- 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.
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