- Postures
- Glasgow Coma Scale
Decorticate and Decerebrate Posturing
Abnormal posture response to stimuli. (A) Decorticate posturing, involving adduction
and flexion of the upper extremities, internal rotation of the lower extremities, and
plantar flexion of the feet.
(B) Decerebrate posturing, involving extension and outward rotation of upper
extremities and plantar flexion of the feet.
Nursing Process: The Care of the Patient with Altered Level of Consciousness—
Diagnoses
- Ineffective airway clearance
- Risk of injury
- Deficient fluid volume
- Impaired oral mucosa
- Risk for impaired skin integrity and impaired tissue integrity (cornea)
- Ineffective thermoregulation
- Impaired urinary elimination and bowel incontinence
- Disturbed sensory perception