Comprehensive Nursing Care Plan for Unconscious Patients
Unconsciousness is a state in which a patient is unable to respond to external stimuli, lacks awareness of themselves and their surroundings, and does not exhibit voluntary movements. It can range from temporary fainting to deep coma. Causes vary widely, including traumatic brain injury, metabolic abnormalities, stroke, poisoning, drug overdose, hypoxia, infection, or systemic shock.
Nurses play a critical role in maintaining vital functions, preventing complications, assessing neurological status, and supporting recovery. A well-structured nursing care plan ensures safe and effective care for unconscious patients.
Understanding Unconsciousness
The level of consciousness is often assessed using the Glasgow Coma Scale (GCS), which evaluates three components:
- Eye Opening Response (E): Score 1–4
- Verbal Response (V): Score 1–5
- Motor Response (M): Score 1–6
Total GCS Score: 3–15 Lower scores indicate deeper impairment.
Common Causes of Unconsciousness
- Head trauma or brain injury
- Stroke or intracranial hemorrhage
- Hypoxia due to respiratory failure or cardiac arrest
- Severe infection such as meningitis or sepsis
- Hypoglycemia or metabolic imbalance
- Drug overdose or poisoning
- Seizure or post-ictal state
Clinical Manifestations
- No verbal response
- No purposeful movement
- Altered or irregular breathing
- Abnormal posturing (decorticate or decerebrate)
- Absence of protective reflexes such as gag or cough
Nursing Assessment for Unconscious Patients
Primary Assessment (ABCDE)
- Airway: Check airway patency and gag reflex
- Breathing: Rate, depth, breath sounds, oxygen saturation
- Circulation: Heart rate, blood pressure, perfusion, ECG
- Disability: GCS score, pupil size and reaction
- Exposure: Assess for trauma, infection signs, injuries
Subjective Data
- History from family or bystanders
- Onset and progression of unconsciousness
- Allergies, medications, previous neurological conditions
Objective Data
- GCS score
- Pupil reaction to light
- Reflexes (corneal, gag, cough)
- Vital signs and oxygen saturation
- Lab tests (glucose, ABGs, electrolytes)
- Imaging (CT, MRI if ordered)
NANDA Nursing Diagnosis for Unconsciousness
- Impaired Gas Exchange related to decreased respiratory effort or airway obstruction.
- Risk for Aspiration related to absent gag reflex and inability to protect airway.
- Impaired Physical Mobility related to decreased neuromuscular function.
- Risk for Pressure Injury related to immobility and reduced sensory perception.
- Self-Care Deficit related to inability to perform ADLs.
- Risk for Infection related to invasive medical devices or decreased immunity.
NOC Outcomes (Expected Results)
| NOC Outcome | Indicator |
|---|---|
| Respiratory Status: Gas Exchange | Maintains normal oxygen saturation & stable ABGs |
| Neurological Status | Improvement in GCS score |
| Tissue Integrity | No pressure injuries or skin breakdown |
| Safety Status | Free from aspiration, falls, or accidental removal of medical devices |
NIC Nursing Interventions and Rationales
1. Airway Management
- Position head in neutral position
- Suction oral secretions as needed
- Insert airway adjunct or endotracheal tube if prescribed
Rationale: Ensures airway patency and prevents obstruction.
2. Breathing Support
- Administer supplemental oxygen
- Monitor SpO₂ and ABGs regularly
- Prepare for mechanical ventilation if indicated
Rationale: Maintains adequate oxygenation to prevent hypoxic brain injury.
3. Aspiration Precautions
- Place patient in side-lying position
- Keep NPO until swallowing function is evaluated
- Elevate head of bed 30–45°
Rationale: Reduces risk of aspiration pneumonia.
4. Pressure Injury Prevention
- Reposition every 2 hours
- Use pressure-relieving mattress or cushions
- Perform daily skin assessment
Rationale: Prevents tissue ischemia and ulcer formation.
5. Eye and Oral Care
- Clean oral cavity every 4 hours
- Lubricate eyes to prevent dryness
Rationale: Maintains hygiene and prevents corneal damage.
6. Neurological Monitoring
- Assess GCS hourly or as ordered
- Monitor pupil size, symmetry, and reaction
- Report sudden changes immediately
Rationale: Early detection of worsening neurological function saves life.
Evaluation
- Is airway clear and oxygenation adequate?
- Is the patient free from aspiration?
- Are skin surfaces intact without pressure ulcers?
- Has neurological status improved or remained stable?
- Are vital signs within normal range?
Conclusion
Caring for an unconscious patient requires continuous monitoring, airway protection, prevention of complications, and comprehensive nursing assessment. Collaboration among nurses, physicians, and caregivers ensures patient stability and supports recovery. A systematic nursing care plan improves outcomes and maintains patient dignity and safety.
References
- American Heart Association. (2020). Advanced Cardiovascular Life Support (ACLS) Provider Manual.
- Potter, P. & Perry, A. (2021). Fundamentals of Nursing. 10th Edition. Elsevier.
- Smeltzer, S.C., Bare, B.G., et al. (2020). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 15th Edition.
- GCS Assessment Guidelines - Teasdale & Jennett, The Lancet.