Management of Patients with a Depressed Level of Consciousness

Joanne V. Hickey

Bahia Elkamand

Unconsciousness or depressed state of consciousness is a physiologic state in which the patient generally is unresponsive to sensory stimuli and lacks awareness of self and the environment. Myriad central nervous system conditions and dysfunction of other body organs can result in unconsciousness. The depth and duration of unconsciousness or depressed state of consciousness span a broad spectrum of presentations from fainting, with momentary loss of consciousness, to prolonged depressed states of consciousness lasting weeks or months. The term coma is reserved for a clinical presentation in which the state of unconsciousness is maintained for a prolonged period, from hours to months. The pathophysiologic basis for coma is direct structural injury or physiologic dysfunction in both cerebral hemispheres, the brainstem, and both hemispheres and brainstem. Coma is typically a transient state evolving toward the recovery of consciousness, persistent vegetative state, or brain death.¹ See Chapters 8 and 15 for a discussion of depressed states of consciousness. In addition, the multiple causes of a depressed state of consciousness, including central nervous systems lesions and metabolic causes, are also discussed in Chapter 7. An in-depth discussion of impairment in consciousness and approach to the patient can be found in selected references.², ³

In neuroscience nursing practice, the nurse often cares for patients with depressed states of consciousness for prolonged periods of time. These patients lack voluntary movement and are confined to bed. The physiologic consequences of short- and long-term immobilization, described in the literature, contribute to poor outcome and disability. Not only does patient survival directly depend on the quality of care provided but also the realization of optimal rehabilitation potential hinges on the quality of care. In addition to managing the primary neurological problem, the nurse must also incorporate a rehabilitation framework to maintain intact function, prevent secondary brain injuries, complications, and disabilities, and restore lost function to the highest degree possible.⁴

In conducting a literature review for this chapter, it was surprising how little is published on comprehensive nursing care of the neurological patient who has a depressed level of consciousness. The purpose of this chapter is to provide a basic comprehensive physical-psychosocial nursing care framework for neurological patients with depressed states of consciousness. Care is designed to achieve optimal outcomes and to include specific points of care relative to the management of the neuroscience patient. Because depressed consciousness can be caused by many neurological problems, there may be variations in care related to the primary diagnosis. The basic standard of care for patients with depressed states of consciousness is outlined in this chapter. Chart 15-1 gives a sample nursing care plan. The nurse works collaborative with other health professionals to achieve optimal patient outcomes.

IMMOBILITY

Kinesis, a word of Greek origin, means motion or to move. The human body is designed for physical activity and movement. Even at rest, the normal healthy adult changes position on average every 11.6 minutes during sleep. A variety of sensory cues prompt the change in body position that prevents detrimental effects of prolonged periods of immobility. Patients with neurological or sensorimotor impairments must rely on others to reposition them to prevent the hazards of immobility. Exercise contributes to health whereas lack of exercise, regardless of the reason, leads to a continuum of multisystem deconditioning and anatomic and physiologic changes. Deconditioning is a complex process of physiologic change due to a period of prolonged inactivity, bed rest, or sedentary lifestyle. It results in functional losses in such areas as activities of daily living and mental status. Depending on the degree of inactivity, deconditioning can occur gradually or rapidly.

Bed rest was first recognized as a therapeutic modality in the 1860s. Several alleged therapeutic benefits from bed rest have been proven incorrect. Bed rest has also been described as the most potentially dangerous treatment prescribed today.⁵ Immobility and reduced exercise capacity has been aggressively studied by space programs worldwide.⁶ Deconditioning from bed rest, independent from the disease effects, contributes significantly to the reduced reserve capacity to perform regular physical activity during periods of relative immobility. The fact that bed rest deconditioning can be partly explained independent of disease underscores the need for physical activity directed at limitation of the debilitating effects of bed rest. This is challenging in patients with altered states of consciousness who are on bed rest, but a collaborative interdisciplinary approach can provide effective clinical interventions.

Immobility produces a disuse phenomenon that results in physiologic as well as psychosocial effects.⁷ The morbidity of immobility is directly associated with the length of time of immobilization and patient-specific risk factors. Some physiologic effects occur almost immediately upon the institution of bed rest whereas other physiologic and pathophysiologic changes occur over a longer period of time. Although there are physiologic changes with short periods (e.g., 1 to 3 days) of immobility, they are generally less severe and may be

reversible. Prolonged periods of immobility, which often occur with coma, spinal cord injury, Guillain-Barré syndrome, and other neurological conditions result in pathophysiologic changes associated with serious dysfunctions and permanent disabilities. Risk factors that increase the probability of complications from immobility include length and degree of immobility, incontinence, poor nutrition, hypotension, infection, altered motor or sensory function, multiorgan failure, underweight or obesity, advanced age, and comorbidity. The effects of immobility give rise to many of the complications in the unconscious patient, hence the need for the implementation of a broad range of interventions.⁸ Elderly people are particularly vulnerable to the deleterious effects of immobility resulting from concurrent age-related factors.⁹ Immobility and its consequences to each body system are well known. Yet, risk assessment and preventive strategies to address these complex, multidimensional problems continue to be challenging. The use of evidence-based practice and best practices should guide nurses and other team members in providing care that leads to optimal outcomes.

CHART 15-1 Interdisciplinary Care Plan for the Patient with a Decreased Level of Consciousness

PATIENT PROBLEM LIST OR NEEDS/EXPECTED OUTCOMES OR GOALS	ACTION PLAN/INTERVENTIONS
Self-care deficit R/T immobility and unconsciousness Primary responsibility: Nurse
Basic self-care and safety needs will be provided such as hygiene, dressing, grooming, feeding, toileting, safety, and privacy.	Provide basic hygiene care. Dress and groom patient. Provide adequate nutritional support by alternate means (e.g., tube feeding, TPN), as ordered. Provide for the elimination needs of the patient. Ensure patient safety—proper identification fall preventions, and privacy (all discipline).
Risk for alteration in respiratory status R/T ineffective cough reflex, immobility, and altered consciousness Primary responsibility: Respiratory therapist and nurse
Maximize ventilation and oxygen exchange. Maintain patent airway.	Complete a comprehensive respiratory assessment (rate, depth, breath sounds, pattern of breathing, secretions) upon admission, every shift and as needed (follow hospital policy). Auscultate the chest every 2 hrs and as needed for breath sounds. Monitor pulse oximetry as ordered. Keep the head and neck in neutral alignment. Elevate head of the bed 30-45 degrees, unless contraindicated. Reposition patient every 1-2 hrs to mobilize secretion. Chest physiotherapy as ordered to mobilize secretions. Administer oxygen as ordered. Suction as needed. Limit suctioning to ≤10 secs and two insertions per attempt. Preoxygenate with 100% oxygen before and after suctioning. Provide tracheostomy care as applicable per hospital policy and guidelines. Provide oral care with brushing of the teeth every shift. Administer medications (e.g., nebulizer treatments/inhalers) as ordered. (Follow hospital policy to indicate which discipline will administer the medications). If patient is on the ventilator: Check the ventilator setting and document per policy. Implement VAP bundle/preventive measures. Monitor for synchronous breathing with the ventilator and report asynchrony to the physician. Wean the patient from the ventilator as ordered with collaboration from respiratory therapy. Monitor blood gases and report any abnormal findings to the physician. Monitor patient for signs and symptoms of respiratory distress or any abnormal finding and notify physician. Move the patient out of bed to a chair at least daily, unless contraindicated.
Risk for aspiration R/T ineffective cough reflex and altered consciousness Primary responsibility: Nurse
Patient will not aspirate.	Elevate head of the bed 30-45 degrees, unless contraindicated. Keep patient NPO until a risk assessment for aspiration is completed or as ordered by the physician. Do not feed the patient if swallowing or airway protection is compromised. Educate and instruct the family about restriction related to feeding the patient. Provide oral care every shift per hospital policy. Check residual from tube feeding every 4 hrs and as needed. Notify physician if residual exceeds 2 times the hourly feeding amount; as ordered by the physician or per hospital policy. Turn feeding off before repositioning patient in bed. Follow aspiration precautions per hospital policy.
Risk for developing infections R/T artificial airway Primary responsibility: Nurse and respiratory therapist
Patient will not develop ventilator-associated pneumonia (VAP) or hospital acquired pneumonia.	Implement-VAP bundle/preventive measures: Elevate head of the bed 30-45 degrees, unless contraindicated. Provide oral care every 4 hrs and as needed with brushing of the teeth every 12 hrs or per hospital policy. Use gastric ulcer prophylaxis as ordered. Use deep vein thrombosis prophylaxis as ordered. Implement daily “sedation vacations” and assess readiness to extubate. Apply TED hose and sequential compression devices as ordered. Monitor endotracheal tube or tracheal tube cuff pressure every shift and as needed. Check endotracheal tube placement and position every shift and as needed. Report all abnormal findings to physician as applicable.
Alteration in cardiac output and tissue perfusion (Cerebral and peripheral) R/T immobility Primary responsibility: Nurse
Optimal cardiac output and tissue perfusion will be maintained.	Monitor vital signs per hospital policy. Monitor apical and peripheral pulses for rate, quality, and rhythm. For a patient on cardiac monitor, observe the monitor frequently; maintain alarms on and on maximum volume at all times. Apply thigh-high elastic hose and sequential compression devices as ordered. Place pillows between legs when patient is position on side. Position the upper leg so that it does not cause pressure on the lower leg. Monitor for signs of deep vein thrombosis. Administer deep vein thrombosis prophylaxis medications as ordered. Keep the head and neck in neutral alignment. Avoid positions known to increase intracranial pressure (e.g., supine, hip flexion) to prevent increase in intrathoracic pressure that will decrease cerebral venous return thus contributes to an increase in intracranial pressure. If an intracranial pressure monitor is being used, observe the monitor reading every 30-60 mins or as ordered for a rise in pressure and any correlation to patient care and activities. Do not cluster patient activities; allow fall of intracranial pressure before beginning another patient care activity or procedure. Monitor intake and output. Monitor laboratory values and correct as needed. Administer vasoactive medications as ordered. Monitor patient’s weight. Report any abnormal findings to physician, as applicable.
Risk for impaired skin integrity R/T immobility and self-care deficit Primary responsibility: Bedside nurse or wound care nurse
Skin will remain intact.	Complete skin risk assessment tool upon admission and daily thereafter (e.g., Braden scale). Asses skin integrity (to include the scalp) every shift, when repositioning and as needed. Select appropriate bed or mattress according to hospital guidelines. Remove elastic hose and sequential compression device and inspect the skin (legs) every shift or per hospital policy, as applicable. Keep skin dry and clean. Do not massage bony or reddened areas. Protect skin from moisture. Turn and reposition every 2 hrs while in bed and reposition every 1 hr while in chair and as needed. Use skin barrier cream to protect skin exposed to urine or stool. Institute measures to contain feces and/or urine if incontinent (e.g., fecal bags, indwelling, or external catheters) as ordered by the physician. Position patient utilizing pillows and support devices; DO NOT USE DONUTS. Provide padding for splints, elbows, and heels (e.g., heel protectors, pillows, and wedges). Apply padding (such as foam wraps) around the ears to protect against irritation from oxygen cannula use. Provide passive range of motion exercises and refer to rehabilitation department for assessment for a restorative program. DO NOT POSITION PATIENT ON REDDENED AREAS OF SKIN. Monitor laboratory data (e.g., pre-albumin, albumin, and total protein). Monitor nutrition and hydration status; notify dietician and physician if findings of inadequate nutrition and hydration (e.g., intolerance of tube feed, high residuals, vomiting, diarrhea, or unexpected/unintentional weight loss noted). Monitor patient’s weight, as orders by the physician or per hospital policy. Monitor intake and output every shift or as ordered. Keep head of bed elevated at or lower than 30 degrees, unless contraindicated, to avoid pressure on the sacral and coccyx area). Prevent friction and shear by: Lift the patient, do not slide or drag the patient when moving (e.g., up, down, or to the sides) the patient in bed. Use assistive/lifting devices to reduce friction and facilitate patient movement. Notify physician and/or consult with wound skin nurse (e.g., hospital policy) for any changes in skin integrity. Provide oral care and apply moisturizers to the lips every 2-4 hrs and as needed. Monitor patient’s mouth and lips for lesions, dryness, and bleeding. Report abnormal findings to physician. Reposition endotracheal tube daily to prevent ulcers of the lips (nurse and/or respiratory therapist). For patients with nasogastric tube (NGT), loosely secure the NGT to prevent ulcers of the nares. May use commercial tapping device to secure the NGT to prevent skin breakdown.
Risk for impaired tissue integrity (Corneal) R/T immobility Primary responsibility: Nurse
The eye will be free from infection and injury.	Inspect the eyes for any irritation and cleanse them every 2-4 hrs and as needed. Apply shield or tape the eyelids, as ordered, to prevent dryness, irritation, and injury. Instill lubricating solution (e.g., methylcellulose drops) as ordered.
Risk for musculoskeletal (motor) impairment R/T depressed state of consciousness and underlying neurological and neuromuscular problems Primary responsibility: Nurse and physical therapist
Range of motion will be maintained, and contractures prevented. No stress fractures or joint dislocation will occur.	Provide passive range of motion exercises as ordered (recommended 4 times/day) Position in proper body alignment; reposition every 2 hrs. Use splints, slings, pillows, trochanter roll, wedge, and foot positioners/athletic shoes as ordered; remove splints and assess skin as ordered and as needed. Reposition decorticates and decerebrates patients every 1 hour and control noxious stimuli to prevent abnormal positioning/posturing. Do not pull or tug on joints.
Impaired elimination (urinary and bowel) R/T immobility Primary responsibility: Nurse and dietician
Adequate urinary elimination will be maintained. Stool will be soft and formed. Bowel will be evacuated daily.	Monitor intake and output. Monitor 24 hours and cumulative balance. Monitor for signs and symptoms (e.g., pain/discomfort, elevated blood pressure) of bladder distention via manual palpation or bladder scan device; and abdominal distension. Consider an intermittent catheterization program. Consider application of an external condom catheter for men rather than indwelling catheter. Initiate bladder and bowel program. Auscultate abdomen for bowel sounds. Monitor bowel movement for frequency, consistency (e.g., formed, loose, watery), and color. For a patient with urinary catheter, ensure that the indication for insertion/continual use meets the guidelines set by the Center for Disease Control and Prevention (CDC).
Risk for urinary infection R/T immobility and possible use of urinary catheters Primary responsibility: Nurse
Hospital acquired urinary tract infection will be prevented.	Confirm valid reason for insertion of catheter. Ensures that urinary catheter is inserted utilizing appropriate indications. Insert catheter using aseptic technique and sterile equipment. Maintain a sterile, continuously closed drainage system. Keep catheter properly secured to prevent movement and urethral traction. Keep collection bag below the level of the bladder at all times, but should never touch the floor. Maintain unobstructed urine flow. Empty collection bag regularly, using a separate collecting container for each patient, and avoid allowing the draining spigot to touch the collecting container. Maintain meatal care every shift and as needed using soap and water. Review catheter necessity daily and remove promptly, when no longer indicated. Monitor urine for color, cloudiness, and odor. Obtain laboratory test as ordered (e.g., urinalysis, urine culture and sensitivity, white blood count) and report abnormal findings promptly to physician. Monitor patient for signs and symptoms of infection (e.g., elevated WBC, elevated temperature, tachycardia, or urine that is cloudy, sediments and foul odor). Administer medications (e.g., antibiotics and antipyretics) as ordered. Report abnormal findings to physician promptly.
Risk for Alteration in Nutrition and Hydration R/T depressed state of consciousness Primary responsibility: Dietician and nurse
Adequate nutrition and hydration will be maintained.	Monitor intake and output record. Monitor vital signs per policy. Monitor 24 hrs and cumulative balance. Monitor patient weight for change from baseline. Monitor skin turgor and skin membrane for signs of dehydration. Monitor laboratory tests (e.g., albumin, pre-albumin, electrolytes, serum/urine osmolality). Administer fluids as ordered. Monitor tube feeding residual and tolerance. Report all abnormal findings to physician as applicable.
Risk for altered sensation and pain/discomfort R/T depressed state of consciousness and immobility Primary responsibility: Nurse and beside nurse
Multisensory stimuli will be provided. Patient will be pain free.	Provide sensory stimuli (e.g., tactile—therapeutic touch and verbal stimulation) by talking to the patient; explain all treatments; provide reality orientation; describe the surrounding, weather. Ask the family for patient’s favorite TV show or radio station and turn them on. Encourage the family to touch and talk to the patient. Assess the patient for pain using nonverbal pain scales/nonverbal pain indicators. Reassess pain after pharmacological or nonpharmacological interventions to ensure appropriate pain management. Prevent conditions that contribute to pain such as bladder distension or fecal impaction. Position the patient in proper body alignment and reposition every 2 hrs and as needed to promote comfort. Consider specialty bed or support surfaces such as pressure distributing mattress to promote comfort. Administer analgesics as ordered. Provide nonpharmacological interventions that promote comfort (e.g., music, TV, reading material, massage, therapeutic touch, positioning). Stimulate as many senses as possible, unless contraindicated. Notify physician for further orders/interventions, if pain management interventions are unsuccessful.
^*R/T = related to.

SPECIALTY BEDS AND SUPPORT SURFACES

Various types of specialty beds and support surfaces are used to prevent skin irritation and decubitus ulcers and other complications of immobility in high-risk patients. A wide range of mattress overlays and mattresses are available, and each manufacturer offers special features that may be of particular value for subgroups of patients. On admission, a risk assessment for pressure ulcers should be conducted using a standardized scale such as the Braden Scale. Based on the score, facilities usually have criteria and clinical practice guidelines that guide bed selection and implementation of treatment options. The cost effectiveness of ordering a specialty bed/support surfaces such as pressure-redistributing mattress must be considered. In addition to conducting a risk assessment of the skin upon admission, the assessment is conducted periodically and as needed to monitor for pressure ulcer development. Institutional guidelines should be followed in the selection and use of specific beds or support surfaces.

Impact and Cost

The Institute of Medicine¹⁰ estimated that as many as 98,000 deaths a year in United States hospitals were attributable to medical errors. Another report found that “never events” added significantly to Medicare hospital payments.¹¹ The added costs for these events, which are defined by the National Quality Forum as “errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients,” are significant and contribute to
the rising cost of health care. New Medicare policies on hospital billing and reporting of hospital-acquired conditions (HACs) have taken effect. As of October 2008, the Centers for Medicare and Medicaid Services (CMS) no longer pays for additional costs associated with “never events” which occur during hospitalization and were not present on the patient’s admission. Because “never events” are devastating and preventable, health care organizations are under increasing pressure to eliminate them completely. A hospital acquired pressure ulcer is listed as a “never event” on the list.

THE CONSEQUENCES OF IMMOBILITY: MANAGEMENT OF THE PATIENT WITH DEPRESSED CONSCIOUSNESS

Comprehensive evidence-based nursing care has a direct impact on patient outcomes. Clinical reasoning, based on a systematic ongoing assessment of all body systems, alerts the nurse to signs and symptoms of complications. The nurse should also integrate evidence-based preventive strategies as well as treatment protocols to achieve optimal outcomes. Ongoing assessment is the basis for identifying patient, nursing, and collaborative problems. Several common collaborative problems applicable to most patients with depressed consciousness are listed in Chart 15-2. Because the patient is immobilized and multiple body systems are threatened, the patient problems of disuse syndrome encompassing all systems and total self-care deficit syndrome addressing the total dependency are prominent concerns for the nurse in providing care.

The remaining content of this chapter is organized according to body systems and related assessment and treatment implications. Several evidence-based practice protocols are included from the Institute of Healthcare Improvement (IHI), Center for Disease Control (CDC), Agency for Health Research and Quality (AHRQ) and other reputable resources. Therefore, when a strong evidence-based guideline is available, it will be included in the appropriate section.

One major repository of practice guidelines is the National Guideline Clearinghouse (NGC) which is a public resource for evidence-based clinical practice guidelines provided on a website by AHRQ (http://guideline.gov). A check of guidelines for pressure ulcers, for example, reveals that there is no shortage of clinical practice guidelines provided by a variety of organizations for the nurse to consult. The problem is that there are often many guidelines on one topic (over 100 on pressure ulcers) so that the task of reading through a variety of guidelines and evaluating the strength of the evidence is daunting and impractical for the nurse. Nurses look for resources which translate the guidelines into the bottom line of what they need to do at the bedside to provide evidence-based quality care.

CHART 15-2 Common Collaborative Problems for the Patient with a Depressed Level of Consciousness

Atelectasis/pneumonia (aspiration, bacterial pneumonia)
Deep vein thrombosis/pulmonary embolism
Ventilator dependency/difficulty to wean
Ventilator-associated pneumonia
Hypoxemia
Tracheal ulceration or necrosis
Anemia
Pressure ulcers
Acute urinary retention
Paralytic ileus

Gastric ulcer
Electrolyte imbalance
Negative nitrogen balance
Peripheral nerve impairment/neuropathies
Corneal ulceration
Stress fractures, contractures
Osteoporosis
Joint dislocation
Pain

The popularity of the concept of a “bundle” is growing in the health care quality improvement literature and practice. A bundle is defined as “a structured way of improving the processes of care and patient outcomes. It usually includes a three to five straightforward set of evidence-based practices, that, when performed collectively and reliably, have been proven to improve patient outcomes.”¹², ¹³, ¹⁴ Key components of this definition are that the items in the bundle are evidence-based practices which means that there is a body of scientific evidence supporting each item rather than practices based on common practices or provider preference. In addition, it is noted that all items in the bundle must be included and provided by competent providers in order to achieve the expected superior outcomes. Including one or two items in a bundle will not lead to optimal outcomes nor will the outcomes be achieved if the provider does not practice according to the accepted standard of care (e.g., hand washing). The bundles are designed to be followed by practitioners across disciplines and, therefore, not specific to any one discipline providing care. The IHI has developed bundles for ventilator care, central line, and sepsis. Other organizations provide the key components of a guideline without calling it a bundle although the same concept of identification of key components of care is applied.

Respiratory Function

In the supine position, ventilation and perfusion are greater in dependent areas of the lungs than in the anterior areas. Prolonged placement in the supine position can alter the ventilation-perfusion (V/Q) match. For example, patient’s mucus secretions accumulate in the dependent areas of the lungs resulting in atelectasis/hypoventilation, and interfere with diffusion of gases across the alveolar-capillary membranes. Perfusion, however, remains constant in the dependent areas. Therefore, there is a V/Q mismatch that results in an intrapulmonary shunt. Hypoxemia is the hallmark of intrapulmonary shunt. The secondary effect of hypoxemia is
cerebral hypoxia. Furthermore, the supine position and horizontal plane cause physiologic changes in the mechanics of breathing and in lung volumes. Mechanical restriction results from decreased overall respiratory muscle strength and from reduced intercostal, diaphragmatic, and abdominal muscle excursion with a consequent decrease in thoracic volume. Normally, breathing in the upright position predominantly results from rib cage movement whereas in the supine position, abdominal muscles predominate. Maximal inspiration capacity is decreased, resulting in decreased vital and functional respiratory capacities.

All lung volumes decrease except for tidal volume. The decrease in thoracic size and increase in intrathoracic blood volume associated with the supine position cause a decrease in residual volume and functional residual capacity (FRC). Normally, FRC exceeds closing volume through maintaining an open airway. When the FRC is exceeded by the closing volume, the partial or complete collapse of lung units causes atelectasis, regional differences in ventilationperfusion ratio (V/Q mismatch), poorly ventilated and overly perfused areas, and arteriovenous shunts. In addition, impaired mucociliary function causes mucus secretions to accumulate in the dependent respiratory bronchiole, which contributes to the development of atelectasis and hypostatic pneumonia. In addition, impairment of the coughing mechanism occurs due to the bed rest and decreased chest cage expansion.

Assessment

Respiratory function is assessed using a number of parameters including airway patency, respiratory rate, quality, and pattern of respirations; chest auscultation; and objective signs of oxygenation (i.e., pulse oximetry). The highest priority in managing a patient is assigned to airway patency, which is the openness of the upper airway (nose, mouth, pharynx, trachea, bronchi) which provides the route for air exchange. Obstruction of the airway may be caused by injury, edema, mucus, or other drainage. Airway patency must be assessed frequently.

Clinical evidence of an ineffective breathing pattern includes apnea, dyspnea, shortness of breath, stridor, rapid or shallow respirations, Cheyne-Stokes pattern, a prolonged expiration or inspiration phase, nasal flaring, pursed lips, intercostal or substernal retraction, abdominal breathing, and altered chest expansion.

Assess and monitor the following.

Airway patency
Rate, quality, and pattern of respirations
Adventitious breath sounds by chest auscultation of both lungs
Correlation of findings of recent chest radiograph with clinical findings
Amount and characteristics (color and tenacity) of airway secretions
Capillary refill and subtle cyanosis or dustiness in periorbital area, ear lobes, and fingernails
Oxygen saturation levels with pulse oximetry
Blood gases as ordered
Lung volumes and respiratory mechanics
Overall work of breathing
Cough reflex
Gag reflex

Respiratory Problems

The patient with depressed consciousness is at high risk for developing respiratory problems. A secondary effect of compromised respiratory function is cerebral hypoxia, which leads to secondary brain injury unless the early signs and symptoms of respiratory insufficiency are recognized and interventions initiated expeditiously. Respiratory problems to be considered include airway obstruction, aspiration, atelectasis, and pneumonia. Pneumonia includes hypostatic pneumonia, bacterial pneumonia, and ventilator-associated pneumonia (VAP) in the intubated mechanically ventilated patient. Other conditions seen in relation to trauma and intracranial hemorrhage are neurogenic pulmonary edema, adult respiratory distress syndrome, and disseminated intravascular coagulation; these conditions are discussed in other chapters.

Airway Obstruction. In the patient with depressed consciousness, a partially or completely obstructed airway can occur because of mucus accumulation or plugging by other foreign materials or through posterior displacement of oropharyngeal soft-tissue structures, particularly the tongue, as a result of improper positioning of the head and neck.¹⁵ A patient lacking the ability to protect his or her airway is unable to selfreposition the head and neck to maintain airway patency. Other mechanical situations which affect respiratory structures include postanesthesia recovery, airway edema following extubation, and diaphragmatic or intercostal muscle paralysis related to spinal cord injury or neuromuscular diseases. Results of partial airway obstruction include alveolar hypoventilation, hypoxia, hypercarbia, increased respiratory rate, and atelectasis. The early signs and symptoms observed are shallow and noisy respirations, increased secretions, and restlessness.

Aspiration. The patient with depressed consciousness is unable to protect his or her airway and, therefore, is at high risk for aspiration. Regurgitation and microaspiration, as well as actual vomiting of gastric contents, may occur, resulting in nosocomial pneumonia. Aspiration of tube feedings from a dislodged feeding tube or vomiting from a distended stomach can also lead to aspiration pneumonia.

Atelectasis and Pneumonia. Atelectasis, a state of alveolar collapse in a segment or lobe, has long been known to be a consequence of prolonged bed rest and immobility. The concurrent stasis and pooling of secretions collected in the dependent position leads to hypostatic pneumonia and a medium ripe for bacterial growth and bacterial pneumonia. If the patient is dehydrated or receiving drugs that affect the tenacity of the secretions, bacteria can rapidly grow. In addition, patients are at high risk for nosocomial infections as a result of a compromised immunologic state and potential for colonization of the endotracheal tube.

Healthcare-associated infections (HAI) are the most common complications in hospitalized patients.¹⁶ The second most common HAI in the United States is ventilator-associated pneumonia (VAP) which is responsible for 25% of infections that occur in intensive care units.¹⁷ VAP is defined by a combination of radiological, clinical, and laboratory criteria which include new or progressive pulmonary infiltrates, fever, leukocytosis, and purulent respiratory
secretions in a mechanically ventilated, intubated patient who is either currently being ventilated or who has been with 48 hours before the onset of infection.¹⁸ VAP is associated with increased mortality, morbidity, length of stay, and cost of care.

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Jul 14, 2016 | Posted by drzezo in NURSING | Comments Off

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