NCLEX Review Guide: The Unconscious Client

Glasgow Coma Scale (GCS)

• The Glasgow Coma Scale is the gold standard for assessing level of consciousness, with scores ranging from 3-15. A score of 8 or below indicates severe brain injury and need for intubation.
• Three components assessed: Eye opening (1-4), Verbal response (1-5), Motor response (1-6). Always document each component separately, not just the total score.
• Best motor response is the most reliable predictor of outcome. Decerebrate posturing (extension) indicates brainstem damage and is worse than decorticate posturing (flexion).

Airway Management

• Airway protection is the highest priority for unconscious clients due to loss of protective reflexes and risk of aspiration. Position client in side-lying or semi-prone position unless contraindicated.
• Suction airway as needed using sterile technique, limiting suctioning to 10-15 seconds to prevent hypoxia. Monitor oxygen saturation continuously and maintain SpO2 >95%.

Positioning and Mobility

• Turn client every 2 hours to prevent pressure ulcers and pneumonia. Use proper body alignment and support all extremities to prevent contractures.
• Avoid prone positioning if increased intracranial pressure (ICP) is suspected. Elevate head of bed 30 degrees to promote venous drainage and reduce ICP.

Positioning Protocol:

1. Assess for contraindications (spinal injury, increased ICP)
2. Use draw sheet and adequate personnel (minimum 2 people)
3. Maintain neutral spine alignment during turns
4. Support extremities with pillows or positioning devices
5. Document position changes and skin assessment

Increased Intracranial Pressure (ICP)

• Early signs include restlessness, confusion, and headache. Late signs include decreased consciousness, abnormal posturing, and Cushing's triad (hypertension, bradycardia, irregular respirations).
• Avoid activities that increase ICP: clustering care, extreme hip flexion, Valsalva maneuver, and hyperthermia. Maintain head in neutral position and avoid neck flexion.

Infection Prevention

• Unconscious clients are at high risk for healthcare-associated infections due to invasive devices and impaired immune responses. Perform meticulous hand hygiene and use sterile technique for all invasive procedures.
• Monitor for signs of pneumonia, urinary tract infections, and wound infections. Implement ventilator-associated pneumonia (VAP) prevention bundle if mechanically ventilated.