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UNCONSCIOUSNESS
Consciousness
It is defined as the state of consciousness of a state, the time and
environment, as well as the responsiveness of a state to that
environment or the external stimuli to adaptation.
Unconsciousness
Unconsciousness is a condition in which the patient is
unresponsive and unaware of the environmental stimuli. It can be
brief, lasting for a few seconds, hours, days longer.
LEVELS OF UNCONSCIOUSNESS
• Lethargy: Sleepy, slow to respond but not appropriate response; opens

eyes to stimuli; oriented.
• Stupor: Aroused by painful stimuli, never fully awake, confused and
unclear conversation n
• Semi-Coma Stage: Moves in response to painful stimuli, no
conversation, protective blinking and pupillary reflex patient.
Ineffective airway clearance related to upper airway obstruction by tongue
and soft tissue.
• Assess respiratory rate pattern, lung sound, hypoxia and cyanosis, presence of
secretion because of inability to clear respiratory secretions to plan the care.
• Elevating the head end of the bed to 30 degree to prevent aspiration.
• Positioning the patient in lateral or semi-prone position to prevent aspiration.
• Insert airway if tongue is paralyzed or obstructing the airway.
• Suction airway intermittently to prevent accumulation of secretion in posterior
pharynx and upper trachea and prevent aspiration.
• Administer humidified oxygen before suctioning and prevent hypoxia.
• "Initiate chest physiotherapy and postural drainage to promote pulmonary
hygiene.
• Prepare client for endotracheal intubation or tra cheostomy and connect
to mechanical ventila tion as needed to maintain respiration, efficient
removal of tracheobronchial secretion, protect from aspiration and
maintain oxygen level.
• Increase amount of fluid administered; at least 2.5 liters a day to loosen
airway secretion and promoting easy removal.
• Auscultate chest at least every 8 hours to detect adventitious breath
sound or absent breath sound.
• Monitor arterial blood gas (ABG) measurement to detect complications
of respiration.
Risk of injury related to unconscious state
• Assess the risk factors for injury: Lack of side rails, seizures,
invasive lines and equipment, restraints and tight dressing.
• Keep side rails up and bed in lowest position whenever the client is
not receiving any direct care to prevent fall.
• Observe seizure precaution for clients with history of seizure
episodes.
• Use padded side rails to prevent injury during seizure activity.
• Keep client's nails short to prevent scratching.
• Use caution when moving the client, give adequate support to limbs
and head to prevent dislocation.
• Always turn the client towards the nurse to prevent fall.
• Protect from external sources of heat such as hot water bags.
• Unconscious client cannot voice pain Release restraints every 2 hours.
• It helps in providing range of motion exercise and prevent complications of
immobility.
• Avoid restraints as far as possible.
• Allow one family member to be with the client.
• Keep bed and bedding free from moisture, dust and debris to prevent skin
excoriation.
• Avoid speaking negatively about the client or his conditions the last sense to
go is the sense of hearing for psychological integrity .
Risk of fluid volume deficit related to inability to ingest food,
dehydration from osmotic diuretics.
• Assess hydration status by examination of skin turgor, mucus membrane,
intake and output changes and analyzing laboratory data electrolytes,
creatinine and blood urea nitrogen (BUN).
• Hydrate the client with use of intravenous (IV) fluids as prescribed to
meet fluids needs.
• Avoid over hydrating the client with IV fluids or blood transfusion
because excessive or rapid administration of fluid may lead to cerebral
edema and increased intracranial pressure (ICP).
• Administer fluids slowly to prevent injury to veins.
• Continue fluid administration with use of Ryle's tube to allow long - term
fluid administration.
• Administer corticosteroids and diuretics in suspected cerebral edema to
maintain normal volume of fluids.
• Maintain intake and output and do proper documentation to detect
abnormality.
• Evaluate peripheral pulse and blood pressure at regular intervals to
measure circulatory adequacy.
Imbalanced nutrition less than body requirement related to inability to
eat swallow as evidenced by weight and other nutritional parameter
less than normal .
• Assess nutritional status through skin and mucus membrane " Administer
IV fluids to meet nutritional mucous
• Administer fluid diet in the form of juices, shake, soup, water , milk and
protein lactose through Ryle's tube feeding, as unconscious patient
cannot take oral feed.
• Increase the quantity as prescribed because metabolic need increases due
to immunodeficiency , protein wasting and lung tissue catabolism
• Provide high calorie, high protein and vitamin rich liquid diet.
• Initiate total parenteral nutrition if the client cant not tolerate Ryle's tube
feed, or according to need.
Ineffective thermoregulation due to damage to hy pothalamus center as
evidenced by persistent elevation of body temperature, warm and dry skin.
• To maintain body temperature.
• Regularly assess the temperature
• Look for possible site of infection.
• Control persistent elevation of temperature with use of antipyretics, cooling
blankets, adequate fluid intake, tepid sponge, cold compress and good
ventilation of room.
• Fever increases metabolic demand of brain, decreases circulation and
oxygenation resulting in cerebral deterioration.
• Control shivering in fever with use blanket , warm environment and heat
application .
• Prevent infection by using aseptic technique during procedure
Altered oral mucous membrane related to mouth breathing, absence of
pharyngeal reflex, inability to ingest fluids as evidenced by dryness,
inflammation, crusting and halitosis.
• To maintain oral hygiene
• Assess oral mucous membrane regularly.
• Inspect mouth every 8 hourly using flash light and tongue depressor to detect
problems in early stage.
• If denture is present, remove them to prevent choking and other complication.
• Provide oral care .
• Cleanse mouth carefully with appropriate solution (potassium permanganate,
listerine) every 2-4 hours to prevent halitosis and infection.
• Provide oral care after suctioning to clean oral cavity adequately.
• Apply thin coat of petroleum jelly after oral care to moisten the lips and
prevent drying and cracking.
• Clean airway to remove secretions to maintain patent airway.
• Change endotracheal tube bandage as soaked bandage increases the
chance of infection and maintain/grooming of the client
• Move endotracheal tube to the opposite side of the mouth to prevent
ulceration of mouth and lips.
• Do tracheostomy care, suctioning to remove secretions followed by oral
care.
• Avoid lemon or alcohol containing agent for cleaning to prevent dryness.
• Gently swab nose with wet cotton applicator and apply water soluble
lubricant to remove encrustation from nose , facilitate nose breathing to
prevent dryness of mouth
Preventing urinary retention
• Palpate for full bladder.
• Empty urinary bladder by inserting an indwelling catheter or use
absorbent pads placed under the buttocks in females.
• Use condom catheter in males.
• Change the dressing (cannula dressing, central venous line dressing,
tracheostomy dressing) as needed or daily.
• Change the tubing of ventilator, change the humidifier of ventilator and
change sterile water according to protocol.

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UNCONSCIOUSNESS

• Lethargy: Sleepy, slow to respond but not appropriate response; opens

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