2.4 Care of the Unconscious Patient

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.

The most common causes of prolonged unconsciousness include: cerebrovascular accident (CVA), head injury, brain tumor, and drug overdose.

Always assume that the patient can hear, even though he makes no response. Address the patient by name and tell him what you are going to do, and refrain from any conversation about the patient's condition while in the patient's presence.

Regularly observe and record the patient's vital signs and level of consciousness. Always take a rectal temperature. Note changes in response to stimuli and especially the return of protective reflexes such as blinking the eyelids or swallowing saliva. Report changes in vital signs to the professional nurse.

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.

AIRWAY AND BREATHING

Maintain a patent airway by proper positioning of the patient. Whenever possible, position the patient on his side with the chin extended. This lateral recumbent position is often referred to as the "coma position." It is the safest position for a patient who is left unattended and prevents the tongue from obstructing the airway.

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

Reposition the patient from side-to-side to prevent pooling of mucous and secretions in the lungs. Administer oxygen as ordered, and always have suction available to prevent aspiration of vomitus.

NUTRITIONAL NEEDS

A patient who is unconscious is normally fed and medicated by gavage. 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. This permits gravity to help move the feeding or medication and reduces the chance of aspiration into the airway.

Always observe the patient carefully when administering anything by gavage. Do not leave the patient unattended while gavage feeding, and keep accurate records of all intake. (Feeding formula, water, liquid medications.)

Fluids for an unconscious patient are maintained by IV therapy. Carefully observe the patient for signs of dehydration or fluid overload, and keep accurate records of IV intake and urine output.

SKIN CARE

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. Lubricate the skin with moisturizing lotion after bathing.

Keep the nails short, as many patients will scratch themselves.

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. Always have suction apparatus immediately available when giving mouth care to the unconscious patient. Apply petrolatum to the lips to prevent drying.

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

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.

If the patient is incontinent, the perineal area must be washed and dried thoroughly after each incident. Change the bed linen if damp or soiled, and observe the skin for evidence of skin breakdown.

Skin care should be provided each time the patient is turned. Examine the skin for areas of irritation or breakdown, then apply lotion, prn. Gently massage the skin to stimulate circulation.

ELIMINATION

The bowel should be evacuated regularly to prevent impaction of stool. 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. The physician may order a liquid stool softener to prevent constipation or impaction. It is generally administered once per day. If enemas are ordered, use proper technique to ensure effective administration and effective return of feces and solution.

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

The bladder should be emptied regularly to prevent infection or stone formation. Give adequate fluids to prevent dehydration, and keep accurate intake and output records, and report low urine output to professional nurse. Provide catheter care at least once per shift to prevent infection in catheterized patients.

POSITIONING

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. Use a foot board at the end of the bed to decrease the possibility of foot drop.

When joints are not exercised in their full range of motion each day, the muscles gradually shrink, forming what is known as a contracture.  It is a nursing care responsibility to maintain the patient's range of motion, so passive exercises must be provided for the unconscious patient to prevent contractures. Exercises with a range of motion (ROM) are performed under the direction of the physical therapist. Nursing personnel must be proficient in ROM exercises because physical therapy personnel will not always be available.

Precautions must be taken to prevent the development of pressure sores. This can be done by using a protective mattress such as a flotation mattress, alternating pressure mattress, or eggcrate mattress. Change the patient's position at least every two hours; and, unless contraindicated, get the patient out of bed and into a cushioned, supportive chair.

Protect the patient from injury by keeping siderails up, padding the rails with pillows or folded blankets, keeping stray objects out of the bed, and using draw sheets for easier turning. Also, keep suction equipment available at the bedside for emergencies.

Use restraints only with physician's order. 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.)  The restless, confused patient will actively resist restraint and thrash about more when not permitted some freedom of movement of the arms and legs. So take precautions to prevent restraint from becoming restricting. Do not cut-off circulation. Do not irritate the skin.