Nursing Foundations · Care of altered functioning of sensory organ & Unconscious patient

Sensory & Unconscious Care

Unconscious patientdefinition

A patient with depressed level of consciousness who has lost protective airway reflexes.

in simple words: The tongue falls back, gag and cough reflexes go — the airway is at risk.

Why airway comes first

In unconsciousness, loss of muscle tone lets the tongue fall back and obstruct the pharynx, while absent gag and cough reflexes allow secretions or vomit to be aspirated. Without a patent airway, cerebral hypoxia can cause irreversible brain damage or death within 3–5 minutes. Airway clearance is therefore the first element of the ABC framework and the highest priority. High yield

Opening the airway

AssessLook for obstruction, gurgling, secretions
Head-tilt chin-liftRoutine opening
Jaw-thrustIf cervical spine injury suspected
SuctionRemove oropharyngeal secretions

Suctioning points

Purpose – Mechanically remove secretions to keep the airway patent
When – Only on assessment findings such as gurgling
Harm – Improper suctioning causes mucosal trauma, bleeding, hypoxia and cardiac arrhythmias

Sensory & Unconscious Care · Nursing Foundations

Mouth & Eye Care

Position is everything

Preventing aspiration is the priority during oral hygiene for an unconscious patient, because absent gag and swallow reflexes let oral secretions or cleaning fluid enter the airway. Side-lying lets gravity drain fluids out of the mouth, so it is the safest position. Assess the gag reflex before starting oral care — it is the priority safety check. Keep suction equipment ready at the bedside.

Position for mouth care

Position	Safety	Reason
Side-lying / lateral recumbent	Safest	Gravity drains oral fluids; prevents aspiration
Supine	Most dangerous	Fluids pool in pharynx; tongue obstructs airway
Fowler's	Unsafe	Head slumps; no adequate drainage
Trendelenburg	Contraindicated	Raises ICP; promotes gastric regurgitation

Special situations

Suspected C-spine injury – Keep neutral and flat (or slight reverse Trendelenburg); continuous suctioning during care
Absent gag reflex – Minimal fluid, suction ready, side-lying, ideally two staff members
Intubated – Suction above the endotracheal tube cuff; frequent oral care prevents ventilator-associated pneumonia
Oral intake – Contraindicated — absent swallowing reflex causes aspiration

Eye care

Comatose patients lose the blink reflex and may have lagophthalmos, leaving the cornea unprotected; damage can develop within 24–48 hours. Eye care aims to prevent corneal irritation and ulceration. Clean from the inner canthus to the outer canthus to keep debris away from the nasolacrimal duct. Padding keeps the cornea moist and protected; a moisture chamber is used when tape or pads cannot be applied.

Sensory & Unconscious Care · Nursing Foundations

GCS & Sensory Tests

Glasgow Coma Scale (GCS)definition

Scores level of consciousness by eye opening, verbal response and motor response.

in simple words: Total 3 (deep coma/brain death) to 15 (fully awake, alert, oriented).

e.g. Eye opening to verbal command = 3; spontaneous = 4; to pain = 2; none = 1.

GCS rules

Score ≤ 8 – Severe brain injury — airway protection such as intubation needed High yield
Drop of ≥ 2 points – Red flag — notify the doctor urgently
Intubated patient – Verbal score documented with 'T' (e.g., GCS 7T); total not calculated, eye and motor still trended

Do not confuse

Scale	Assesses
GCS	Level of consciousness (3–15)
APGAR	Newborn transition to extrauterine life
Braden	Risk of pressure injuries

Snellen chart – Distance visual acuity

Tested from 20 feet (6.1 m)
Both eyes, then each eye
20/20 is normal
Does NOT test near, peripheral or colour vision

Other sensory tools

Ishihara plates — colour vision deficiency
Ophthalmoscope / slit-lamp — cataract (lens clouding)
Palpation — touch: temperature (dorsal hand), texture/pulsation (finger pads)
Hearing aid — amplifies sound; cochlear implant — stimulates auditory nerve