

(2) Observe the patient for signs of dehydration or fluid overload.

2-25. SKIN CARE

a. The unconscious patient should be given a complete bath every other day. (This prevents drying of the skin.) The patient’s face and perineal area should be bathed daily.

(1) The skin should be lubricated with moisturizing lotion after bathing.

(2) The nails should be kept short, as many patients will scratch themselves.

b. Provide oral hygiene 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.

(1) Always have suction apparatus immediately available when giving mouth care to the unconscious patient.

(2) Apply petrolatum to the lips to prevent drying.

c. Keep the nostrils free of crusted secretions. Prevent drying with a light coat of lotion, petrolatum, or water-soluble lubricant.

d. Check the eyes frequently for signs of irritation or infection. Neglect can result in permanent damage to the cornea since the normal blink reflex and tear-washing mechanisms may be absent. Use only cleansing solutions and eye drops ordered by the physician. One such solution, methyl cellulose (referred to as “artificial tears”) may be ordered for instillation at frequent intervals to prevent irritation.

e. If the patient is incontinent, the perineal area must be washed and dried thoroughly after each incident.

(1) Change the bed linen if damp or soiled.

(2) Observe the skin for evidence of skin breakdown.

f. Skin care should be provided each time the patient is turned.

(1) Examine the skin for areas of irritation or breakdown.

(2) Apply lotion, prn.

(3) Gently massage the skin to stimulate circulation.

2-26. ELIMINATION

a. The bowel should be evacuated regularly to prevent impaction of stool.

(1) Keep accurate record of bowel movements. Note time, amount, color, and consistency.

(2) A liquid stool softener may be ordered by the physician to prevent constipation or impaction. It is generally administered once per day.

(3) Assess for fecal impaction. The patient may be incontinent of stool, yet never completely evacuate the rectum. Small, frequent, loose stools may be the first signs of an impaction as the irritated bowel forces liquid stools around the retained feces.

(4) If enemas are ordered, use proper technique to ensure effective administration and effective return of feces and solution.

b. The bladder should be emptied regularly to prevent infection or stone formation.

(1) Adequate fluids should be given to prevent dehydration.

(2) Keep accurate intake and output records.

(3) Report low urine output to professional nurse.

(4) Provide catheter care at least once per shift to prevent infection in catheterized patients.

2-27. POSITIONING

a. When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. The unconscious patient cannot tell you that he is uncomfortable or is experiencing pressure on a body part.

(1) Limbs must be supported in a position of function. Do not allow flaccid limbs to rest unsupported.

(2) When turning the patient, maintain alignment and do not allow the arms to be caught under the torso.

(3) Change the patient’s position to a new weight-bearing surface every two hours. This decreases the likelihood of complications such as decubitus ulcers, orthostatic pneumonia, and thrombophlebitis.

(4) Utilize a foot board at the end of the bed to decrease the possibility of foot drop.

b. 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.

(1) Exercises with a range of motion (ROM) are performed under the direction of the physical therapist.

(2) Nursing personnel must be proficient in ROM exercises.

(a) Physical therapy personnel will not always be available.

(b) It is a nursing care responsibility to maintain the patient’s range of motion.

c. Precautions must be taken to prevent the development of pressure sores.

(1) Utilize a protective mattress such as a flotation mattress, alternating pressure mattress, or eggcrate mattress.

(2) Change the patient’s position at least every two hours.

(3) Unless contraindicated, get the patient out of bed and into a cushioned, supportive chair.

d. Protect the patient from injury.

(1) Keep siderails up.

(2) Pad the rails with pillows or folded blankets.

(3) Keep stray objects out of the bed.

(4) Use draw sheets for easier turning.

(5) Keep suction equipment available at the bedside for emergencies.

e. Restraints.

(1) Use restraints only with physician’s order.

(2) Use “mitten” restraints to prevent the patient from pulling at catheters, IV lines, his hair, and so on. (Patients not in deep coma may scratch or pick at themselves.)

(3) The restless, confused patient will actively resist restraint and thrash about more when not permitted some freedom of movement of the arms and legs.

(4) Take precautions to prevent restraint from becoming restricting. Do not cut-off circulation. Do not irritate the skin.