What intervention should the nurse take when providing oral care for the unconscious client

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Nursing care of unconscious Patient

1. 1. MATHEW VARGHESE V MSN(RAK),FHNP (CMC Vellore),CPEPC Nursing officer AIIMS Delhi NURSING CARE OF AN UNCONSCIOUS PATIENT 1
2. 2. Discussion Points  Definition of Unconsciousness.  Etiology of Unconsciousness.  Pathophysiology of unconsciousness Signs and Symptoms.  Diagnostic testing, and treatment options.  Nursing management of Unconscious patients 2
3. 3. BASICS 3
4. 4. RAS (Reticular Activating System)  The reticular activating system, or RAS, is a piece of the brain that starts close to the top of the spinal column and extends upwards around two inches.  It has a diameter slightly larger than a pencil.  All of your senses are wired directly to this bundle of neurons that's about the size of your little finger.  Often, the RAS is compared to a filter or a nightclub bouncer that works for your brain. 4
5. 5.  While it may be a fairly small part of your brain, the RAS has a very important role: it's the gatekeeper of information that is let into the conscious mind.  It makes sure your brain doesn't have to deal with more information than it can handle. Thus, the reticular activating system plays a big role in the sensory information you perceive daily. 5
6. 6.  The brain requires a constant supply of oxygenated blood and glucose to function. Interruption of this function will cause loss of consciousness within few seconds and permanent brain damage in minutes. 6
7. 7. CONSCIOUSNESS  A state of awareness of yourself and your surroundings  Ability to perceive sensory stimuli and respond appropriately to them 7
8. 8. UNCONSCIOUSNESS  Abnormal state - client is unarousable and unresponsive. Coma is a deepest state of unconsciousness.  Unconsciousness is a symptom rather than a disease.  Degrees of unconsciousness that vary in length and severity:  Brief – fainting  Prolonged – deep coma 8
9. 9. Etiology  STRUCTURAL OR SURGICAL UNCONSCIOUSNES S  Trauma  Epidural / Subdural hematoma  Brain contusion  Hydrocephalus  Stroke  Tumor METABOLIC OR MEDICAL UNCONSCIOUSNESS  Infection  Meningitis  Encephalitis  Hypo/hyperglycemia  Heptic encephalopathy  Hyponatremia  Drug /alcohol overdose  Poisoning9
10. 10. Pathophysiology Damage to the brain and skull Inflammation, edema and haemorrhage Increased ICP Diffused damage to the cerebral tissues Blocks the signal to the RAS (Reticular activating system) UNCONSCIOUSNESS10
11. 11. Signs and Symptoms  The person will be unresponsive (does not respond to activity, touch, sound, or other stimulation). 11
12. 12. An unconscious person:  Is unaware of his surroundings and does not respond to sound  Makes no purposeful movements  Does not respond to questions or to touch  Confusion  Drowsiness  Inability to speak or move parts of his or her body  Loss of bowel or bladder control (incontinence)  Respiratory changes  Abnormal pupil reactions 12
13. 13. Effects of Altered LOC or Coma: 1. Full recovery with no Long term residual effects 2. Recovery with residual damage (learning deficits, emotional difficulties, impaired judgement) 3. Persistent vegetative state (cerebral death or brain death) 13
14. 14. Diagnostic test:  X-ray -SKULL  MRI (magnetic resonance imaging) : tumors, vascular abnormalities, IC bleed  CT (computerized tomography) : cerebral edema, infarctions, hydrocephalus, midline shift  Lumbar puncture : cerebral meningitis, CSF evaluation  PET (positron emission tomography)  EEG: electric activity of cerebral cortex  Blood test like CBC, LFT, RFT, ABG etc. 14
15. 15. Medical management The goal of medical management are to preserve brain function and prevent further damage.  Ventilator support  Oxygen therapy  Management of blood pressure  Management of fluid balance  Management of seizures : anti epileptic , sedatives, paralytic agents 15
16. 16.  Treating Increased ICP : mannitol, corticosteroids  Management of temperature regulation (fever): ice packs, tepid sponging,Antipyretics,NSAIDS  Management of elimination : laxatives and high fibre diet  Management of nutrition: TPN and RT feeds  DVT prophylaxis 16
17. 17. Surgery if necessary  Craniotomy : Skull/bone flap is kept in the abdomen  Cranioplasty  Burr-hole 17
18. 18. Nursing Management GOALS OF NURSING CARE • Maintain adequate cerebral perfusion • Remain normothermic • Be free from pain, discomfort, and infection • Attain maximal cognitive, motor and sensory function 18
19. 19. Assessment :  Nurses frequently need to monitor the conscious level as impairments may complicate the existing condition and may cause complications and further deterioration.  GLASGOW COMA SCALE.  The Glasgow Coma Scale is a neurological scale – Gives a reliable, objective record of the level of consciousness (LOC) of a person, for initial as well as continuing assessment.  The nurse observes and describes three aspects of the patients behavior: 1. Eye opening 2. Verbal response 3. Motor response.19
20. 20. 20
21. 21. Interpretation of Glasgow Coma Scale.  Highest score is 15/15 – Good orientation  Lowest score is 3/15 - Deep coma. Considered brain dead if client dependant on a ventilator GCS ≤ 8 – Severe brain injury GCS 9 – 12 - Moderate brain injury GCS ≥ 13 – Mild brain injury 21
22. 22. Limitations of GCS scoring. Eye opening:  If severe facial/eye swelling/ptosis is present one cannot test eye responses.  The patient who is in deep coma with flaccid eye muscles will show no response to stimulation.  However if the eyelids are drawn back the eyes may remain open. This is very different from spontaneous eye opening and must be recorded as ‘none’. 22
23. 23. Verbal Response:  The verbal response may be compromised by the presence of an endotracheal/ tracheostomy tube.  Hearing defect/ speech defect may alter patient’s response. Written instructions may be used. Motor Response:  Asymmetrical responses(focal deficit): Best motor response should be recorded. e.g. if patient localizes pain on his left side but flexes to pain on his right side, localizing response is recorded.  Explain the use of pain stimuli to the relatives.  Pain infliction may result in bruising. 23
24. 24. Physical Assessment  Voluntary movement – Strength and asymmetry in the upper extremities  Deep tendon Reflexes – biceps, triceps and patella  Pupillary light reflex (pupil size)  Corneal blink reflex  Gag swallowing reflex 24
25. 25. 25
26. 26. Potential nursing diagnosis :  Ineffective airway clearance  Ineffective cerebral tissue perfusion  Risk for increased ICP  Imbalanced fluid volume  Impaired skin integrity  Self care deficit  Imbalanced nutrition  Incontinence : bowel and /or bladder  Risk for aspiration  Risk for contractures  Altered family process 26
27. 27. Maintaining a patent airway  The breath sounds must be assessed every 2 hourly.  ABG results must be interpreted to determine the degree of oxygenation provided by the ventilators or oxygen.  Assess for cough and swallow reflexes  Use an oral artificial airway to maintain patency  Tracheostomy or endotracheal intubation and mechanical ventilation maybe necessary PREVENTING AIRWAY OBSTRUCTION  Position on alternate sides 2-4 hrs to prevent secretions accumulating in the airways on one side.  Maintain the neck in a neutral position 27
28. 28.  Oronasopharyngeal suction may be necessary to aspirate secretions.  If facial palsy or hemi paralysis is present the affected side must be kept the uppermost.  Chest percussion and postural drainage may be prescribed to assist in the removal of tenacious sections  Dentures are removed  Nasal and oral care is provided to keep the upper airway free of accumulated secretions debris 28
29. 29. Ineffective cerebral tissue perfusion  Assess the GCS, SPO2 level and ABG of the patient.  Monitor the vital signs of the patients (increased temperature)  Head elevation of 30 degrees, neutral position maintained to facilitate venous drainage.  Reduce agitation .(Sedation.)  Reduce cerebral edema (Corticosteroids, osmotic or loop diuretics.) Generally peaks within 72 hrs after trauma and subsides gradually. 29
30. 30.  Schedule care so that harsh activity [suctioning ,bathing, turning] are not grouped together, with breaks between care for recovery.  Talk softly and limit touch and stimulation.  Administer laxatives, antitussives and antiemetics as ordered  Manage temperature with antipyretics and cooling measures.  Prevent seizure with ordered dilantin.  Administer mannitol 25-50 g IV bolus if ICP >20, as prescribed. 30
31. 31. Risk for increased ICP.  Assess the GCS score, assess signs of increased ICP .  Head elevation of 30 degrees, neutral position maintained to facilitate venous drainage and prevent aspiration.  Pre-oxygenation before suctioning should be mandatory , and each pass of the catheter limited to 10 seconds, with appropriate sedation to limit the rise in ICP.  Insertion of an oral airway to suction the secretions.  The breath sounds must be assessed every 231
32. 32. Signs of increased ICP  Restlessness  Headache  Pupillary changes: ASSESS every hourly  Respiratory irregularity  Widening pulse pressure, hypertension and bradycardia. (CUSHING’S TRIAD)  NORMAL ICP : 5 TO 15 mm of Hg 32
33. 33. Imbalanced fluid and electrolyte  Intake-Output chart should be meticulously maintained.  Daily weight should be taken.  Assess and document symptoms that may indicate fluid volume overload or deficit.  Diuretics may be prescribed to correct fluid overload and reduce edema.  Over hydration and intravenous fluids with glucose are always avoided in comatose patients as cerebral oedema may follow. 33
34. 34. Impaired skin integrity  The nurse should provide intervention for all self-care needs including bathing, hair care, skin and nail care.  Frequent back care should be given.  Comfort devices should be used.  Positions should be changed.  Special mattresses or airbeds to be used.  Adequate nutritional and hydration status should be maintained.  Patient’s nails should be kept trimmed.  Cornea should be kept moist by instilling methyl cellulose 0.5% to 1%.34
35. 35.  Protective eye shields can be applied or the eyelids closed with adhesive strips if the corneal reflex is absent. These measures prevent corneal abrasions and irritation.  Inspect the oral cavity.  Keep the lips coated with a water-soluble lubricant to prevent encrustation, drying, cracking. Inspect the paralyzed cheek.  Frequent oral hygiene every 4 hourly.  Nasal passages may get occluded so they may be cleaned with a cotton tipped applicator. 35
36. 36.  PROPER POSITIONING  Lateral position on a pillow to maintain head in a neutral position  Upper arm positioned on a pillow to maintain shoulder alignment  Upper leg supported on a pillow to maintain alignment of the hip  Change position to lie on alternate sides every 2-4hrs  For hemiplegia – position on the affected side for brief periods,taking care to prevent injury to soft tissue and nerves, oedema or disruption of the blood supply  Maintaining correct positioning enables secretions to drain from the client’s mouth, the tongue does not36
37. 37. Self care deficit  Attending to the hygiene needs of the unconscious patient should never become ritualistic, and despite the patient's perceived lack of awareness, dignity should not be compromised.  Involving the family in self care needs.  Incontinence, perspiration, poor nutrition, obesity and old age also contribute to the formation of pressure ulcers.  Care should be taken to examine the skin properly, noting any areas which are red, dry or broken.  Fingernails and toenails also need to be assessed 37
38. 38. Bathing:  Minimum two nurses should bathe an unconscious patient as turning the patient may block the airway.  Proper assessment of the condition of the skin must be done when giving a bed bath.  Hair care should not be neglected. 38
39. 39. Oral Hygiene:  A chlorhexidine based solution is used.  Airway should be removed when providing oral care. It should be cleaned and then reinserted.  If the patient has an endotracheal tube the tube should be fixed alternately on each side.  Minimum of four-hourly oral care to reduce the potential of infection from micro-organisms.  Also not to damage the gingiva by using excessive force 39
40. 40. Eye Care:  In assessing the eyes, observe for signs of irritation, corneal drying, abrasions and oedema.  Gentle cleaning with gauze and 0.9% sodium chloride should be sufficient to prevent infection.  Artificial tears can also be applied as drops to help moisten the eyes.  Corneal damage can result if the eyes remain open for a longer time.  Tape can be used to close the eyes. 40
41. 41. Nasal Care:  Cleaning of the nasal mucosa with gauze and water  Nasogastric tube placement damage to the nasal mucosa Ear Care:  Clean around the aural canal, although care must be taken not to push anything inside the ear. 41
42. 42. Imbalanced nutrition  Diet prescribed nutrition based on individuals requirements specifically to meet energy needs, tissue repair, replace fluid loss to maintain basic life functions 42
43. 43. METHODS  TPN (Total parenteral nutrition) TPN is considered for prolonged unconsciousness.  Intravenous fluids are administered for comatose patients. As fluid intake is restricted and glucose is avoided to control cerebral oedema and intravenous infusion cannot be considered as a nutritional support.  Enteral feeding via Nasogastric, nasojejunal OR PEG tube . 43
44. 44. Risk for injury  Side rails must be kept whenever the patient is not receiving direct care.  Seizure precautions must be taken.  Adequate support to limbs and head must be given when moving or turning an unconscious patient. Protect from external sources of heat.  Over sedation should be avoided – as it impedes the assessment of the level of consciousness and impairs respiration.  Assess the Need for restrain. 44
45. 45. Impaired bowel/ bladder functions  Assess for constipation and bladder distention.  Auscutate bowel sounds.  Stool softeners or laxatives may be given.  Bladder catheterization may be done.  Meticulous catheter care must be provided under aseptic techniques.  Monitor the urine output and colour.  Initiate bladder training as soon as consciousness has regained. 45
46. 46. Risk for contractures  Maintain the extremities in functional positions by providing proper support.  Remove the support devices every four hours for passive exercises and skin care.  Foot support should be provided. 46
47. 47. Sensory stimulation  Brain needs sensory input  Widely believed that hearing is the last sense to go  Talk, explain to the patient what is going on  Upon waking many clients remember….. and will accurately recall events and processes that happened while they were “sleeping”. (unconscious)  Some have reported they longed for someone to talk to them and not about them 47
48. 48. Nurses must:  Show respect  Encourage family to contribute to the care of their loved ones  Afford the privacy both the client and family deserve Encourage stimulation by:  Massage  Combing/washing hair  Playing music/radio/CD/TV  Reading a book  Bring in perfumed flowers  Update them with family news 48
49. 49. Altered family process  Include the family members in patient’s care.  Communicate frequently with the family members.  The family members should be allowed to stay with the patient when and where it is possible.  Use external support systems like professional counsellors, religious clergy etc.  Clarifications and questions should be encouraged. 49

What do you do oral care with on an unconscious client?

What is the priority when providing oral hygiene to an unconscious client?

What nursing interventions could be implemented for oral care?