Unconsciousness is a condition in which there is depression
of cerebral function ranging from stupor to coma.
Coma may be defined as no eye opening on stimulation,
absence of comprehensible speech, a failure to obey commands.
Unconsciousness is a lack of awareness of one' s environment
and the inability to respond to external stimuli.
observe the patient' s condition and prevent any complications.
Poisonous drugs (stomach wash, refer
Asses the patient' s level of consciousness by Glasgow coma
Responds to command
7 or less generally indicates coma
(Changes from baseline are most important)
Nursing Management :
of effective airway : -
An adequate airway must be maintained at all times.
It must be necessary to hold the patients jaw forward or
place the patient in the lateral position to prevent the tongue obstructing
airway by falling back.
Loosen the garments to allow free movements of the chest and
Frequent suction is required to prevent the pooling of
secretion in the patients pharynx
It necessary insert oral airway for easy breathing.
b. maintenance of fluid &
electrolyte balance and nutrition :
The diet must contain an adequate supply of all nutrients
required for life. Nutrition may be supplied by intravenous fluids or gastric
tube feeding. (refer practicals)
Administer prescribed intravenous fluids with Electrolytes
and vitamins.(refer practicals)
Monitor Intake and output chart accurately and record.
Monitor vital signs and record.
of personal hygiene and care of pressure areas including prevention of foot
Sponging is performed as frequently as necessary
Keep the skin dry, clean and free of moisture to prevent bed
Apply back care every 4th hourly and 2nd
hourly position changing to relieve pressure on pressure areas
Clip the nails
Range of motion exercises at least 4 times daily.
Cleanse the mouth with the prescribed solution every 2nd
hourly and apply emollients to prevent parotitis.
Irrigate the eye with sterile prescribed solution to remove
discharge and debris.
Clean the ear with swab and dry carefully especially behind
The bed linen must be kept wrinkle free and dry.
Side railing on both sides are helpful to protect the
The feet should be kept at right ankles to the legs with a
help of pillow or sand bags to prevent foot drop.
If the patient is observed for any sign of urinary
incontinency retention and constipation, report to the physician.
If the patient has incontinence of urine - provide bedpans
or catheterization can be done according to Doctor' s order to record the
accurate output.(refer practicals)
If the patient has retention of urine, apply gentle pressure
over the bladder region. It will help in partially emptying the bladder.
If the patient is constipated, a glycerine suppository or
enema is advised according to doctor' s prescription.
Perineal care, vaginal douch, catheter care to be provided
Palpate the abdomen for distension Ascultate bowel sounds.
Develop an interpersonal relationship with the family.
Provide frequent update information on patient condition
Involve the relatives in routine care
Provide comfortable physical environment
Teach family to report any unusual symptoms.