Question

A patient has been brought into the Emergency Department accompanied by by-standers who saw the patient collapse in the street. The patient is unconscious. How should the nurse proceed to assess the patient?

Answer 1

When a patient arrives in the ER department fully unconscious he is totally dependent on the nurse for all his needs,as he is not able to express himself what he needs.The nursing care should be organized in such a way ,that the patient recieves the utmost care.

The initial assessment of the patient starts with

• Assessing the mental status of the patient
• The next important criteria to look into is ,whether the cranial nerves are functioning properly.
• Check for Reflexes.
• Adequate functioning of motor and sensory nerves.
• The final score of Glasgow coma Scale out of 15.

For an unconscious patient the priority management is to maintain proper airway,by elevateing the head end of the bed to prevent aspiration of fluid into the lungs and suctioning at regular intervals.Secondly ,protect the client from falling from the bed ,by keeping up the side rails.Thirdly ,Check the vital signs,at the same time the other nurse should initiate an IV line and assisst the doctor during the insertion of an NG tube.Fourthly change the position of the patient every 2 hours,to prevent the formation of pressure ulcers and massaging the back.Fifthly as per the doctors order ,insert Urinary Catheter.Communicate with the patient,by calling his name and explaining about each procedure which is being done ,this will help him slowly orient himself to the environment.As soon as the family arrives explain to them the current treatment regimen the patient is getting and explain to them the importance of their support to the patient.