nursing care of unconscious patient,,,,,,,.docx

NURSING DIAGNOSES: Impaired breathing due to neurologic impairment. Risk for injury associated with lack of adaptive and defensive resources due to decreased LOC. Risk for hypovolemia associated with inability to take fluids by mouth. Risk for impaired nutritional intake associated with inability to...

NURSING DIAGNOSES: Impaired breathing due to neurologic impairment. Risk for injury associated with lack of adaptive and defensive resources due to decreased LOC. Risk for hypovolemia associated with inability to take fluids by mouth. Risk for impaired nutritional intake associated with inability to ingest nutrients to meet metabolic needs. Impaired oral mucous membrane integrity associated with mouth breathing, absence of pharyngeal reflex, and altered fluid intake. Risk for impaired skin integrity associated with prolonged immobility. Risk for injury associated with diminished or absent corneal reflex. Impaired thermoregulation associated with damage to hypothalamic center. Impaired urination associated with altered impairment in neurologic sensing and control. Bowel incontinence associated with impairment in neurologic sensing and control and also associated with changes in nutritional delivery methods. Impaired health maintenance associated with neurologic impairment. Interrupted family process associated with health crisis. POTENTIAL COMPLICATIONS: Respiratory distress or failure Pneumonia Aspiration Pressure injury Venous thromboembolism (VTE) Contractures Planning and Goals: The goals of care for the patient with altered LOC include normalization of breathing, protection from injury, attainment of fluid volume balance, maintenance of nutritional needs, achievement of intact oral mucous membranes, maintenance of normal skin integrity, absence of corneal injury, attainment of effective thermoregulation, and effective urinary elimination. Additional goals include bowel continence, restoration of health maintenance, maintenance of intact family or support system, and absence of complications. Because the protective reflexes of the patient who is unconscious are impaired, the quality of nursing care provided may mean the difference between life and death. The nurse must assume responsibility for the patient until the basic reflexes (coughing, blinking, and swallowing) return and the patient becomes conscious and oriented. Therefore, the major nursing goal is to compensate for the absence of these protective reflexes. Nursing Interventions ACHIEVING AN ADEQUATE BREATHING PATTERN: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure normalization of the breathing pattern. Obstruction of the airway is a risk because the epiglottis and tongue may relax, occluding the oropharynx, or the patient may aspirate vomitus or nasopharyngeal secretions. The accumulation of secretions in the pharynx presents a serious problem. Because the patient cannot swallow and lacks pharyngeal reflexes, these secretions must be removed to eliminate the danger of aspiration. Elevating the head of the bed to 30 degrees helps prevent aspiration. Positioning the patient in a lateral or semi prone position also helps because it allows the jaw and tongue to fall forward, thus promoting drainage of secretions. Positioning alone is not always adequate, however. Suctioning and oral hygiene may be required. Suctioning is performed to remove secretions from the posterior pharynx and upper trachea. Before and after suctioning, the patient is adequately ventilated to prevent hypoxia. Chest physiotherapy and postural drainage may be initiated to promote pulmonary hygiene, unless contraindicated by the patient’s underlying condition. The chest should be auscultated at least every 8 hours to detect adventitious breath sounds or absence of breath sounds. Despite these measures, or because of the severity of impairment, the patient with altered LOC often requires intubation and mechanical ventilation. Nursing actions for the patient who is mechanically ventilated include maintaining the patency of the endotracheal tube or tracheostomy, providing frequent oral care, monitoring arterial blood gas measurements, and maintaining ventilator settings. PROTECTING THE PATIENT: For the protection of the patient, side rails are padded. Two rails are kept in the raised position during the day and three at night; however, raising all four side rails is considered a restraint by The Joint Commission if the intent is to limit the patient’s mobility. Care should be taken to prevent injury from invasive lines and equipment, and other potential sources of injury should be identified, such as restraints, tight dressings, environmental irritants, damp bedding or dressings, and tubes and drains. Protection also includes ensuring the patient’s dignity during altered LOC. Simple measures such a providing privacy and speaking to the patient during nursing care activities preserve the patient’s dignity. Not speaking negatively about the patient’s condition or prognosis is also important, because patients in a coma may be able to hear. The patient who is comatose has an increased need for advocacy, and the nurse is responsible for seeing that these advocacy needs are met. MAINTAINING FLUID BALANCE AND MANAGING NUTRITIONAL NEEDS: Hydration status is assessed by examining tissue turgor and mucous membranes, assessing intake and output trends, and analyzing laboratory data. Fluid needs are met initially by administering the required IV fluids. However, IV solutions (and blood component therapy) for patients with intracranial conditions must be given slowly. If they are given too rapidly, they can increase ICP. The quantity of fluids given may be restricted to minimize the possibility of cerebral edema. If the patient does not recover quickly and sufficiently enough to take adequate fluids and calories by mouth, a feeding or gastrostomy tube will be inserted for the administration of fluids and enteral feedings. Research suggests that patients fed within 48 hours of injury have improved outcomes over those in whom nutrition is delayed. PROVIDING MOUTH CARE: The mouth is inspected for dryness, inflammation, and crusting. The patient who is unconscious requires careful oral care, because there is a risk of parotitis if the mouth is not kept scrupulously clean. The mouth is cleansed and rinsed carefully to remove secretions and crusts and to keep the mucous membranes moist. A thin coating of petrolatum on the lips prevents drying, cracking, and encrustations. If the patient has an endotracheal tube, the tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips. If the patient is intubated and mechanically ventilated, good oral care is also necessary. Research suggests that comprehensive mouth care with antiseptic such as chlorhexidine and head of bed elevation decreases ventilator-associated pneumonia and improves the oral health in patients who are intubated. MAINTAINING SKIN AND JOINT INTEGRITY: Preventing skin breakdown requires continuing nursing assessment and intervention. Special attention is given to patients who are unconscious, because they cannot respond to external stimuli. Assessment includes a regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin. Turning also provides kinesthetic (sensation of movement), proprioceptive (awareness of position), and vestibular (equilibrium) stimulation. After turning, the patient is carefully repositioned to prevent ischemic necrosis over pressure areas. Dragging or pulling the patient up in bed must be avoided, because this creates a shearing force and friction on the skin surface. Maintaining correct body position is important; equally important is passive exercise of the extremities to prevent contractures. The use of splints or foam boots aids in the prevention of foot drop and eliminates the pressure of bedding on the toes. The use of trochanter rolls to support the hip joints keeps the legs in proper alignment. The arms are in abduction, the fingers lightly flexed, and the hands in slight supination. The heels of the feet are assessed for pressure areas. Specialty beds, such as fluidized or low–air-loss beds, may be used to decrease pressure on bony prominences. PRESERVING CORNEAL INTEGRITY: Some patients who are unconscious have their eyes open and have inadequate or absent corneal reflexes. The cornea may become irritated, dry, or scratched, leading to ulceration. The eyes may be cleansed with cotton balls moistened with sterile normal saline to remove debris and discharge. Artificial tears or methylcellulose may be prescribed to provide lubrication. Periorbital edema often occurs after cranial surgery. If cold compresses are prescribed, care must be exerted to avoid contact with the cornea. Eye patches should be used cautiously because of the potential for corneal abrasion from contact with the patch; eye shields may provide eye protection with less risk of injury. MAINTAINING BODY TEMPERATURE: High fever in the patient who is unconscious may be caused by infection of the respiratory or urinary tract, drug reactions, or damage to the hypothalamic temperature-regulating center. A slight elevation of temperature may be caused by dehydration. The environment can be adjusted, depending on the patient’s condition, to promote a normal body temperature. If body temperature is elevated, a minimum amount of bedding is used. The room may be cooled to 18.3°C (65°F). However, if the patient is an older adult and does not have an elevated temperature, a warmer environment is needed. Because of damage to the temperature-regulating center in the brain or severe intracranial infection, patients who are unconscious often develop very high temperatures. Such temperature elevations must be controlled, because the increased metabolic demands of the brain can exceed cerebral circulation and oxygen delivery, potentially resulting in cerebral deterioration. Studies suggest that hyperthermia may contribute to poor outcome after brain injury but not through a decreased brain oxygen level. Persistent hyperthermia with no identified clinical source of infection indicates brain stem damage and a poor prognosis. Strategies for reducing fever include: Removing all bedding over the patient (with the possible exception of a light sheet, towel, or small drape) Administering acetaminophen or ibuprofen as prescribed Giving cool sponge baths Using a hypothermia blanket Monitoring temperature frequently to assess the patient’s response to the therapy and to prevent an excessive decrease in temperature and shivering PREVENTING URINARY RETENTION: The patient with an altered LOC is often incontinent or has urinary retention. The bladder is palpated or scanned at intervals to determine whether urinary retention is present, because a full bladder may be an overlooked cause of overflow incontinence. A portable bladder ultrasound instrument is a useful tool in bladder management and retraining programs. If the patient is not voiding, a program of intermittent catheterization should be devised in order to reduce the patient’s risk of urinary tract infection. A catheter may be inserted during the acute phase of illness to monitor urinary output. Because catheters are a major cause of urinary tract infection, the patient is observed for fever and cloudy urine. The area around the urethral orifice is inspected for drainage and cleansed routinely. The urinary catheter is usually removed if the patient has a stable cardiovascular system and if no diuresis, sepsis, or voiding dysfunction existed before the onset of coma. Although many patients who are unconscious urinate spontaneously after catheter removal, the bladder should be scanned with a portable bladder ultrasound device periodically for urinary retention. An external catheter (condom catheter) for the male patient and absorbent pads or female incontinence device for the female patient can be used for patients who are unconscious and can urinate spontaneously, although involuntarily. As soon as consciousness is regained, a bladder training program is initiated. The patient who is incontinent is monitored frequently for skin irritation and skin breakdown. Appropriate skin care is implemented to prevent these complications. PROMOTING BOWEL FUNCTION: The abdomen is assessed for distention by listening for bowel sounds and measuring the girth of the abdomen with a tape measure. There is a risk of diarrhea from infection, antibiotic agents, and hyperosmolar fluids. Frequent loose stools may also occur with fecal impaction. Commercial fecal collection bags are available for patients with fecal incontinence. Immobility and lack of dietary fiber can cause constipation. The nurse monitors the number and consistency of bowel movements and performs a rectal examination for signs of fecal impaction. Stool softeners may be prescribed and can be given with tube feedings. To facilitate bowel emptying, a glycerin suppository or bowel stimulant may be indicated. The patient may require an enema routinely to empty the lower colon. MONITORING AND MANAGING POTENTIAL COMPLICATIONS: Pneumonia, aspiration, and respiratory failure are potential complications in any patient who has a depressed LOC and who cannot protect the airway or turn, cough, and take deep breaths. The longer the period of unconsciousness, the greater the risk of pulmonary complications. Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. Complete blood count and arterial blood gas measurements are assessed to determine whether there are adequate red blood cells to carry oxygen and whether ventilation is effective. Chest physiotherapy and suctioning are initiated to prevent respiratory complications such as pneumonia. Oral care interventions are performed for patients receiving mechanical ventilation to maintain oral health and decrease the incidence of pneumonia. If pneumonia develops, cultures are obtained to identify the organism so that appropriate antibiotic agents can be given. The patient with altered LOC is monitored closely for evidence of impaired skin integrity, and strategies to prevent skin breakdown and pressure injuries are continued through all phases of care, including hospitalization, rehabilitation, and home care. Factors that contribute to impaired skin integrity (e.g., incontinence, inadequate dietary intake, pressure on bony prominences, edema) are addressed. If pressure injuries develop, strategies to promote healing are undertaken. Care is taken to prevent bacterial contamination of pressure injuries, which may lead to sepsis and septic shock. The patient should also be monitored for signs and symptoms of VTE, which may manifest as a deep vein thrombosis (DVT) or pulmonary embolism (PE). Prophylaxis with subcutaneous heparin or lowmolecular weight heparin (dalteparin, danaparoid) as well as anti-embolism stockings or pneumatic compression devices are prescribed according to the patient’s risk factors for thrombosis and bleeding. The nurse observes for signs and symptoms of DVT or PE. Patients with a prolonged decrease in LOC are at risk for developing contractures. During acute care, the patient is turned every 2 hours and passive range of motion performed at least twice a day. Splints, provided by occupational therapy, are applied to the hands and feet in a rotating manner to maintain functional joint alignment. Hand splints have been reported to be safe and beneficial for patients in decreasing spasticity and improving hand opening.