- Interrupted family processes
Collaborative Problems/Potential Complications
- Respiratory distress or failure
- Pneumonia
- Aspiration
- Pressure ulcer
- Deep vein thrombosis (DVT)
- Contractures
Nursing Process: The Care of the Patient with Altered Level of Consciousness—
Planning
- Goals may include:
- Maintenance of clear airway
- Protection from injury
- Attainment of fluid volume balance
- Maintenance of skin integrity
- Absence of corneal irritation
- Effective thermoregulation
- Accurate perception of environmental stimuli
- Maintenance of intact family or support system
- Absence of complications
Interventions
- A major nursing goal is to compensate for the patient's loss of protective reflexes and
to assume responsibility for total patient care. Protection also includes maintaining the
patient‘s dignity and privacy.
- Maintaining an airway
- Frequent monitoring of respiratory status including auscultation of lung sounds
- Positioning to promote accumulation of secretions and prevent obstruction of upper
airway—HOB elevated 30°, lateral or semiprone position
- Suctioning, oral hygiene, and Chest Physiotherapy