Medical Surgical Nursing

 Bowel incontinence related to impairment in neurologic sensing and control and

also related to changes in nutritional delivery methods

 Disturbed sensory perception related to neurologic impairment

 Interrupted family processes related to health crisis

Collaborative Problems/Potential Complications
Based on the assessment data, potential complications may include:

 Respiratory distress or failure

 Pneumonia

 Aspiration

 Pressure ulcer

 Deep vein thrombosis (DVT)

 Contractures

Planning and Goals
The goals of care for the patient with altered LOC include maintenance of a clear
airway, protection from injury, attainment of fluid volume balance, achievement of
intact oral mucous membranes, maintenance of normal skin integrity, absence of
corneal irritation, attainment of effective thermoregulation, and effective urinary
elimination. Additional goals include bowel continence, accurate perception of
environmental stimuli, maintenance of intact family or support system, and absence of
complications (Rice et al., 2005).