Nursing Care of an Unconscious Patient

Nursing Care of an Unconscious Patient

Learning Outcomes

  • Definition of Unconsciousness.
  • Etiology of Unconsciousness.
  • Pathophysiology of unconsciousness
  • Signs and Symptoms.
  • Diagnostic testing and treatment options.
  • Nursing management of Unconscious patients

Basics of Brain Anatomy

  • Cortex
  • Cranium
  • Occipital Lobe
  • Parietal Lobe
  • Frontal Lobe
  • Basal Ganglia
  • Temporal Lobe
  • Cerebellum
  • Dura
  • Brain Stem
  • Spinal Cord

Reticular Activating System (RAS)

  • The reticular activating system, or RAS, is a part of the brain that starts close to the top of the spinal column and extends upwards around two inches.
  • It has a diameter slightly larger than a pencil.
  • All senses are wired directly to this bundle of neurons about the size of the little finger.
  • The RAS is the gatekeeper of information that is let into the conscious mind.
  • It makes sure the brain doesn't have to deal with more information than it can handle.
  • The reticular activating system plays a big role in the sensory information you perceive daily.

Brain's Requirement

  • The brain requires a constant supply of oxygenated blood and glucose to function.
  • Interruption of this function will cause loss of consciousness within a few seconds and permanent brain damage in minutes.

Consciousness

  • A state of awareness of yourself and your surroundings.
  • Ability to perceive sensory stimuli and respond appropriately to them.

Unconsciousness

  • Abnormal state - client is unarousable and unresponsive.
  • Coma is the deepest state of unconsciousness.
  • Unconsciousness is a symptom rather than a disease.
  • Degrees of unconsciousness that vary in length and severity:
    • Brief – fainting
    • Prolonged – deep coma

Etiology of Unconsciousness

Structural/Surgical

  • Trauma
  • Epidural / Subdural hematoma
  • Brain contusion
  • Hydrocephalus
  • Stroke
  • Tumor

Metabolic/Medical

  • Infection
    • Meningitis
    • Encephalitis
  • Hypo/hyperglycemia
  • Hepatic encephalopathy
  • Hyponatremia
  • Drug /alcohol overdose
  • Poisoning /intoxication

Pathophysiology

  • Damage to the brain and skull.
  • Inflammation, edema, and hemorrhage.
  • Increased ICP (Intracranial Pressure).
  • Diffused damage to the cerebral tissues.
  • Blocks the signal to the RAS (Reticular activating system).
  • Results in Unconsciousness.

Signs and Symptoms

  • Unresponsiveness (does not respond to activity, touch, sound, or other stimulation).
  • Unawareness of surroundings and no response to sound
  • No purposeful movements
  • Does not respond to questions or to touch
  • Confusion
  • Drowsiness
  • Inability to speak or move parts of the body
  • Loss of bowel or bladder control (incontinence)
  • Respiratory changes
  • Abnormal pupil reactions

Effects of Altered LOC or Coma

  • Full recovery with no long-term residual effects.
  • Recovery with residual damage (learning deficits, emotional difficulties, impaired judgment).
  • Persistent vegetative state (cerebral death or brain death).

Diagnostic Tests

  • X-ray - SKULL
  • MRI (magnetic resonance imaging): tumors, vascular abnormalities, IC bleed
  • CT (computerized tomography): cerebral edema, infarctions, hydrocephalus, midline shift
  • Lumbar puncture: cerebral meningitis, CSF evaluation
  • PET (positron emission tomography)
  • EEG: electric activity of cerebral cortex
  • Blood test like CBC, LFT, RFT, ABG etc.

Medical Management

  • The goals of medical management are to preserve brain function and prevent further damage.
    • Ventilator support
    • Oxygen therapy
    • Management of blood pressure
    • Management of fluid balance
    • Management of seizures: anti-epileptic, sedatives, paralytic agents
    • Treating Increased ICP: mannitol, corticosteroids
    • Management of temperature regulation (fever): ice packs, tepid sponging, antipyretics, NSAIDS
    • Management of elimination: laxatives and high fiber diet
    • Management of nutrition: TPN and RT feeds
    • DVT prophylaxis

Surgery (If Necessary)

  • Craniotomy: Skull/bone flap is kept in the abdomen
  • Cranioplasty
  • Burr-hole

Craniotomy vs. Craniectomy

  • Craniotomy
    • Usually the first part of further brain surgery
    • The bone flap is temporarily removed
    • It's later returned to the skull after surgery
  • Craniectomy
    • Often performed to relieve pressure on the brain
    • The bone flap is surgically removed
    • It's not immediately put back after surgery

Nursing Management

Goals of Nursing Care

  • Maintain adequate cerebral perfusion
  • Remain normothermic
  • Be free from pain, discomfort, and infection
  • Attain maximal cognitive, motor, and sensory function

Assessment

  • Frequent monitoring of conscious level is needed as impairments may complicate the existing condition and may cause complications and further deterioration.
  • Glasgow Coma Scale (GCS)
    • A neurological scale that gives a reliable, objective record of the level of consciousness (LOC) of a person, for initial as well as continuing assessment.
    • The nurse observes and describes three aspects of the patients behavior:
      • Eye-opening
      • Verbal response
      • Motor response.

Glasgow Coma Scale

  • Behavior
    • Eye-opening response
      • Spontaneously (4)
      • To speech (3)
      • To pain (2)
      • No response (1)
    • Best verbal response
      • Oriented to time, place, and person (5)
      • Confused (4)
      • Inappropriate words (3)
      • Incomprehensible sounds (2)
      • No response (1)
    • Best motor response
      • Obeys commands (6)
      • Moves to localized pain (5)
      • Flexion withdrawal from pain (4)
      • Abnormal flexion (decorticate) (3)
      • Abnormal extension (decerebrate) (2)
      • No response (1)
  • Total score:
    • Best response: 15
    • Comatose client: 8 or less
    • Totally unresponsive: 3

Interpretation of Glasgow Coma Scale

  • Highest score is 15/15 – Good orientation
  • Lowest score is 3/15 - Deep coma. Considered brain dead if client dependant on a ventilator
  • GCS ≤ 8 – Severe brain injury
  • GCS 9 – 12 - Moderate brain injury
  • GCS ≥ 13 – Mild brain injury

Limitations of GCS Scoring

  • Eye opening
    • If severe facial/eye swelling/ptosis is present one cannot test eye responses.
    • The patient who is in deep coma with flaccid eye muscles will show no response to stimulation.
    • However, if the eyelids are drawn back the eyes may remain open. This is very different from spontaneous eye opening and must be recorded as ‘none’.
  • Verbal Response
    • The verbal response may be compromised by the presence of an endotracheal/ tracheostomy tube.
    • Hearing defect/ speech defect may alter patient’s response. Written instructions may be used.
  • Motor Response
    • Asymmetrical responses(focal deficit): Best motor response should be recorded.
      • e.g. if patient localizes pain on his left side but flexes to pain on his right side, localizing response is recorded.
    • Explain the use of pain stimuli to the relatives.
    • Pain infliction may result in bruising.

Physical Assessment

  • Voluntary movement – Strength and asymmetry in the upper extremities
  • Deep tendon Reflexes – biceps, triceps and patella
  • Pupillary light reflex (pupil size)
  • Corneal blink reflex
  • Gag swallowing reflex

Posturing

  • Decorticate (Flexor)
    • Arms are like "C's"
    • Moves in toward the "Cord"
    • Problems with the cervical spinal tract or cerebral hemisphere.
  • Decerebrate (Extensor)
    • Arms are like "E's"
    • Problems Within Midbrain or Pons.

Potential Nursing Diagnoses

  • Ineffective airway clearance
  • Ineffective cerebral tissue perfusion
  • Risk for increased ICP
  • Imbalanced fluid volume
  • Impaired skin integrity
  • Self-care deficit
  • Imbalanced nutrition
  • Incontinence: bowel and /or bladder
  • Risk for aspiration
  • Risk for contractures
  • Altered family process

Maintaining a Patent Airway

  • The breath sounds must be assessed every 2 hourly.
  • ABG results must be interpreted to determine the degree of oxygenation provided by the ventilators or oxygen.
  • Assess for cough and swallow reflexes.
  • Use an oral artificial airway to maintain patency.
  • Tracheostomy or endotracheal intubation and mechanical ventilation may be necessary

Preventing Airway Obstruction

  • Position on alternate sides every 2-4 hours to prevent secretions accumulating in the airways on one side.
  • Maintain the neck in a neutral position.
  • Oronasopharyngeal suction may be necessary to aspirate secretions.
  • If facial palsy or hemi paralysis is present, the affected side must be kept the uppermost.
  • Chest percussion and postural drainage may be prescribed to assist in the removal of tenacious secretions.
  • Dentures are removed
  • Nasal and oral care is provided to keep the upper airway free of accumulated secretions debris

Ineffective Cerebral Tissue Perfusion

  • Assess the GCS, SpO2 level, and ABG of the patient.
  • Monitor the vital signs of the patients (increased temperature).
  • Head elevation of 30 degrees, neutral position maintained to facilitate venous drainage.
  • Reduce agitation. (Sedation.)
  • Reduce cerebral edema (Corticosteroids, osmotic or loop diuretics.) Generally peaks within 72 hrs after trauma and subsides gradually.
  • Schedule care so that harsh activity [suctioning, bathing, turning] are not grouped together, with breaks between care for recovery.
  • Talk softly and limit touch and stimulation.
  • Administer laxatives, antitussives, and antiemetics as ordered
  • Manage temperature with antipyretics and cooling measures.
  • Prevent seizure with ordered dilantin.
  • Administer mannitol 25-50 g IV bolus if ICP >20, as prescribed.

Risk for Increased ICP

  • Assess the GCS score, assess signs of increased ICP.
  • Head elevation of 30 degrees, neutral position maintained to facilitate venous drainage and prevent aspiration.
  • Pre-oxygenation before suctioning should be mandatory, and each pass of the catheter limited to 10 seconds, with appropriate sedation to limit the rise in ICP.
  • Insertion of an oral airway to suction the secretions.
  • The breath sounds must be assessed every 2 hourly.

Signs of Increased ICP

  • Restlessness
  • Headache
  • Pupillary changes: ASSESS every hourly
  • Respiratory irregularity
  • Widening pulse pressure, hypertension, and bradycardia. (Cushing’s Triad)
  • Normal ICP: 5 to 15 mm of Hg

Imbalanced Fluid and Electrolyte

  • Intake-Output chart should be meticulously maintained.
  • Daily weight should be taken.
  • Assess and document symptoms that may indicate fluid volume overload or deficit.
  • Diuretics may be prescribed to correct fluid overload and reduce edema.
  • Over hydration and intravenous fluids with glucose are always avoided in comatose patients as cerebral oedema may follow.

Impaired Skin Integrity

  • The nurse should provide intervention for all self-care needs including bathing, hair care, skin and nail care.
  • Frequent back care should be given.
  • Comfort devices should be used.
  • Positions should be changed.
  • Special mattresses or airbeds to be used.
  • Adequate nutritional and hydration status should be maintained.
  • Patient’s nails should be kept trimmed.
  • Cornea should be kept moist by instilling methyl cellulose 0.5% to 1%.
  • Protective eye shields can be applied or the eyelids closed with adhesive strips if the corneal reflex is absent. These measures prevent corneal abrasions and irritation.
  • Inspect the oral cavity.
  • Keep the lips coated with a water-soluble lubricant to prevent encrustation, drying, cracking. Inspect the paralyzed cheek.
  • Frequent oral hygiene every 4 hourly.
  • Nasal passages may get occluded so they may be cleaned with a cotton-tipped applicator.

Proper Positioning

  • Lateral position on a pillow to maintain head in a neutral position.
  • Upper arm positioned on a pillow to maintain shoulder alignment
  • Upper leg supported on a pillow to maintain alignment of the hip.
  • Change position to lie on alternate sides every 2-4hrs
  • For hemiplegia – position on the affected side for brief periods, taking care to prevent injury to soft tissue and nerves, oedema or disruption of the blood supply
  • Maintaining correct positioning enables secretions to drain from the client’s mouth, the tongue does not obstruct the airway, and postural deformities are prevented.

Self-Care Deficit

  • Attending to the hygiene needs of the unconscious patient should never become ritualistic, and despite the patient's perceived lack of awareness, dignity should not be compromised.
  • Involving the family in self-care needs.
  • Incontinence, perspiration, poor nutrition, obesity, and old age also contribute to the formation of pressure ulcers.
  • Care should be taken to examine the skin properly, noting any areas which are red, dry, or broken.
  • Fingernails and toenails also need to be assessed
  • Chronic illnesses, such as diabetes, need more attention.

Bathing

  • Minimum two nurses should bathe an unconscious patient as turning the patient may block the airway.
  • Proper assessment of the condition of the skin must be done when giving a bed bath.
  • Hair care should not be neglected.

Oral Hygiene

  • A chlorhexidine-based solution is used.
  • Airway should be removed when providing oral care. It should be cleaned and then reinserted.
  • If the patient has an endotracheal tube, the tube should be fixed alternately on each side.
  • Minimum of four-hourly oral care to reduce the potential of infection from micro-organisms.
  • Also, not to damage the gingiva by using excessive force.

Eye Care

  • In assessing the eyes, observe for signs of irritation, corneal drying, abrasions, and oedema.
  • Gentle cleaning with gauze and 0.9% sodium chloride should be sufficient to prevent infection.
  • Artificial tears can also be applied as drops to help moisten the eyes.
  • Corneal damage can result if the eyes remain open for a longer time.
  • Tape can be used to close the eyes.

Nasal Care

  • Cleaning of the nasal mucosa with gauze and water.
  • Nasogastric tube placement damage to the nasal mucosa

Ear Care

  • Clean around the aural canal, although care must be taken not to push anything inside the ear.

Imbalanced Nutrition

  • Diet prescribed nutrition based on individuals requirements specifically to meet energy needs, tissue repair, replace fluid loss to maintain basic life functions

Methods of Nutritional Support

  • TPN (Total parenteral nutrition) TPN is considered for prolonged unconsciousness.
  • Intravenous fluids are administered for comatose patients. As fluid intake is restricted and glucose is avoided to control cerebral oedema and intravenous infusion cannot be considered as a nutritional support.
  • Enteral feeding via Nasogastric, nasojejunal OR PEG tube.

Risk for Injury

  • Side rails must be kept whenever the patient is not receiving direct care.
  • Seizure precautions must be taken.
  • Adequate support to limbs and head must be given when moving or turning an unconscious patient. Protect from external sources of heat.
  • Over sedation should be avoided – as it impedes the assessment of the level of consciousness and impairs respiration.
  • Assess the Need for restrain.

Impaired Bowel/Bladder Functions

  • Assess for constipation and bladder distention.
  • Auscultate bowel sounds.
  • Stool softeners or laxatives may be given.
  • Bladder catheterization may be done.
  • Meticulous catheter care must be provided under aseptic techniques.
  • Monitor the urine output and color.
  • Initiate bladder training as soon as consciousness has regained.

Risk for Contractures

  • Maintain the extremities in functional positions by providing proper support.
  • Remove the support devices every four hours for passive exercises and skin care.
  • Foot support should be provided.

Sensory Stimulation

  • The brain needs sensory input.
  • It is widely believed that hearing is the last sense to go.
  • Talk, explain to the patient what is going on.
  • Upon waking, many clients remember and will accurately recall events and processes that happened while they were “sleeping”. (unconscious).
  • Some have reported they longed for someone to talk to them and not about them.

Nurses Must

  • Show respect
  • Encourage family to contribute to the care of their loved ones
  • Afford the privacy both the client and family deserve
  • Encourage stimulation by:
    • Massage
    • Combing/washing hair
    • Playing music/radio/CD/TV
    • Reading a book
    • Bring in perfumed flowers
    • Update them with family news

Altered Family Process

  • Include the family members in patient’s care.
  • Communicate frequently with the family members.
  • The family members should be allowed to stay with the patient when and where it is possible.
  • Use external support systems like professional counselors, religious clergy etc.
  • Clarifications and questions should be encouraged.