Nursing: Unconscious Patient Care

Body Temperature Measurement

• In unconscious patients, body temperature is never taken orally (mouth)
• Rectal or tympanic (if not contraindicated) temperature measurement is preferred over axillary temperature

Collaborative Problems and Potential Complications of Patients with Altered Level of Consciousness

• Respiratory distress or failure
• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures

Goals for the Patient with Altered Level of Consciousness

• Maintenance of clear airway
• Protection from injury
• Attainment of fluid volume balance
• Maintenance of skin integrity
• Absence of corneal irritation
• Effective thermoregulation
• Accurate perception of environmental stimuli
• Maintenance of intact family or support system
• Absence of complications

Nursing Interventions for the Patient with Altered Level of Consciousness

• Compensation for loss of protective reflexes
• Assumption of responsibility for total patient care
• Earliest sign of increasing ICP is a change in LOC
• Slowing of speech and delay in response to verbal suggestions are other early indicators

Cerebral Response to ICP

• Cerebral perfusion pressure (CPP) is closely linked to ICP
• CPP = MAP (mean arterial pressure) – ICP
• Normal CPP is 70 to 100
• A CPP of less than 50 results in permanent neurologic damage

Early Manifestations of Increased ICP

• Changes in LOC
• Restlessness, confusion, increasing drowsiness, increased respiratory effort, purposeless movements
• Pupillary changes and impaired ocular movements
• Weakness in one extremity or one side
• Headache: constant, increasing in intensity, or aggravated by movement or straining

Late Manifestations of Increased ICP

• Respiratory and vasomotor changes
• VS: Increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate
• Temperature increase
• Cushing triad: bradycardia, hypertension, bradypnea
• Projectile vomiting
• Further deterioration of LOC; stupor to coma
• Hemiplegia, decortication, decerebration, or flaccidity
• Respiratory pattern alterations including Cheyne–Stokes breathing and arrest
• Loss of brainstem reflexes: pupil, gag, corneal, and swallowing

Assessment of the Patient with Increased Intracranial Pressure

• Obtain history of events leading to illness
• Evaluate mental status, LOC
• Assessment of selected cranial nerves
• Assess cerebellar function, reflexes, motor and sensory function
• Glasgow Coma Scale, pupil checks
• Frequent vital signs
• Assessment of intracranial pressure

ICP Monitoring

• Location of the Foramen of Monro for Calibration of ICP Monitoring System

Collaborative Problems and Potential Complications of the Patient with Increased Intracranial Pressure

• Brainstem herniation
• Diabetes insipidus
• SIADH

Goals for the Patient with Increased Intracranial Pressure

• Maintenance of patent airway
• Normalization of respirations
• Adequate cerebral tissue perfusion
• Fluid balance
• Absence of infection
• Absence of complications

Nursing Interventions for the Patient with Increased Intracranial Pressure

• Frequent monitoring of respiratory status and lung sounds
• Measures to maintain a patent airway
• Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage
• Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP
• Maintain a calm, quiet atmosphere and protect patient from stress
• Monitor fluid status carefully; every hour I&O during acute phase
• Use strict aseptic technique for management of ICP monitoring system