Care of the Unconscious

What is the highest possible Glasgow Coma Scale (GCS) score?

15

What is the lowest possible Glasgow Coma Scale (GCS) score indicating severe/totally unresponsive state?

3

What GCS score indicates a comatose state?

8 or lower

What term describes a patient with no response at all, usually seen in the ICU?

Unconscious

What does a lower GCS score indicate?

Deeper coma

What tool is used to measure decreases in consciousness and disruptions in nervous system function?

Glasgow Coma Scale

What component of GCS assesses spontaneous eye opening, response to speech, pain, or no response?

Eye Opening Response

What is the GCS eye opening score for spontaneous eye opening?

4

What is the GCS eye opening score for opening eyes to speech?

3

What is the GCS eye opening score for opening eyes to pain?

2

What is the GCS eye opening score for no eye opening?

1

What finger is most sensitive when applying pain stimulus for eye opening assessment?

Middle finger

What finger is least sensitive when applying pain stimulus for eye opening assessment?

Pinky finger

What GCS verbal score corresponds to orientation to time, place, and person?

5

What GCS verbal score corresponds to confused but appropriate response?

4

What GCS verbal score corresponds to inappropriate words?

3

What GCS verbal score corresponds to incomprehensible sounds?

2

What GCS verbal score corresponds to no verbal response?

1

What GCS motor score corresponds to obeying commands?

6

What GCS motor score corresponds to localizing pain?

5

What GCS motor score corresponds to withdrawal from pain (flexion withdrawal)?

4

What GCS motor score corresponds to abnormal flexion?

3

What term describes abnormal flexion posturing?

Decorticate

What GCS motor score corresponds to abnormal extension?

2

What term describes abnormal extension posturing?

Decerebrate

What GCS motor score corresponds to no motor response?

1

What does PERRLA stand for?

Pupils Equal Round Reactive to Light and Accommodation

What assessment evaluates pupil equality, shape, and reaction to light and accommodation?

PERRLA

Why do comatose patients require eye care?

Absence of blinking and lubrication increases risk for corneal dryness, abrasion, and infection

What type of lubricant must be used for eye care?

Water-based lubricant

What is the purpose of eye care in unconscious patients?

Protect the eye

What is another purpose of eye care in unconscious patients?

Cleanse the eye

Why must debris be removed from unconscious patients’ eyes?

To enhance absorption of medications

Why must exposed corneal areas be kept moist?

Prevent dryness and corneal damage

Who is responsible for assessing the patient’s eyes and administering sterile lubricant?

Nurse

What should AP report immediately during delegated eye care?

Eye drainage or irritation

What sterile solution is used for eye care cleansing?

Normal Saline Solution

From which direction should the eye be cleaned?

Inner canthus to outer canthus

How many strokes per eye pad during cleaning?

One stroke, flip, one stroke, discard

What must never touch the eye when applying ointment?

Tip of ointment tube

When should sterile soaked eye pads be applied?

When blink reflex is absent

How often should eye pads be removed and eyes reassessed?

Every 2–4 hours or as ordered

Why do unconscious patients require nasal care?

Prevent dryness, obstruction, infection, and ensure adequate oxygenation

How often should nasal care be done?

At least once per shift or as needed

What material is used to clean nasal passages?

Cotton-tip applicator

Why must head of bed be elevated during nasal care?

Prevent aspiration

How should cotton applicator be inserted in nasal care?

Insert cotton part only and rotate in circular motion

Why is oral care essential in unconscious patients?

Increased risk of infection due to plaque, dry mouth, and reduced salivation

What respiratory complication can result from poor oral care?

Aspiration pneumonia

What reflex must be assessed before oral care?

Gag reflex

What suction device is used during oral care?

Yankauer

What angle should the head of bed be elevated during oral care?

30 degrees

How should front teeth be brushed?

Up and down motion

How should side teeth be brushed?

Circular then horizontal motion

How should tongue be brushed?

Gently to remove debris

What method is used for flossing?

C-method

Is flossing generally performed in ICU patients?

No

What should never be used to separate a patient’s teeth?

Fingers

What improvised tool can hold the mouth open?

Padded tongue depressor

What should be done if unconscious patient has braces?

Be extra gentle and clean each bracket

Is it ideal for unconscious patients to wear dentures?

No

When should dentures be removed?

Upon intubation and before/after operation

Why must mouthwash be diluted?

Unconscious patients cannot react if too strong

What can be used in community settings if mouthwash unavailable?

Salt and water solution

What is post-mortem care also called?

Last care

What must be confirmed before initiating post-mortem care?

Patient has been pronounced dead

What stage of death involves skin becoming pale?

Pallor mortis

What stage of death involves cooling of the body?

Algor mortis

When does body temperature start to decrease after death?

About 1 hour after being pronounced dead

What stage of death involves stiffening of the body?

Rigor mortis

When does rigor mortis begin?

Within 2 hours

What stage of death causes purplish discoloration?

Livor mortis

During post-mortem care, how should the body be positioned?

Supine with arms at side

If mouth is open post-mortem, what should be placed under chin?

Rolled towel

When are contraptions not removed during post-mortem care?

If patient is for autopsy

How far from insertion site should tubes be cut if for autopsy?

2 inches

What religious group requires body facing Mecca?

Islam

Who performs final washing in Islam?

Imam

How soon must Muslims be buried?

Same day

Are autopsy and organ donation permissible in Islam?

No, unless required by law

What religious group prohibits embalming and flowers?

Judaism

Within how many hours should Jewish burial occur?

24 hours

What sacrament is common in Christian death rituals?

Anointing of the sick

What religion believes in reincarnation?

Hinduism

In Hinduism, which direction should head face?

East

What is left open after death in Buddhism?

Mouth and eyes

What is required after death in Buddhism?

Strict silence