10 May 2012

Nursing Care unconscious patient/Client and Intervention

Nursing Care and Intervention of unconscious patient/Client
  • Always take a rectal temperature.
  • Report changes in vital signs to the charge nurse
  • Note changes in response to stimuli.
  • Note the return of protective reflexes such as blinking the eyelids or swallowing saliva.
  • Keep the patient's room at a comfortable temperature. Check the patient's skin temperature by feeling the extremities for warmth or coolness. Adjust the room temperature if the patient's skin is too warm or too cool.
  • Maintain a patent airway by proper positioning of the patient. Position the patient on his side with the chin extended. This prevents the tongue from obstructing the airway.
  • Administer oxygen as ordered.
  • Always have suction available to prevent aspiration of vomitus.
  • A patient who is unconscious is normally fed and medicated by gavage. (G-Tube)
  • Keep accurate records of IV intake and urine output.
  • Observe the patient for signs of dehydration or fluid overload
  • Provide oral hygiene at least twice per shift. Include the tongue, all tooth surfaces, and all soft tissue areas. The unconscious patient is often a mouth breather. This causes saliva to dry and adhere to the mouth and tooth surfaces.
  • Always have suction apparatus immediately available when giving mouth care to the unconscious patient.
  • Apply petrolatum to the lips to prevent drying.
  • Change the bed linen if damp or soiled.
  • Observe the skin for evidence of skin breakdown.
  • The bowel should be evacuated regularly to prevent impaction of stool.
  • Provide catheter care at least once per shift to prevent infection in catheterized patients
  • When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. The unconscious patient cannot tell you that he/she is uncomfortable or is experiencing pressure on a body part.
  • It is a nursing care responsibility to maintain the patient's range of motion.
  • Precautions must be taken to prevent the development of pressure sores.
  • Change the patient's position at least every two hours.