Learning outcomes
By the end of this section, you should know how to:
▪ maintain an adequate airway for the unconscious patient
▪ assess and record the level of consciousness using the Glasgow Coma Scale
▪ care for the unconscious patient.
Background knowledge required
Revision of the anatomy and physiology of the nervous system, with special reference to the brain
Review of local policy and national guidelines relating to the care of the unconscious patient.
Indications and rationale for care during a state of unconsciousness
Nursing intervention is required when a patient’s level of consciousness is such that, unaided, he or she can no longer maintain a clear airway, the normal protective reflexes are so reduced that the patient can no longer maintain the safety of the environment, and the patient is unable to perform the everyday activities of living (Hickey 2003).
The unconscious state is most commonly associated with:
▪ patients who have a cerebral vascular accident, when areas of brain tissue will be damaged and have a diminished blood supply, e.g.:
— cerebral haemorrhage
— cerebral embolus or ischaemia
— subarachnoid haemorrhage
▪ patients who have taken an overdose of analgesic drugs, which will affect the function of the brain cells
▪ patients who have a traumatic head injury as brain cells may be damaged by the injury
▪ patients who have a brain tumour causing pressure on and damage to the brain
▪ patients who are in a comatose state caused by:
— severe infection as hyperpyrexia may affect brain cell function
— hypothermia because a severe temperature change reduces brain cell activity (Hickey 2003)
— metabolic disturbances, i.e. uncontrolled diabetes mellitus (hyperglycaemia or hypoglycaemia), which may result in reduced brain cell function
▪ patients who have received prescribed anaesthetic medication during and following surgery, which affects the patient’s neurological state
▪ patients in the terminal stage of illness when cerebral function is diminished.
1. Bed with a detachable head
2. Padded cot sides
3. Disposable airway – either Guedel oropharyngeal or nasopharyngeal
4. Ambu bag with valve and mask
5. Equipment for oral, pharyngeal or tracheal suction
6. Equipment for oxygen therapy
7. Equipment for a nasogastric, PEG or total parenteral nutrition feeding system
8. Mouth care tray
9. Eye care tray
10. Catheter care tray
11. Equipment for endotracheal intubation if required.
Details of the equipment for specific nursing practices can be found in the relevant sections of this book.
Equipment for assessing the level of consciousness
Pen torch to assess eye pupil size and reaction
Level of consciousness assessment chart, e.g. the Glasgow Coma Scale (GCS)
Sphygmomanometer and stethoscope to measure blood pressure
Thermometer
Pulse oximeter – to measure peripheral oxygen saturation (Spo2).
The Glasgow Coma Scale
This enables an assessment of level of consciousness to be made, using a numbered scale (Fig. 44.1). The assessment involves examining the patient’s behavioural responses to the environment. Three categories are examined: eye opening, verbal response and motor responses, for example limb movements. Each level of behavioural response is recorded during the assessment and given a maximum score of 4, for a spontaneous eye-opening response, 5, for an orientated verbal response, and 6, for obeying commands in the motor response category (National Institute for Clinical Excellence 2003). A total score of 15 indicates fully conscious.
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