|• The unconscious client is in a state of depressed cerebral functioning with unresponsiveness to stimulation of sensory and motor function.
• Some causes include head trauma, hemorrhage, tumor, infection, cerebral toxins, and shock.
• primitive or no response to painful stimuli
• decreased cranial nerve and reflex activity
• altered respirations
|• Assess the patency of the airway and keep an airway and emergency equipment at the bedside. Maintain a patent airway and ventilation because a high CO2 level increases intracranial pressure. Assess lung sounds for the accumulation of secretions. Suction fluids from the airway as needed.
• Monitor blood pressure, pulse, and heart sounds.
• Assess neurological status, including LOC, pupillary reactions, and motor and sensory function, using a coma scale.
• Monitor drainage from the ears or nose for the presence of CSF.
• Assess the eyes for the presence of a corneal reflex and irritation, and instill artificial tears or cover the eyes with eye patches.
• Place the client in a semi-Fowler’s position. Avoid Trendelenburg’s position. Provide range-of-motion exercises to prevent contractures. Use a footboard or high-topped sneakers to prevent foot drop. Use splints to prevent wrist deformities. Initiate physical therapy as appropriate.
• Use side rails. Avoid restraints.
• Remove dentures and contact lenses.
• Monitor the status of skin integrity. Initiate measures to prevent skin breakdown. Change the position of the client every 2 hours, avoiding injury when turning.
• Provide frequent mouth care.
• Monitor intake and output and daily weight. Maintain NPO status until consciousness returns. Maintain nutrition as prescribed and monitor fluid and electrolyte balance. Provide intravenous or enteral feedings as prescribed. Assess bowel sounds. Monitor elimination patterns.
• Check the gag and swallow reflex before resuming a diet, and begin the diet with ice chips and fluids when the client becomes alert.
• Do not leave the client unattended if unstable.
• Assume that the unconscious client can hear.