What should a nurse do when they are working with someone who is unresponsive, withdrawn, and immobile?
This article will discuss the appropriate actions to take in this situation. A client should be monitored by the nurse for signs of life, such as a pulse. The heart rate and respiratory rate can also be checked to determine if these vital body functions are still functioning properly.
The muscle tone may need to be assessed next: rigidity or spasticity?
Passive movement is possible with low-grade spasticity, but not with high-grade spasticity. If there’s no response after checking all three areas (pulse/heartrate/muscle tone), then it would be appropriate to move on in this flowchart situation:
“Is the unresponsive person awake?”
If they’re asleep, you might want them to wake up. If someone does not respond regardless of how many times you check, it might be prudent to call for emergency medical assistance. If someone is not breathing and there’s no response after checking all three areas (pulse/heartrate/muscle tone), then CPR should start immediately.
