O7 · Needs of sedated or unconscious patient
Risk Surgery and intensive care
Definition
The person cannot protect their own airway, skin, eyes, or position.- Sedatives
- coma
- paralysis
- ventilator
- Cannot move
- no cough
- eyes unprotected
- skin at risk
📋 Scenario
An ICU patient on a ventilator and sedation cannot turn or protect his airway.
Subjective (S): (Sedated; cannot speak.)
Objective (O): Ventilated and sedated; no cough or gag reflex; eyes partly open; skin intact; cannot turn himself.
Assessment tools for this scenario: CP-SURG Post-op & Critical Care Check CP-SKIN Skin & Wound Score
Validated scales to consider: RASS, CPOT, Aldrete, Braden Scale, TIME wound chart
**CarePath diagnosis:** Needs of sedated or unconscious patient related to sedatives and loss of protective reflexes (risk factors); no signs of the problem are present yet.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Turn regularly. | Changing position regularly relieves pressure on the skin, helps the lungs expand and prevents joint stiffness. |
| Give eye and mouth care. | Without blinking or normal saliva, eyes and mouth dry out and become infected, so regular cleaning and lubrication protects them. |
| Suction. | Without a cough or gag, secretions collect in the airway, so suction clears them and helps prevent chest infection. |
| Monitor. | Continuous monitoring finds changes in breathing, heart rate, sedation level or ventilator function early so problems are treated before they become dangerous. |
| Protect skin. | Keeping skin clean, dry and free from pressure lowers the chance of breakdown in a patient who cannot move himself. |
| Keep communicating. | Hearing may still be present, so speaking to him explains care, supports dignity and may reduce distress. |
**Expected outcomes**
- Airway protected.
- Skin intact.
- Eyes protected.
- Repositioned every 2 hours.
- No complications.
**Linking the data to the diagnosis**
The patient is sedated and cannot speak. He is on a ventilator with no cough or gag reflex, his eyes are partly open, his skin is intact and he cannot turn himself. He has not yet come to harm, so a risk statement fits, and it rests on sedatives and loss of protective reflexes. The nurse acts for him because he cannot protect his airway, eyes and skin. The plan aims for a protected airway, intact skin, protected eyes, repositioning every 2 hours and no complications.
CarePath diagnosis
Needs of sedated or unconscious patient related to sedatives and loss of protective reflexes (risk factors); no signs of the problem are present yet.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Turn regularly. | Changing position regularly relieves pressure on the skin, helps the lungs expand and prevents joint stiffness. |
| 2. Give eye and mouth care. | Without blinking or normal saliva, eyes and mouth dry out and become infected, so regular cleaning and lubrication protects them. |
| 3. Suction. | Without a cough or gag, secretions collect in the airway, so suction clears them and helps prevent chest infection. |
| 4. Monitor. | Continuous monitoring finds changes in breathing, heart rate, sedation level or ventilator function early so problems are treated before they become dangerous. |
| 5. Protect skin. | Keeping skin clean, dry and free from pressure lowers the chance of breakdown in a patient who cannot move himself. |
| 6. Keep communicating. | Hearing may still be present, so speaking to him explains care, supports dignity and may reduce distress. |
Expected outcomes
- Airway protected.
- Skin intact.
- Eyes protected.
- Repositioned every 2 hours.
- No complications.
Linking the data to the diagnosis
The patient is sedated and cannot speak. He is on a ventilator with no cough or gag reflex, his eyes are partly open, his skin is intact and he cannot turn himself. He has not yet come to harm, so a risk statement fits, and it rests on sedatives and loss of protective reflexes. The nurse acts for him because he cannot protect his airway, eyes and skin. The plan aims for a protected airway, intact skin, protected eyes, repositioning every 2 hours and no complications.