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The Unconscious Client

2 min read

References:

  1. Saunders Comprehensive Review for the NCLEX-RN Examination, 9th Edition, ISBN 978-032-37-9530-2, by Linda Anne Silvestri, Angela E. Silvestri, and Jessica Grimm (Ch. 59, pp. 858-859)

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, cerebral toxins, shock, hemorrhage, tumor, and infection.

  1. Assssment: Unarousable, primitive/no response to painful stimuli, altered respirations, decreased cranial nerve and reflex activity.

Care of the Unconscious Client

  1. Assess patency of the airway and keep airway and emergency equipment readily available.
  2. Monitor blood pressure, pulse, and heart sounds.
  3. Assess respiratory and circulatory status.
  4. Do not leave the client unattended if unstable.
  5. Maintain a patent airway and ventilation, because a high carbon dioxide (CO2) level increases intracranial pressure.
  6. Assess lung sounds for the accumulation of secretions; suction as needed.
  7. Assess neurological status, including level of consciousness, pupillary reactions, and motor and sensory function, using a coma scale.
  8. Place the client in a semi-Fowler’s position.
  9. Change position of the client every 2 hours, avoiding injury when turning.
  10. Avoid Trendelenburg’s position.
  11. Use side rails unless contraindicated or according to agency protocol.
  12. Assess for edema.
  13. Monitor for dehydration.
  14. Monitor intake and output and daily weight.
  15. Maintain NPO (nothing by mouth) status until consciousness returns.
  16. Maintain nutrition as prescribed (intravenous or enteral feedings), and monitor fluid and electrolyte balance (when consciousness returns, check the gag and swallow reflex before resuming a diet).
  17. Assess bowel sounds.
  18. Monitor elimination patterns.
  19. Monitor for constipation, impaction, and paralytic ileus.
  20. Maintain urinary output to prevent stasis, infection, and calculus formation.
  21. Monitor the status of skin integrity.
  22. Initiate measures to prevent skin breakdown.
  23. Provide frequent mouth care.
  24. Remove dentures and contact lenses.
  25. Assess the eyes for the presence of a corneal reflex and irritation, and instill artificial tears or cover the eyes with eye patches.
  26. Monitor drainage from the ears or nose for the presence of cerebrospinal fluid.
  27. Assume that the unconscious client can hear.
  28. Avoid restraints where possible.
  29. Initiate seizure precautions if necessary.
  30. Provide range-of-motion exercises to prevent contractures.
  31. Use a footboard or high-topped sneakers to prevent footdrop.
  32. Use splints to prevent wrist deformities.
  33. Initiate physical therapy as appropriate.

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