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Problem-solving table 7.1 Prevention and resolution (Procedure guidelines 7.17.6)

Moving and positioning the unconscious patient

Definition

Consciousness is a state of awareness of self, environment and one’s response to that environment. To be fully conscious means that the individual appropriately responds to the external stimuli. An altered level of consciousness represents a decrease in this full state of awareness and response to environmental stimuli (Boss 1998).

Anatomy and physiology

Physiological changes in the unconscious patient

Unconsciousness is a physiological state in which the patient is unresponsive to sensory stimuli and lacks awareness of self and the environment (Hickey 2003b). There are many central nervous system conditions that can result in the patient being in an unconscious state. The depth and duration of unconsciousness span a broad spectrum of presentations from fainting, with a momentary loss of consciousness, to prolonged coma lasting several weeks, months or even years. The physiological changes that occur in unconscious patients will depend on the cause of unconsciousness, on the length of immobility while unconscious, outcome and quality of care. Also drugs, for example some muscle relaxants such as those used in intensive care, can contribute to muscle weakness, raised intraocular and intracranial pressure, electrolyte imbalances and airway tone (Booij 1996). Unconsciousness can lead to problematic changes for patients which have implications for nursing interventions, including moving and positioning.

Evidence-based approaches

Principles of care

The general principles of care already mentioned earlier in the chapter are all relevant to this section. However, there are some other general principles that also need to be considered for these patients.

Sedation

In the critically ill patient sedation is an essential part of the management. In addition to managing the primary neurological problem, the nurse must also incorporate a rehabilitation framework to maintain intact function, prevent complications and disabilities, and restore lost function to the maximum that is possible.

Communication

There is evidence that unconscious patients are aware of what is happening to them and can hear conversations around them (Jacobson and Winslow 2000, Lawrence 1995). It is therefore important to tell them what is going to happen, that is that they are going to be moved, and explain the procedure just as it would be explained to the conscious patient.

Immobility

The human body is designed for physical activity and movement. Therefore any lack of exercise, regardless of reason, can result in multisystem deconditioning, anatomical and physiological changes. Guidance from a physiotherapist for passive exercises early in the period of unconsciousness may help in the prevention of further complications. There is, however, no evidence to justify the inclusion of regular passive movements within the standard management of a patient’s care. Intervention will be specific to the patient’s presentation (Harrison 2000, Pryor and Prasad 2008).

The risk of deep vein thrombosis and pulmonary embolism is increased in the unconscious patient. This is due to several factors including blood pooling in the legs, hypercoagulability and prolonged pressure from immobility in bed (Hickey 2003a).

Effects of immobility of muscle

Decreased muscle strength: the degree of loss varies with the particular muscle groups and the degree of immobility. The antigravitational muscles of the legs lose strength twice as quickly as the arm muscles and recovery takes longer.

Muscle atrophy: this means loss of muscle mass. When the muscle is relaxed, it atrophies about twice as rapidly as in a stretched position. Increased muscle tone prevents complete atrophy so patients with upper motor neurone disease lose less muscle mass than those with lower motor neurone disease (Hickey 2003a). For more information see Moving and positioning the patient with neurological impairment.