Talking to Unconscious Patients

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Who You’ll Hear

Kati Kleber, MSN RN– Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.

Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center.

What You’ll Learn

• Patient Care
• Family support
• Consents

Talking to Unconscious Patients

Key Focus:  Effective communication skills for interacting with the unconscious patient and their family.

Think about these:

• How does caring for a patient who can communicate differ from one who cannot?
• How do you talk to the patient?
• How do you talk to the patient’s family?
• How do you encourage the family interact with the patient?
• What about consents?  Healthcare power of attorney vs. next of kin

Patient Care

• Assessments:
  • Recognize how your routine assessment differs between conscious and unconscious patient
  • Be Aware that eyes closed does NOT always mean the patient is unconscious
    • Always check to see if patient can follow commands
    • Commands may involve extremity movement (like showing thumbs up or wiggling toes), but also check for voluntary eye movement (like blinking eyes, or extra-occular movements).
      • Neuro Nugget:  Locked-In Syndrome – A rare neurological syndrome involving complete paralysis of all voluntary muscle movement except for the muscles of the eyes. Occurs most often in patients with brain injury involving the pons.
• Medications:
  • Remember pain medicine and sedatives can increase length of stay and risk of complications, such as delirium
  • Be Mindful of medication dosage; use the smallest effective dosage
  • Consider weaning sedating drugs, if possible (follow your hospital protocols or physician orders)
• Professional Behavior:
  • We cannot predict and unconscious patient’s level of awareness, nor what they will remember following their illness.
  • Humanize their experience; do not simply perform a series of tasks.
    • ALWAYS talk directly to the patient during all interactions.
      • Interact with the patient like you would anyone else
      • Explain what you are going to do, before you do it (examples: turning, blood draws, mouth care)
      • Talking to the patients may reduce traumatic experiences/memories
    • DO NOT say anything or do anything around an unconscious patient that you would not do if they were awake.
      • For example, do not enter their room to complain about their family members or other staff.
• Memories/Delirium:
  • Patients have reported various memories following a significant illness
    • Memories may be full, partial, or distorted. (For example, IV pump alarm may have been heard as a fire alarm they needed to escape).
    • Some report hearing conversations of people wanting to “give up”.
    • Some report remembering staff voices, but do not recognize faces.
    • May only remember traumatic experiences; have trouble reconciling their experiences vs. reality.
  • Patients who develop delirium have a higher long-term mortality rate.
    • Post-ICU Syndrome is actively being studied.
    • ICU Delirium can have prolonged and profound impacts on patients and their families.
  • References:

Patient & Family Report: Memories from the ICU

Family Support

• Encourage families to talk to patient.
  • Familiar voices can be comforting to the patient
  • Assure them that the patient may be able hear them, despite no clear indication from the patient.
  • Engage in regular conversation.  Talk about the weather, what’s happening with other members of the family, special occasions coming up, etc.  Anything the patient would normally participate prior to the illness.
  • Model this behavior, as the nurse.
• Discourage family assessments.
  • Examinations should be done by medical personnel. Persistent attempts by the family to get patients to “follow commands” between nurse assessments can lead to patient fatigue, frustration, and possible refusal to participate in future exams.
  • Neuro Nugget: Prepare family for when, why, and how we apply noxious stimuli during the assessment of the unconscious patient.  Watching us cause pain can cause distress for the family.
• Offer guidance on establishing periods of rest.
  • Families have the best of intentions when trying to help care for the patient.  Give suggestions on when/how much time to allow for periods of rest between assessments and during the night.
• Engage their involvement, where possible.
  • Families want to participate.  Give them a “job,” when appropriate.  For example, teach them how to perform passive range of motion.  Be sure to explain when, and for how long, it should be done.

Consents

• Establishing who will provide consent for the incapacitated patient is essential.
  • Ideally, this will be done at admission, or as soon as possible.
  • Identifying this person(s) before there is an emergent need is ideal.
  • Case Management may be a resource, if assistance needed
• Informed Consent Policy
  • Refer to your institutions policy for guidance
  • Be aware that the healthcare power of attorney (HCPOA) may override the Next-of-Kin.
  • HCPOA/Next-of-Kin does not override first person consent, if the patient is of sound mind.
• HCPOA (Healthcare Power of Attorney)
  • Do not confuse with Durable Power of Attorney
  • Request copy of the legal document.  Verbal confirmation is inadequate in court of law.
  • Electronic medical record may already contain a scanned image of the document.

More Resources:

• How to Assess An Unconscious Neuro Patient Like a Neuro ICU Nurse
• Top Tips for New Neuro Nurses
• Neuro ICU Nurse – What You Need To Know