patient care report for unconscious

Assessment of the unconscious patient The first priority is to ensure safety before approaching the patient. Use the SAFE approach and evaluate the ABCs. If there is any suspicion that the patient may have been a victim of trauma, the neck is immobilised in a rigid cervical collar while the airway is being assessed.

Full Answer

What is the focus of this article on unconscious patients?

This article focuses on unconscious patients where the initial cause appears to be non-traumatic and provides a practical guide for their immediate care. KEYWORDS: Unconscious, coma, neurological injury, hypoglycaemia, drug toxicity Key points

How do you care for an unconscious patient?

Conclusion The unconscious patient is challenging, in terms of immediate care, diagnosis, specific treatment and predicting prognosis. A systematic and logical approach is required, with an emphasis on teamwork. Appropriate measures to resuscitate, stabilise and support an unconscious patient must be performed rapidly.

What are the initial investigations in an unconscious patient?

Box 1. Initial investigations in an unconscious patient Full blood count Blood glucose – even if the capillary blood glucose is normal Urea and electrolytes Calcium and bone profile Liver function tests Clotting screen Toxicology screen – including paracetamol, salicylate and blood alcohol level electrocardiogram (ECG)

When should senior physicians be involved in the care of unconscious patients?

Senior physicians must be involved early in the care of an unconscious patient, to liaise with critical care and speak with the patient's relatives or advocates, especially when decisions regarding cardiopulmonary resuscitation or ceiling of care are required Introduction

How do you assess an unconscious patient?

To determine if the patient is unconscious and unable to follow commands, use the Glasgow Coma Scale (GCS) to test eye opening, best motor response, and best verbal response. An unconscious patient is likely to open her eyes only in response to pain, if at all; obviously, you can't test her best verbal response at all.

What are the 5 steps for taking care of an unconscious patient?

What you need to doStep 1 of 5: Open the airway. Place one hand on the person's forehead and gently tilt their head back. ... Step 2 of 5: Check breathing. ... Step 3 of 5: Put them in the recovery position. ... Step 4 of 5: If you suspect spinal injury. ... Step 5 of 5: Call for help.

How do you write a good patient care report?

There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

What is included in a patient care report?

The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.

What are the nursing care for unconscious patient?

Care of Unconscious PatientMaintaining patient's airway.Protecting the patient from falling off the bed.Maintaining fluid balance and managing nutritional needs.Maintaining skin integrity.Preventing urinary retention.Incontinence care.Providing sensory stimulation.More items...

What do you do when someone is unconscious?

If someone seems unconscious or unresponsive, the first thing to do is ask if they are OK in a loud voice. If they don't respond, gently shake them. But if they might have a spinal cord injury, it is best not to move the person until emergency services arrive.

How do you write a patient care report for a narrative?

How to Write an Effective ePCR NarrativeBe concise but detailed. Be descriptive in explaining exactly what happened and include the decision-making process that led to the action. ... Present the facts in clear, objective language. ... Eliminate incorrect grammar and other avoidable mistakes. ... Be consistent and thorough.

What is a PCR document?

The PCR documentation is considered a medical document that becomes part of the patient's permanent medical record. It is also considered a legal document in cases where liability and/or malpractice issues arise. It is the source in which all medical billing claims are based.

How do you write a proper PCR?

The following five easy tips can help you write a better PCR:Be specific. ... Paint a picture of the call. ... Do not fall into checkbox laziness. ... Complete the PCR as soon as possible after a call. ... Proofread, proofread, proofread.

What is the most important single sign in the assessment of the unconscious patient with a head injury?

A change in conscious level is the most important single sign in the assessment of the unconscious patient with a head injury.

What is Chapter 16 of the Psychiatric Manual?

Chapter 16. The unconscious patient. The unconscious patient is unable to ensure their own safety and in deeper levels of coma may be unable to protect their own airway.

Patient outcome

The patient was fluid resuscitated, given appropriate insulin treatment, and treated for underlying sepsis. She received intensive care for five days and then underwent one month of rehabilitation. She returned to her baseline function and was discharged home with ongoing support from the district nurse.

Footnotes

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work..