Nursing Care Plan for Unconsciousness

Nursing care plan for unconsciousness 1

Nursing Diagnosis and Interventions for Unconsciousness

Unconsciousness is when a person is unable to respond to people and activities. Often, this is called a coma or being in a comatose state. Fainting due to a drop in blood pressure and a decrease of the oxygen supply to the brain is a temporary loss of consciousness.

Consciousness is a state of being wakeful and aware of self, environment and time.

Loss of consciousness should not be confused with the notion of the psychoanalytic unconscious or cognitive processes (e.g., implicit cognition) that take place outside of awareness.

Loss of consciousness may occur as the result of traumatic brain injury, brain hypoxia (e.g., due to a brain infarction or cardiac arrest), severe poisoning with drugs that depress the activity of the central nervous system (e.g., alcohol and other hypnotic or sedative drugs), severe fatigue, and other causes.

Causes of Unconsciousness :

  • Head Injury
  • Skull Fracture
  • Asphyxia
  • Fainting
  • Extremes of Body Temperature
  • Cardiac Arrest
  • Blood Loss
  • Cerebro vascular Accident
  • Epilepsy
  • Infantile Convulsions
  • Hypoglycemia
  • Hyperglycemia
  • Drug Overdose
  • Hypothermia
  • Poisonous Substances and Fumes

Clinical symptoms associated with loss of consciousness is

  • Loss of consciousness is qualitative.
  • GCS less than 13.
  • Severe headache.
  • Projectile vomiting.
  • Papilledema.
  • Asymmetric pupils.
  • Pupillary reaction to light slow down or negative.
  • Fever.
  • Restless.
  • Seizures.
  • Retention of mucus / sputum in the throat.
  • Retention or urinary incontinence.
  • Hypertension or hypotension.
  • Tachycardia or bradycardia.
  • Tachypnoea or dyspnea.
  • Local edema or anasarka.
  • Cyanosis, pallor, and so on.

Nursing Care Plan for Unconsciousness

Primary Assessment

1. Airway

  • Does the patient speak and breathe freely.
  • There was a decrease of consciousness.
  • Abnormal breath sounds: stridor, wheezing, wheezing, etc..
  • The use of a respirator muscles.
  • Restless.
  • Cyanosis.
  • Seizures.
  • Retention of mucus / sputum in the throat.
  • Hoarseness.
  • Cough.

2. Breathing

  • Is there any abnormal breath sounds: stridor, wheezing, wheezing, etc..
  • Cyanosis.
  • Tachypnoea.
  • Dyspnea.
  • Hypoxia.
  • The short length of inspiration expiration.

3. Circulation

  • Hypotension / hypertension.
  • Tachypnoea.
  • Hypothermia.
  • Pale.
  • Cold extremities.
  • Decreased capillary refill.
  • Decreased urine production.
  • Pain.
  • Enlarged lymph nodes.

Secondary Assessment

Past medical history
Do clients ever suffered from:

  • Stroke.
  • Infection of the brain.
  • DM.
  • Diarrhea and excessive vomiting.
  • Brain tumors.
  • Intoksiaksi insecticides.
  • Head trauma.
  • Epilepsy, etc..

Physical Examination

1. Activity and rest

o Subjective Data:

  • Difficulties in the move.
  • Weakness.
  • Loss of sensation or paralysis.
  • Easily tired.
  • Difficulties break.
  • Pain or muscle spasms.

o Objective data:

  • Changes in the level of consciousness.
  • Changes in muscle tone (flaccid or spastic), paraliysis (hemiplegia), general weakness.
  • Impaired vision.

2. Circulation

o Subjective Data:

  • History of stroke.
  • History of heart disease.
  • Valvular heart disease, dysrhythmias, heart failure, bacterial endocarditis.
  • Polycythemia.

o Objective data:

  • Arterial hypertension.
  • Dysrhythmias.
  • ECG changes.
  • Pulsation: probability varies.
  • Pulse carotid, femoral and iliac artery or abdominal aorta.

3. Elimination

o Subjective Data:

  • Urinary incontinence / Alvi.
  • Anuria

o Objective data
Abdominal distention (very full bladder).
Absence of bowel sounds (paralytic ileus).

4. Food / fluid

o Subjective Data :

  • Nausea.
  • Loss of appetite.
  • Vomitus indicates PTIK.
  • Loss of sensation of the tongue, cheek, throat.
  • Dysphagia.
  • History of diabetes mellitus, Increased fat in the blood.

o Objective data :

  • Obesity (a risk factor).

5. Sensorineural

o Subjective Data :

  • Syncope.
  • Headache : the intra-cerebral hemorrhage or subarachnoid hemorrhage.
  • Weakness.
  • Tingling / numbness.
  • Reduced visibility.
  • Touch : loss of sensors on the extremities and the face.
  • Impaired sense of taste.
  • Disorders of smell.

o Objective data :

  • Mental status.
  • Loss of consciousness.
  • Behavioral disturbances (such as : lethargy, apathy, attack)
  • Impaired cognitive function.
  • Extremities : weakness / paraliysis not draw the hand grip, reduced deep tendon reflexes.
  • Facial paralysis / parese.
  • Aphasia ( damage to or loss of the function of language, expressive possibility / difficulty saying the word, receptive / difficulty saying the word comprehensive, global / combination of the two).
  • Loss of the ability to know or see, tactile stimuli.
  • Lose the ability to hear.
  • Apraxia : lose the ability to use the motor.
  • Reaction and the size of the pupil : the pupil reaction to light the positive / negative, pupil size isokor / anisokor, the diameter of the pupil.

6. Pain / comfort

o Subjective Data:

  • Headaches vary in intensity.

o Objective data:

  • Unstable behavior.
  • Restless.
  • Muscle tension.

7. Respiration

o Subjective Data: smokers (risk factors)

8. Security

o Objective data:

  • Motor / sensory: problems with vision.
  • Change in perception of the body.
  • Trouble seeing objects.
  • Lost awareness of the sick body.
  • Not being able to recognize objects, colors, words, and faces ever recognized.
  • Disruption responds to heat, and cold / body temperature regulation disorders.
  • Disruptions in deciding, little attention to security.
  • Diminished sense of self.

9. Social interaction

o Objective data:

  • Problem speak.
  • The inability to communicate.

Cranial Nerves Test :

N I. Olfactory nerve
Smell checked with odors such as tobacco, perfume, patients were asked to mention with eyes closed.

N II. Optic nerve
Fisus checked by examination in each eye. Used optotipe snalen mounted at a distance of 6 feet from the patient. Vision clearly determined by the ability to read a row of letters there.

N III Oculomotor nerve, N IV Trochlear nerve, N VI Abducens nerve
Examined along with assessing the ability of eye movement in all directions, the diameter of the pupil, light reflex and accommodation reflexes.

N V. Trigeminal nerve
Trigeminal sensory and motor function,
Sensory examined on the surface of the skin forehead, cheeks, and lower jaw as well as cotton and scratch your eyes closed.
Examined motor abilities bite it, palpate both musculus masseter tone when instructed to bite motion.

N VII facial nerve
Facial motor function
Examined the ability of raised eyebrows, frowning, shedding lips, smile, grimace (showing front teeth) whistling, puffed cheeks.
Sensory function checked sense of taste on the tongue surface is extended (sugar, salt, sour).

N VIII vestibulocochlear nerve (auditory vestibular nerve)
Auditory function tests checked by Rinne, Weber, Schwabach with a tuning fork.

N IX  Glossopharyngeal nerve, N X  Vagus nerve:
Examined the location of the ovules in the middle or the deviation and the patient’s ability to swallow.

N XI / Accessory nerve
Examined the ability to lift the left shoulder and right (contraction M.trapezius) and head movements.

N XII Hypoglossal nerve
Examined the ability of sticking her tongue in a straight position, movement of the tongue pushing the left and right cheek from the inside.

Diagnostic Test

  • Neuroimaging: CT and MRI brain scans.
  • EEG.
  • Thyroid function tests, particularly TSH (thyroig stimulating hormone).
  • Evaluation of gas exchange; AGD, or pulse oximetry.
  • Metabolic sreen; GDS, urea, creatinine, albumin. Ammonia, Vit B12, electrolyte (sodium, chloride, potassium, phosphorus, calcium and magnesium.
  • Evaluation of body fluids; osmolarity of serum and urine.
  • Toxicology screening panel (blood and urine), serum levels of ETOH.
  • Cerebrospinal fluid (CSF), blood culture, urine, and sputum.
  • Lumbar puncture, knowing the value of intracranial pressure.
  • Radiology; skull x-ray. Chest x-ray.
  • Blood test; CBC, platelet count, and VDRL.
  • Cardiac study; ECG.

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