6. unconscious patient care

Unconscious Patient Care

&Communication Skills required in Critical

Care1Prof. Dr. RS Mehta, BPKIHS

Care of unconscious patients.(Unconscious, Bedridden, Critically ill, terminally ill)

• Person who has no control upon him self or his environment.

• Is fully dependent upon others for monitoring his/her vital functions.

Conditions of immobility: - • Patient on traction, CVA, chronically ill,

terminally. ill, post –operative, unconscious patients, #, accident, injury etc.

2Prof. Dr. RS Mehta, BPKIHS

Stages and causes of impaired consciousness: -

Acute stage: - Caused by intra cranial diseases and metabolic upset.

• Clouding of consciousness. • Contusion, hyper excitability and irritability. • Delirium. • Illusion. and hallucination, • Delusions (persistent misperceptions). • Stuper: aroused only by vigorous stimuli. • Coma: Pt. totally unaware.


Chronic stage: - • Dementia–memory, thinking, motor loss,

cortical tissue degeneration• Vegetative – total lack of cognitive

function, eye open-no response. • Akinetic mutism – silent immobility.

Damage of cerebral frontal lobe. • Locked in syndrome – Paralysis of 4

limbs and cranial nerves.


Assessment: -

• G.C.S. (eye + verbal + moter). • Vital signs: - TPR, BP, • Pupil – size and reaction. • Limb movement and tendon reflex. etc.


• Complications of immobility: - • Skin: - Pressure sore, laceration. • Respiratory: - Hypostatic pneumonia, pull.

Embolism.• C.V. complications: - DVT, postural

hypotension, thrombo embolsm. • G.I. system: - Paralytic ilius, constipation,

distention.• Urological: - UTI, stone. • Muskulo skeleton: - Contracture, osteoporosis,

dystrophy, weakness. • Neurological: - Foot drop. • Psychological: - Anxiety, depression.


Assessment of bedridden patients: -

• Emergency assessment: - A.B.C. • Atonic bowel: - Paralytic illims, dist., N/V, pain. • Orthostatic hypotention: - • Neurogenic status: - Hypotension, cold, temp.

etc. • Skin: pressure sore, bruise, wound. • D.V.T.: - Pain, tenderness, pulse, temp. etc. • Psychological: - Sad, depression, agitated,

anxious, critical, fear etc.


Care of unconcious / terminally ill or bed ridden patients.

Nsg. Aims: - • Identify problems. • Prevent secondry complications. • Maximise functional recovery. • Support patient and relatives. • Care of psychological aspects,


Care of unconscious Pt: - • Emg. Management: - ABC.

• Air – way clearance: - suctioning / positioning. • Prevention of risk of injury: -

– Altered cognitive status. – Strain, padding and support. – Side rails, foot splint / board.

• Maintanance of fluid volume: - – I/O, IVF, N/G feeding, orally.

• Care of oral cavity – mouth care 4 hrly. • Maintain tissue integrity of cornea: -

– / abscent corneal reflex, eye care, pad.


• Prevention from cold: - – Damage of hypothalamic center. – Warm clothing / protection.

• Catheter care / VS urinary care. – Incontinence care, – Catheterized. – Retention care, – Stimulation intemittat – Catheterization, folly’s.

• Bowel care: - • Constipation care – fluid / fiber / laxatives. • Diarrhea – fluid / ors. • Impaction – digital removal.


• Prevention of pressure ulcer: - • Back care, positioning, air / water matters etc. • Skin care: - Positioning, bed bath, hair wash, nail. • Nutritional care: - N/G, TPN, IVF, I/O. • Pyrexia: - room cold, ventilation, TPR, cold. • Promoting sensory stimulation: -

– To prevent from sensory deprivation.

Care: - Touching the Pt., communicating with Pt., avoid negative comments near Pt., Orient Pt. about: time, place, person ev.8 hrly. Divertional therapy: radio, music etc.

• Monitoring and managing potential comp: - e.g. Pneumonia, aspiration, respiratory failure.

Care: - TPR, BP, blood count, ABG, suctioning, chest physio., C/S – blood and secretions.


Specific needs and care: -• Care of skin and prevention of bedsore. • Bowel management. • Prevention of physical detormities. • Nutritional needs of patient. • Care of urinary pladder. • Different therapies to the bed-ridden Pt.

– Recreation games, Phone, paper, pray, radio. etc.

– Divertional Relax. ex., meditation, touch. etc. – Oceupational th. Typing / phone/computer tee.

(esp. handicap).


Management of patient with immobility:Nursing aims: -

– Identify problems. – Prevint secondry complications. – Maximise functional recovery. – Support patient and relatives. – Care of psychological aspects and their

relatives.


The components of basic nursing care for bed ridden patients are: -

14 principles of V. hendersons

• Respiration, eating and drinking, elimination, maintain desirable posture, rest and sleep, dressing and undressing, maintain body temperature, keep body clean and well groomed, avoid dangers of environment, communicate effectively, practice his religion, work or productive occupation, recreational activity and to learn.


Specific needs and care: - Care of skin and prevention of bed-sore:

- – Position change 2 hrly. – Back care. – Air/water mattress. (if need). – Care of pressure points. – Avoid friction. – Nutrition diet. – Family teaching.


Bowel management: - Complication: - Constipation, impaction, diarrhea, atonic dysreffexia (SCI), etc.

• Bowel history: - Frequency, consistency and stimulus. • Physical stat us: - reason, activity, age, G.I. pre. • Privacy: - Sound, smell, cartons, commod. • Positioning: - upright with pillows, SCI-no bed pan. • Intra abdominal pressure: - Massage, deep breathing. • Oral medications: - laxative, sedatives ,

– Suppositories. – Diet/fluid/exercise.

• Digital stimulation: - Index finger (1/2” – 2”) (nerve stimulatory.


Prevention of physical deformities: -

• Wrist drop: - Quadriplegia, disuse syndrome. – Due to pressare on radial nerve.

• Care: - Soft ball on hand, use of splint, slab, exercise, skin care.

• Foot drop: j- Para plegia, Quadriplegia. – Due to peroneal nerve damage.

• Care: - Position change 2 hrly, Rom = 1-2 hrly, use of splint, foot board, sand bag.

• Use of bed cradal: - pressure on tre. • External rotation of hip: - • of folled towel unaer buttock to knee.


Nutritional needs of patient: - • Assess nutritional needs of patients: - food habit,

preference, appetite, bowel sound, flatus, constipation, HB%, serum protein, Wt.,

• Consultation with dietician mean planning. • Develop rapport with patients. • Plenty of fluid 2-3 cit/24 hrs. • Diet: - protein , iron rich, vitamins, minerals, fiber, low

calcium diet etc. • Avoid gas forming food: - onion, radish, cabbage. • Avoid spicy foods. • Care of environment: j- clean, foul smell , quit, free from

distractions. • Meal secure: - small quantity, digestible tasty, low fat,

delicious. • Maintain I/O, Wt. vitals.


Care of urinary bladder: -• Assess urinary status: - retention, incontinence,

UTI, calculi etc. • Adequete fluid intake: - 2-3 lit/day. • Indewling catheter – SOS. • Maintain – I/O, fluid balance. • Skin care. • Pelvic muscle exercise. • Supra pubic stimulation. etc.


Different therapies to the bed ridden Pt. Recreational therapy: - as per need.

• games, phone, paper, pray, radio etc as per hobby. Divertional therapy: - Relaxation exercise, meditation, therapeutic touch, wheel chair use. etc.

• Occopational therapies: - – Help in physical, mental and social development. – Therapy: - according to intrest and skill of Pt. – Help – from other govt. or training insti.

• E.g.: - computer work, typing, telephone, teaching. • Preparation of family: -

• Family is backbone of Pt’s support. • Family: - type, income, education, IPR etc. • Be non-Judgmental and realistic.


Points to remember: -• Put air way if Pt. is unconscious. • Tracheostomy – if air way obstruction. • Suction equipment available. • Assess breath sound 1-2 hrly. • Never give fluid / food to shallow. • Lateral position. • Perineal care. • Examine abdomen for distention. • Involve family in care (general wards).


NEED ASSESSMENT OF CRITICALLY ILL CLIENTS: • Respiratory status:

– Airway patency. – RR, chest movemenft. – Breath sound – any adnentircois sound. – Any air leaks – on ventilator. – Pattern of breathing, spo2.

• CVS Status: – HR, meart sound, peripheral puloes, peripheral edema, neck vew.

distension. – Continuous ECG. – CVP. – BP.

• Renal status: – Fluid and electrolyte balance. – Daily wt. – I/O chart. – Hydration, bld. volume. – Corinary output.


• Gastrointestinal status. – Nutritional status. – Bowel sound. – Constipation + or – – Diarrhea P or -

• Cutaneous monitoring. – Skin calour. – Temperature.

• Injury made assessment. • Skin condition. • Infection. • Mobility. • Sensory stimulation need. • Family need.


NEUROLIGICAL ASSESSMENT: Level of consciousness: - GCS Use. – Eye opening. score.

• Spontaneous 4 • To command 3 • To pain 2 • None 1

Verbal response • Oriented 5 • Confused 4 • Inappropriate words 3 • Incomprehensive SUD. 2 • None 1

– Motor response: • Obeys command 6 • Localizes to painful stimuli 5 • withdraws to painful stimuli 4 • Flexion to painful stimuli 3• Extension to painful stimuli 2 • None to painful stimuli 1 Minimum score: 3 , Maximum score: 15 , Score less than 8: prognosis poor. Score > 8: prognosis fair. Record every 12 hrly.


CRITICAL CARE NURSE SKILL CHECKLIST

Please indicate your level of experience (0, 1, 2, or 3)

[Key: 0 = Theory, no practice, 1 = Limited, 2 =

Confident, 3 = Very Confident]


1.GENERAL 2. Admit unstable patient 0 1 2 3 3. Transport ICU patient within hospital for testing 0 1 2 3 4. Maintain Isolation technique 0 1 2 35. Orientation on Admission 0 1 2 36. Start peripheral IV 0 1 2 3 7. Giving Discharge Teaching 0 1 2 3


1.CARDIOVASCULAR 2. Assess heart sounds and peripheral pulses 0 1 2 3 3. Interpret arrhythmias 0 1 2 3 4. Identify pacemaker malfunction 0 1 2 3 5. Intervene appropriately for arrhythmias 0 1 2 3 6. Assist with arterial line insertion 0 1 2 3 7. Provide care to the patient with an arterial line 0 1 2 3 8. Remove arterial line 0 1 2 3 9. Assist and provide care with S/G insertion 0 1 2 3 10.Assist with central line insertion 0 1 2 3 11.Draw blood samples from central line 0 1 2 3 12.Remove central line 0 1 2 3 13.Assist with cardio version 0 1 2 3 14.Set up and run 12 Lead ECG 0 1 2 3 15.Provide care for the patient with acute MI 0 1 2 3 16.Provide care for the patient with acute heart failure 0 1 2 3 17.Provide care for the post-op cardiac surgery patient 0 1 2 3 18.Provide care for the patient in shock 0 1 2 3 19.Perform CPR 0 1 2 3 20.Perform defibrillation 0 1 2 3 21.Provide care for the patient requiring temporary pacing or TCP 0 1 2 3 22.Participate as a team member in resuscitation 0 1 2 323.suctioning using bronscope (TT) 0 1 2 3


1.PULMONARY Assess lung sounds 0 1 2 3 2. Set up oxygen devices 0 1 2 3 3. Obtain pulse oximetry reading 0 1 2 3 4. Interpret ABG 0 1 2 3 5. Assess ventilator settings 0 1 2 3 6. Troubleshoot ventilator alarms 0 1 2 3 7. Suction using in-line suction catheter 0 1 2 3 8. Use Ambu bag 0 1 2 3 9. Assist with intubation 0 1 2 3 10.Assist with chest tube insertion 0 1 2 3 11.Provide care for the patient with mechanical ventilation 0 1 2 3 12.Provide care for the patient with PEEP therapy 0 1 2 3 13.Provide care for the patient with chest tube 0 1 2 3 14.Provide care for the patient with a tracheostomy 0 1 2 315.Assist in spirometory 0 1 2 3

16.NEUROLOGICAL 17.Identify sudden change in loss of consciousness 0 1 2 3 18.Assess sensory, motor, speech 0 1 2 3 19.Assess reflexes (Babinski, gag) 0 1 2 3 20.Identify and intervene for seizure 0 1 2 3 21.Obtain ICP and CPP values and care 0 1 2 3 22.Provide care for the post-op neurosurgical patient 0 1 2 3 23.Provide care for the patient with acute stroke 0 1 2 3 24.Provide care for the patient in a comatose state 0 1 2 3


1. GI/RENAL/ENDOCRINE 2. Insert NG, duodenal tube 0 1 2 3 3. Provide care for the patient with GI bleed 0 1 2 3 4. Provide care for the patient with hemodialysis 0 1 2 3 5. Provide care for the patient with DKA 0 1 2 3 6. Provide care for the patient with TPN 0 1 2 3 7. Provide care for the patient with enteral nutrition 0 1 2 3 8. MEDICATOINS 9. Titrate vasoactive drugs 0 1 2 3 10.Calculate mcg/min and mcg/kg/min 0 1 2 3 11.Use IV infusion pump to calculate drug doses 0 1 2 3 12.Care of epidural catheter 0 1 2 3 13.Administer IV dopamine 0 1 2 3 14.Administer IV norepinephrine (Levophed) 0 1 2 3 15.Administer IV nitroglycerine 0 1 2 3 16.Administer IV dobutamine (Dobutrex) 0 1 2 3 17.Administer IV metoprolol (Lopressor) 0 1 2 3 18.Administer IV lidocaine 0 1 2 3 19.Administer IV amiodarone (Cordarone) 0 1 2 3 20.Administer IV adenosine 0 1 2 3 21.Administer IV diltiazem (Cardizem) 0 1 2 3 22.Administer IV verapamil 0 1 2 3 23.Administer IV atropine 0 1 2 3 24.Administer IV thrombolytics (TPA, streptokinase) 0 1 2 3 25.Administer IV heparin 0 1 2 3 26.Administer IV benzodiazepines (Valium, Versed, Ativan) 0 1 2 3 27.Administer IV Propofol (Diprivan) 0 1 2 3 28.Administer IV neuromuscular blocking agents (Pavulon, Norcuron) 0 1 2 3 Administer IV morphine 0 1 2 3 29Prof. Dr. RS Mehta, BPKIHS

1. PAIN/WOUND MANAGEMENT 2. Assess pain level/tolerance 0 1 2 3 3. Care of patient with anesthesia/analgesia 0 1 2 3 4. Care of patient with IV conscious sedation 0 1 2 3 5. Care of patient with narcotic analgesia 0 1 2 3 6. Assess wound status/ healing 0 1 2 3 7. Care of patient with sterile dressing changes 0 1 2 3 8. Care of patient with burns 0 1 2 3 9. Care of patient with pressure sores/staged Decubitus ulcers 0 1 2 3H. EXPERIENCE WITH AGE GROUPS 1. Calculate body weight to verify correct dosing of medication 0 1 2 3 2. Set age-appropriate short-term and long-term goals in care planning 0 1 2 3 3. Provide age-appropriate education, considering possible vision and hearing 4. impairment for Older than 65years. 0 1 2 3


Communication Skills required in

Critical Care



Introduction

Most vital issue in the field of critical care nursing.

This takes many forms of communication between patient and nurse, nurse and doctor, between patient and relatives.

Communication can be of two types, verbal and non-verbal.


Distance to be maintained in Communication: Review

• Distance is proximity between people which gives important signal.

Intimate distance = 18 inches- Nurse and patient

Personal distance =18 inches to 4ft between family and friends

Social distance = 4 to12ft – professional

Public distance=12ft for public speaking34Prof. Dr. RS Mehta, BPKIHS

Continue….

The advancement in medicine and the growth in monitoring and regulating body systems in critical care unit brought about significant changes in the role of the critical care nurse.

It has extended and expanded to incorporate technical aspects of care, thereby the nurse is forced to focus skills on physiological needs of the patient and family.



Continue… The quality of critical care nurse depends on the

extent to which she has developed whole range of skills which enables her to provide total care to her clients. The patient in critical care unit experiences physiological crisis, a threat to his survival.

Uncertainty and threat to life poses a series of real, imagined or potential threats to family members whose main concern is the safety and survival of the patient. The anxiety and distress experienced under these circumstances will have an impact on the excessive demands upon their abilities to cope.(Millar, 1989)


Continue….

The abnormal patterns of sensory information are received from the patient internal and external environments, the patient has to mark sense or to interpret these signals, when their cognitive abilities have been affected by the pathophysiology of the illness, the drug therapy and the inability to communicate easily, either verbally or non-verbal (Asthworth,1980,Hudak et al 1986).


Continue….

Communication is fundamental to any human relationship. It involves exchange of information through verbal and nonverbal behaviour.

To families in critical care, the interpersonal skills of the caregiver makes significant change in their overall experience of critical illness.

The patients rely on them for information, support, reassurance, comfort, empathy and security. Behaviors which express this commitment, are motivated by values , which cannot be replaced by technology (Julie. P,1994) 39Prof. Dr. RS Mehta, BPKIHS

Continue….

Competent communication includes cognitive and behavioral abilities, the knowledge about the communication process and the skills to enact the knowledge Wiemann (1977) summarizes the process as selecting interaction choices, accomplishing interpersonal and contextual constraints of communication situations.



Continue….

In a typical critical care unit patients are admitted or transferred from other units on an emergency basis.

The initial emphasis of nursing care must be to meet the patient’s physical and physiological needs working along with the multidisciplinary team to achieve homeostasis.

Once this achieved her attention turns to family who is experiencing major situational crisis caused by the unexpected and unpredictable events which have led to the admission to the critical care unit. 42Prof. Dr. RS Mehta, BPKIHS


Continue….

The challenge for the nurse is to enable the patients and the family members to utilize the available resources within themselves to cope with the situation.

The ability of the nurse to meet the needs for open and honest information about the patient with the family determines the outcome of the crisis.


Importance of communication

Effective communication and good inter-personal relational skills of the caregivers can modify the patients sensory perceptual alteration.

Effective communication has a valuable contribution towards the well being of the patient, the family and it positively affects the outcome of the illness.

Thus it is a challenge for every critical care nurse to develop the effective skills of communication and to incorporate into her daily routine inspite of the great demands on her time to meet the physiological needs. 45Prof. Dr. RS Mehta, BPKIHS

Interpersonal goals for nurses in critical care unit

Develop open, trusting relationship with patients and relatives.

Assess the family’s ability to grasp the information.

Repeat and reinforce the information/


Continue….

Interpret the medical and technical language.

Prepare the family for visiting and demonstrating their care and concern to the patient through verbal and nonverbal communication.

Assess the ability of the family to deal with crisis and in assisting with plan of care.



Continue….

Nurses may have to spend enormous time in getting the patient to cooperate and participate in the activities of care that are planned.

Letter boards and nonverbal signs and signals and closed questions which enable the patient to node or shake the head will assist in maintaining communication with the patient who has impaired communication related to disease process or therapeutic management.


Continue….

Another event in the critical care unit where communication plays an important role in getting the patient prepared for a transfer form the unit due to the dependency developed over the time.

It is important to maintain continuity of care between the unit and ward areas.



Thank You


Health & Medicine

6. unconscious patient care