The unconscious patient is a very special patient. Requires to spend a lot of time on it. The nurse must take care of the patient in every dimension, the patient will not say what help he wants from us.
That is why we nurses have to recognize all care problems of the patient. This article is an attempt to concisely describe the basic nursing problems of every unconscious mechanically ventilated patient without considering specific nursing problems for various disease entities.
1. Possibility of pressure ulcers due to pressure:
- Assessment of the risk of pressure ulcers on one of the scales
- Daily assessment of the condition of the skin throughout the body and recording in the history of nursing
- The Unconscious Patient position on the pressure-relief mattress.
- The patient’s position changes, the frequency of changes should adapt to the patient’s condition. Optimally, every two hours
- Daily full-body toilet with a change of bed linen and skincare with lotions suitable for skin exposed to pressure sores
- Protection of skin with secretions and excreta through the use of bladder drainage, the use of disposable foundations, and diaper pants.
- Ensuring proper nutrition of the patient, unless there are contraindications to the nutrition of the patient.
2. Positioning an unconscious patient:
Monitoring the patient’s condition minimize the risk of complications resulting from lack of movement, care should be taken to position and change the position of the Unconscious Patient. Most patients are recommended for the high or half-high positions due to feeding by stomach tube, cardiopulmonary failure.
In this way, we prevent aspiration of gastric contents and facilitate breathing by reducing pressure on the chest Upper limbs, which should be in a flexed position and forearms slightly raised in a way that allows blood to drain.
Changes in the position of the Unconscious Patient should be adapted to the patient’s condition the lower limbs should be bent at the hip and knee joints, free heels, feet set at right angles, this prevents pressure sores and the formation of clubfoot.
Observation and monitoring of the Unconscious Patient condition are one of the basic tasks of a nurse working in ICU wards.
The parameters controlled by the nurse
- Monitoring the heart rate, heart rate, and rhythm
- Blood pressure measurement
- Measuring body temperature
- Measurement of central venous pressure
- Control diuresis, maintaining fluid balance
- Measurement of cardiac
3. The possibility of occurrence of ventilator-associated pneumonia:
Occurrence from respiratory pneumonia can be prevented by proper and sufficiently frequent oral care and the correct toilet of the bronchial tree.
- The head of the bed should be raised to 30-450
- Comprehensive oral care should be performed twice a day
- Oral care using a rinse, every 6-8 hours, 3-4 times a day.
- Detailed guidelines regarding oral care have been developed by the Polish Society of Anaesthesiological and Intensive Care Nurses
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4. Possibility of inflammation and damage to the eye surface
Patients in ICU wards often have a disorder of natural eye defense mechanisms such as tear production and reflex eye closing.
- Monitoring and observation of the patient’s eyes 2-4 times a day to detect any changes
- Protecting the eyes against opening during respiration, it is recommended to use closed systems.
- Maintain eye hygiene
- Prevent drying of the eye surface
- Keeping eyelids closed
5. Possibility of catheter infection
Central access care:• Assess the puncture site daily by inspecting and palpating the dressing
- Change the gas dressing daily
- Changing the dressing according to sterility
- Change the recommended transparent dressing once a week
- Changing the dressing in case of dirt, loosening, moisturizing, or suspected infection
6. Care of the line Arterial:
- Maintenance of Patency and protection against accidental removal of the cannula
- Observation of distal parts of the limb for signs of ischemia or necrosis (fading, cooling)
- Daily assessment of the puncture site
- Regular dressing change, gas dressings daily, transparent at least once a week
- Accurate arterial line marking to avoid intra-arterial mistake