Caring for the patient with altered consciousness

The patient with an altered level of consciousness has lost the protective reflexes and the movement that keep a conscious person safe without anyone noticing -- the cough, swallow and gag that guard the airway, the blink that keeps the cornea moist, the shifting of weight that spares the skin, the muscle activity that keeps the joints mobile and the venous blood moving, and the sense of a full bladder or bowel -- so the nursing care replaces each one, and the airway comes first: the patient is placed on the side or semi-prone so the tongue falls forward and secretions drain instead of pooling, the head of the bed is raised unless the injury forbids it, the mouth and pharynx are suctioned as secretions gather, the chest is listened to and the breathing watched because a snoring, gurgling or irregular breath is an obstructing airway and not sleep, and nothing is given by mouth until the swallow is shown to be safe; then the eyes are cleaned, lubricated and shielded when the lids do not close, the mouth is cleaned regularly because it is the flora of the mouth that turns a silent aspiration into a pneumonia, the body is turned and repositioned on a schedule with the joints moved through their range and positioned against contracture and foot drop, the skin is inspected at every turn, fluid and nutrition are given by tube or by vein because the patient cannot ask for a drink, the bladder is assessed for retention and a catheter is used only while it is needed, the bowel is kept moving so that impaction does not follow immobility, the temperature is watched because a fever may come from the injured brain as well as from an infection and a high one harms the brain further, the patient is protected from injury with padded rails and never restrained against agitation because straining against a restraint raises the pressure in the head, and the patient is spoken to and oriented as if every word is heard, with the family taught to do the same -- while through all of it the nurse watches for the complications this patient cannot report: an obstructing airway, aspiration and pneumonia, a pressure injury, a corneal abrasion, a contracture, a deep vein thrombosis, urinary retention and infection, and constipation, each one preventable and each one found late in a patient who cannot say what hurts.