Page 2041 - Saunders Comprehensive Review For NCLEX-RN

Box 58-6

Care of the Unconscious Client

▪ Assess patency of the airway and keep airway and emergency equipment
readily available.
▪ Monitor blood pressure, pulse, and heart sounds.
▪ Assess respiratory and circulatory status.
▪ Do not leave the client unattended if unstable.
▪ Maintain a patent airway and ventilation, because a high carbon dioxide (CO )
2
level increases intracranial pressure.
▪ Assess lung sounds for the accumulation of secretions; suction as needed.
▪ Assess neurological status, including level of consciousness, pupillary reactions,
and motor and sensory function, using a coma scale.
▪ Place the client in a semi-Fowler’s position.
▪ Change position of the client every 2 hours, avoiding injury when turning.
▪ Avoid Trendelenburg’s position.
▪ Use side rails unless contraindicated or according to agency protocol.
▪ Assess for edema.
▪ Monitor for dehydration.
▪ Monitor intake and output and daily weight.
▪ Maintain NPO (nothing by mouth) status until consciousness returns.
▪ 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).
▪ Assess bowel sounds.
▪ Monitor elimination patterns.
▪ Monitor for constipation, impaction, and paralytic ileus.
▪ Maintain urinary output to prevent stasis, infection, and calculus formation.
▪ Monitor the status of skin integrity.
▪ Initiate measures to prevent skin breakdown.

▪ Provide frequent mouth care.
▪ Remove dentures and contact lenses.
▪ Assess the eyes for the presence of a corneal reflex and irritation, and instill
artificial tears or cover the eyes with eye patches.
▪ Monitor drainage from the ears or nose for the presence of cerebrospinal fluid.
▪ Assume that the unconscious client can hear.
▪ Avoid restraints.
▪ Initiate seizure precautions if necessary.
▪ Provide range-of-motion exercises to prevent contractures.
▪ Use a footboard or high-topped sneakers to prevent footdrop.

2041