CARE of Unconscious Patient Ebook 2024 PDF

CARE of unconscious patient EBook 2024 Under Supervisoin : Asst.Prof : Maysa Elbiaa - Dr. Monira Fayed Content Table N Title 1 Introduction 2 Common definitions 3 Causes of unconsciousness 4 Ass...

CARE of unconscious patient EBook 2024 Under Supervisoin : Asst.Prof : Maysa Elbiaa - Dr. Monira Fayed Content Table N Title 1 Introduction 2 Common definitions 3 Causes of unconsciousness 4 Assessment of unconscious patient 5 Nursing care for unconscious patient 6 Communication with unconscious patient 0 1 Introduction Caring for an unconscious patient presents unique challenges and responsibilities for healthcare providers. Unconsciousness can result from various medical conditions, including traumatic brain injuries, strokes, drug overdoses, or metabolic disturbances. Understanding the complexities of managing these patients is crucial for ensuring their safety and promoting recovery. Effective nursing care is essential for maintaining the physiological stability of unconscious patients while addressing their unique needs. This care encompasses a variety of interventions aimed at monitoring vital signs, maintaining airway patency, ensuring proper nutrition and hydration, and preventing complications such as pressure sores or infections. Additionally, providing sensory stimulation and involving family members in the care process can enhance the patient's overall experience and support their recovery journey. In this guide, we will explore common definitions related to unconsciousness, delve into its causes, and outline a systematic approach for assessing and caring for unconscious patients. By equipping healthcare providers with the necessary knowledge and skills, we can improve patient outcomes and provide compassionate care during one of the most vulnerable times in a person's life. 1 2 Definitions consciousness: is a state of being awake, aware, alert (aware of person, place and time) and responsive to stimuli SemiConsciousness: Is apparent in the patient who is not oriented, does not follow commands, and requires persistent stimuli to achieve a state of alertness. Unconsciousness: abnormal state in which a person is not alert and not fully responsive to surroundings (may show some response to stimuli) Remember that A person who is unconscious & unable to respond to the spoken words can often hear what is spoken. Coma: is the deepest state of unconsciousness where patient is not aware, not alert and doesn't respond to any stimuli, their brain functions at very minimal level that’s capable to stay alive (looks like someone in deep sleep). Unlike when a person is asleep, someone who is unconscious cannot cough, clear his throat, or turn his head if in distress. When unconscious, a person is in danger of choking, making it very important to keep the airway clear while awaiting medical care. 2 3 Causes Causes A- Metabolic Causes 1- endocrine dysfunction 2- Organ failure 3-Electrolyte imbalance Hypoglycemia (-) Liver Hypernatremia (Na+) Hyperglycemia (+) (hepatic encephalopathy) Hyponatremia (Na-) Hyperosmolar states Hypercalcemia (Ca+) Hypothyroidism (-) Kidney (Uremia) Hypothermia (-) B- Causes related to brain 1- Head Trauma 2- Vascular Causes 3- brain tumor Intracerebral hemorrhage Epidural hematoma Subarachnoid hemorrhage Subdural hematoma Posterior fossa hemorrhage Diffuse axonal injury Supratentorial hemorrhage Cerebral Venous Sinus Thrombosis Brain contusion Hydrocephalus Ischemic stroke C- Cardiovascular Causes 1- Cardiac Arrest 3- Shock 2- Arrhythmias 4- severe hypotension D- Respiratory and Toxicological Causes 1- hypoxia Depressants (opioids, benzodiazepines) 2-Drug Overdose Alcohol Poisoning (carbon monoxide, cyanide) E- Neurological Causes 1- Seizures 2- Infections Meningitis Encephalitis F- Psychogenic Causes 3 4 Assessment Here is an updated version of the neurological examination for an unconscious patient, incorporating the "Alert, Verbal, Painful, Unresponsive (AVPU)" scale and the "FOUR Score" assessment: History A comprehensive history of events leading to the patient's hospitalization is crucial for understanding the potential causes of unconsciousness. Neurological Examination Key components of the neurological examination include: Level of Consciousness (LOC): Assessed using the Glasgow Coma Scale (GCS), which evaluates eye, verbal, and motor responses. Also assessed using the AVPU Scale: Alert: The patient is fully alert and responsive. Verbal: The patient responds to verbal stimuli. Painful: The patient only responds to painful stimuli. Unresponsive: The patient shows no response to any stimuli. Pupil Size and Reactivity: The size of the pupils and their responsiveness to light should be evaluated. Breathing Patterns: Observation of the patient’s respiratory patterns to detect any abnormalities. 4  Assessment Eye Movements and Oculovestibular Responses: Examination of eye movement reflexes to assess brain function. Motor Responses: Evaluating muscle tone, reflexes, and posture for signs of neurological injury. FOUR Score (Full Outline of Unresponsiveness Score): Eye response (E): Evaluates if the patient can open their eyes spontaneously. Motor response (M): Assesses movement in response to commands or pain. Brainstem reflexes (B): Checks for pupil and corneal responses. Respiration (R): Evaluates breathing patterns and whether the patient requires ventilation. This combination of GCS, AVPU, and FOUR Score provides a comprehensive neurological assessment for determining the patient’s level of consciousness and the severity of the condition. 5 5 Nursing Care Patient monitoring Vital signs monitoring: This includes measuring and tracking parameters such as blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation levels. ECG/EEG monitoring: Electrocardiogram , Electroencephalogram monitoring involves recording the electrical activity of the heart and the brain to detect any abnormalities or irregularities in heart rhythm or brain electricity. Pulse oximetry: This non-invasive method measures the oxygen saturation level in a patient's blood by using a device called a pulse oximeter arterial blood gas (ABG): monitoring of respiratory condition using arterial puncture with high attention to its complications as nerve injury and hematoma. Continuous glucose monitoring: This is used for patients with diabetes to monitor their blood sugar levels continuously throughout the day. Neurological monitoring: using GCS. Monitor urine output: per hour & bowel movement. Laboratory investigations: (with minimal blood sample to prevent blood loss, nosocomial anemia) as CBC, electrolytes, cardiac enzyme, kidney function & liver function. 6  Nursing Care Maintain patent airway Positioning the patient in lateral or prone position. Suctioning and oral hygiene. (Posterior pharynx and upper trachea). Chest physiotherapy (Use pulmonary hygiene techniques to mobilize secretions such as vibration, percussion, rib springs and shaking [Shaking is a coarser movement in which the chest wall is rhythmically compressed. Effects: Direct secretions towards larger airways & Stimulates cough]). Modified postural drainage positions (usually with the head of the bed flat unless patient has an increase in intracranial pressure above ٣٠ mmHg.) Removing denture, tracheal suctioning, hydration & Humidification. if unconsciousness is prolonged and an artificial airway is still required then a tracheostomy should be considered. Close monitoring of the patient's respiratory function (pulse oximetry) is important and any changes should be reported. NGT Care To prevent aspiration: Insert NGT to decompress the stomach. Elevate head of the bed to ٣٠ degree to prevent aspiration. Avoid suctioning & chest 7  Nursing Care NGT Care Before administering bolus feedings, fluids, or medicines, reassess the tube placement at every shift and for continuous feedings. After each feeding session and medication administration, flush the tube with ٣٠ ml of water to prevent occlusion. Assess the patient’s nose for skin irritation or breakdown. Remove any crusts or secretions from around the nose. Make sure the skin is clean and dry before applying new tape. Re-tape daily and at alternate sites to avoid constant pressure on one area of the nose. Gently wash around the patient’s nose with soap and water. Provide nasal hygiene daily and as per need. If you notice redness or irritation on one side of the face you may consider putting the NG tube in the other nostril. Provide adequate oral hygiene for the patient every ٢hours and as needed. Make a routine of mouthwash, water, and toothpaste to clean the tongue, inside of the cheeks, gums, and mucous membranes of the patient. 8  Nursing Care Maintain fluid and electrolyte balance :- Assessing Fluid Status: Regularly monitor vital signs, including blood pressure, heart rate, and urine output, to assess the patient's fluid status. Assess for signs of dehydration or fluid overload, such as dry mucous membranes, decreased urine output, or edema. Administering Fluids: Intravenous (IV) fluids are commonly used to maintain fluid balance in unconscious patients. The type and rate of fluid administration will depend on the patient's specific needs and underlying condition. The healthcare team will determine the appropriate fluid type, such as isotonic or hypotonic solutions, based on the patient's electrolyte and fluid balance. The rate of fluid administration should be carefully monitored to avoid overhydration or dehydration. It may need to be adjusted based on the patient's urine output and other clinical indicators. Monitoring Input and Output: Accurate documentation of fluid intake and output is essential. This includes measuring and recording all fluids administered, including IV fluids, medications, and enteral feedings. Urine output should be closely monitored to ensure adequate kidney function and hydration. A urinary catheter may be used to measure urine output accurately. Other sources of fluid loss, such as drainage from surgical sites or wound dressings, should also be monitored and accounted for. Electrolyte Monitoring: Electrolyte levels, such as sodium, potassium, and magnesium, should be regularly monitored and maintained within the appropriate range. 9  Nursing Care Maintaining Body Temperature The environment can be adjusted, depending on the patient’s condition, to promote a normal body temperature. Because of damage to the temperature-regulating center in the brain or severe intracranial infection, unconscious patients 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. Strategies for reducing fever include: Frequent temperature monitoring to assess the patient’s response to the therapy and to prevent an excessive decrease in temperature and shivering. Removing all bedding over the patient (with the possible exception of a light sheet, towel, or small drape) Giving cool sponge baths. Using a hypothermia blanket. allowing an electric fan to blow over the patient to increase surface cooling. Administering acetaminophen as prescribed. Protection & skin care Take care to avoid falls (padded side rails, Keep the bed in the lowest position, Avoid over Sedation). Identify potential sources of injury should be identified, such as restraints, tight dressings, environmental irritants, damp bedding or dressings, tubes & drains. Keeping the skin dry and clean. Maintaining correct body position. turn the patient every ٢hours to enhance blood circulation and prevent skin breakdown resulting pressure ulcer formation. After turning, the patient is carefully repositioned to prevent ischemic necrosis over pressure areas. Moisturizing:- Applying moisturizers and special creams can make the skin more resilient Using soft, pressure-relieving padding in beds reduce the risk of developing pressure ulcers. 10  Nursing Care Oral & mucus membrane care. Perform oral care at least every ٢ to ٤ hours or as needed, using a soft toothbrush, or a moistened gauze pad. Use a mild, non-alcoholic mouthwash or plain water for oral rinsing. Apply a water-based lubricant or lip balm to prevent drynesand cracking of the lips. Cleanse the patient's tongue and oral cavity gently but thoroughl to reduce the risk of infection. If the patient has dentures, remove and clean them regularly using an appropriate denture cleaner. Daily Repositioning of ET T. Eye Care In assessing the eyes, observe for signs of irritation, corneal drying, abrasions and oedema Gentle cleaning with gauze and ٠٫٩٪ sodium chloride should be sufficient to prevent infection and dryness and remove discharge. Cold compresses may be prescribed for Periorbital edema(swelling around the eyes) Corneal damage can result if the eyes remain open for a longer time so that Tape can be used to close the eyes. Avoid passing the suction catheter near the patient eyes. Antibiotic Drops as a prophylactic treatment to prevent infection as Musculoskeletal care Passive ROM of upper and lower extremities including prolonged stretchingto avoid contractures and deformities. Use of splints (by keeping most joints in the neutral or functional position). Inhibitive casting or patient’s shoes can also be used. Proper positioning for all joints of the body. 11  Nursing Care Urinary system care Palpate for a full bladder.The bladder is palpated to determine whether urinary retention is present, because a full bladder may be an overlooked cause of overflow incontinence. An external catheter (condom catheter) for the male patient and absorbent pads for the female patient can be used for unconscious patients who can urinate spontaneously, although involuntarily. If the patient is not voiding, an indwelling urinary catheter is inserted and connected to a closed drainage system. Because catheters are a major cause of urinary tract infection, the patient is observed for fever and cloudy urine. Inspect the area around the urethral orifice for drainage Monitor the incontinent patient for skin irritation and skin breakdown & implement appropriate skin care 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. monitors the number and consistency of bowel movements perform a rectal examination for signs of fecal impaction. Stool softeners may be prescribed and can be administered with tube feedings. To facilitate bowel emptying, a glycerin suppository may be indicated. The patient may require an enema every other day to empty the lower colon. 12  Nursing Care Providing sensory stimulation Provided at proper time to avoid sensory deprivation. Efforts are made to maintain the sense of daily rhythm by keeping the usual day and night patterns for activity and sleep. Maintain the same schedule each day. Touch and talk. Orient the Patient (day, date, & time). Proper communication. Always address the Patient by name, and explain the procedure each time. Family teaching Teach patient's family members coping skills, the nurse reinforces and clarifies information about the patient’s condition. permits the family to be involved in care, and listens to and encourages ventilation of feelings and concerns while supporting decision making about management and placement after hospitalization. Families may benefit from participation in support groups offered through the hospital, rehabilitation facility, or community organizations. Teach patient's family about the condition and its needs as positioning and skin care. Allow significant others to stay with the patient. 13 6 Communication the importance of communication with unconscious patients is crucial for their emotional and psychological well-being. Providing verbal input can help maintain a sense of connection, potentially aiding in their recovery. It also emphasizes the role of supportive interactions in reducing stress, preserving self-identity, and combating feelings of isolation, which can be vital for overall healing. There are two type of communication with unconscious patients : Verbal Communication Verbal communication with unconscious patients" refers to the use of spoken or written words to interact with patients who are unresponsive 1. Introducing Yourself: "Hi, I'm [Your Name], and I'm here to take care of you." 2. Soothing Tone: "You're safe now. We're here to help you." 3. Reassuring Statements: "You're in a hospital, and we have medical professionals ready to assist you. 4. Simple Instructions: "I'm going to check your vitals now; just relax." 5. Describing Actions: "I'm applying some pressure to your arm for the IV." 6.Provide updates and explanations: Even though the patient is unconscious, it is important to provide updates and explanations about their care and treatment to keep family members informed Nonverbal Communication is essential when interacting with unconscious patients as they may not be able to respond verbally. Here are some strategies to effectively communicate with unconscious patients: 1. Maintain eye contact: Even though the patient is unconscious, maintaining eye contact can help establish a connection and show that you are present and attentive. 2. Use touch: Gently touching the patient's hand or shoulder can convey care and reassurance. 3. Use facial expressions: Smiling or offering a concerned facial expression can convey empathy and compassion. 4. Be mindful of your body language: Ensure that your body language is open and welcoming, and avoid any gestures that may be perceived as threatening or aggressive. 14  Thank You Content Prepard By : Design By : Mostafa Lotfy Gamal Abdelnassar Team Leader : Osama Mohamed Group B 15