NURSING CARE RELATED TO THE SENSORY AND
NEUROLOGICAL SYSTEMS
2-27
2-27. POSITIONING
a. When positioning the unconscious patient, pay particular attention to maintaining proper body alignment. The unconscious patient cannot tell you that he is uncomfortable or is experiencing pressure on a body part.
(1) Limbs must be supported in a position of function. Do not allow flaccid limbs to rest unsupported.
(2) When turning the patient, maintain alignment and do not allow the arms to be caught under the torso.
(3) Change the patient's position to a new weight-bearing surface every two hours. This decreases the likelihood of complications such as decubitus ulcers, orthostatic pneumonia, and thrombophlebitis.
(4) Utilize a foot board at the end of the bed to decrease the possibility of foot drop.
b. When joints are not exercised in their full range of motion each day, the muscles will gradually shrink, forming what is known as a contracture. Passive exercises must be provided for the unconscious patient to prevent contractures.
(1) Exercises with a range of motion (ROM) are performed under the direction of the physical therapist.
(2) Nursing personnel must be proficient in ROM exercises.
(a) Physical therapy personnel will not always be available.
(b) It is a nursing care responsibility to maintain the patient's range of motion.
c. Precautions must be taken to prevent the development of pressure sores.
(1) Utilize a protective mattress such as a flotation mattress, alternating pressure mattress, or eggcrate mattress.
(2) Change the patient's position at least every two hours.
(3) Unless contraindicated, get the patient out of bed and into a cushioned, supportive chair.
d. Protect the patient from injury.
(1) Keep siderails up.
(2) Pad the rails with pillows or folded blankets.
(3) Keep stray objects out of the bed.
(4) Use draw sheets for easier turning.
(5) Keep suction equipment available at the bedside for emergencies.
e. Restraints.
(1) Use restraints only with physician's order.
(2) Use "mitten" restraints to prevent the patient from pulling at catheters, IV lines, his hair, and so on. (Patients not in deep coma may scratch or pick at themselves.)
(3) The restless, confused patient will actively resist restraint and thrash about more when not permitted some freedom of movement of the arms and legs.
(4) Take precautions to prevent restraint from becoming restricting. Do not cut-off circulation. Do not irritate the skin.
