is apparent in the patient who is

not oriented, does not follow

commands or needs persistent
stimuli to achieve a state of
alertness and full cognition.
 - is the most important indicator
of patient’s condition
ALTERED LEVEL OF
CONSCIOUSNESS
a clinical state of unarousable
unresponsiveness in w/c there
are no purposeful responses to
internal/external stimuli.
 Non purposeful responses to
painful stimuli and brainstem
reflexes may be present
 - duration 2 to 4 weeks
COMA
Akinetic Mutism
- is a state of
unresponsiveness to
the environment in w/c
the patient makes no
voluntary movement.
Persistent Vegetative State-

the unresponsive patient

resumes sleep-wake cycles
after coma but is devoid of
cognitive or affective mental
function.
 Locked-in Syndrome
- result from a lesion
affecting the pons and
result of tetraplegia and
inability to speak but eye
movement remain
intact.
ALC- is not a disorder
- CAUSE: neurologic (head injury,
stroke), toxicologic, metabolic
- disruption of cells of the NS or
neurotransmitters, or brain anatomy
Clinical Manifestations:
- ↓in the state of alertness &
consciosness
- changes in eye response, verbal and
motor response
- behavioral changes
COMA- does not open the eyes, respond
verbally or move the extremities
DIAGNOSTIC FINDINGS:
- CT scan
- MRI
-EEG
examination assessment significance
Level of Eye opening, verbal Clinical significance:
responsiveness and motor Obeying command is a
responses, pupils favorable response
(size equality,
reaction to light

Pattern of respiration Respiratory pattern disturbance of

respiratory center of
brain may result to
various respiratory
patterns
Facial symmetry asymmetry sign of paralysis
(sagging)
eyes equal, reactive Coma in toxic or
pupils,equal or metabolic state.
unequal diameter
fixed dilated pupil ↑ ICP, injury of
midbrain
Swallowing paralysis in paralysis in
reflex CN CN

10,12 10,12
Neck stiff neck, no meningitis,
movement fracture
Pathologic Firm + Babinski
Reflexes pressure reflex
fanning of the
toe
N- flexion of
toe
COMPLICATIONS:
- respiratory failure, pneumonia, pressure
ulcers and aspiration

MEDICAL MANAGEMENT:
- FIRST! Maintain a patent airway
- circulatory status is monitored- perfusion
- administer IVF
- nutritional support
- pharmacologic mgt
NURISNG MANAGEMENT:
1.#Ineffective airway clearance related to
altered LOC#
Maintain airway and proper ventilation
- remove/suction secretion
- elevated HOB
- position: lateral or semi-prone
- provide chest physiotherapy postural
drainage
2. # Risk of injury related to
decreased LOC#
• Protecting the patient
- used padded siderails
- prevent injury from invasive
lines/procedure
- preserve patient’s dignity-
provide privacy and speaking to
the pt. during nsg. care
3. *deficient fluid volume r/t inability to
take fluid by mouth*
Maintaining fluid balance and Nutritional
needs
- administer IVF: assessed hydration
status through skin turgor, mucus, I&O
-(IVF- may increase ICP)
- enteral feedings
4. * impaired oral mucus membrane
r/t mouth breathing, absence of
pharyngeal reflex, and altered
fluid intake
Providing Mouth Care
- inspect for mouth dryness,
inflammation or crusting
- cleanse & rinse the mouth
- provide petrolatum
-move ET tube to the opposite side
daily to prevent ulceration
5. * Risk for impaired skin integrity r/t
prolonged immobility*
Maintain Skin and Joint Mobility
- provide regular schedule in
changing pt’s position
- avoid dragging/pulling patient in
bed
- maintain correct body position
- use splints, foam boots, trochanter
roll-prevent footdrop
6. *impaired tissue integrity of cornea r/t
diminished or absent corneal reflex*
Preserved Corneal Integrity
- cleanse eyes w/ cotton balls moistened
with normal saline
-instill artificial tears q 2 hrs-if prescribe
- provide cold compress- careful not to
touch the cornea ( periorbital edema)
- eye patch- caution-potential for corneal
abrasion
 * Ineffective thermoregulation r/t
7.

damage to hypothalic center*

Maintaining Body Temperature
- hyperthermia
use minimal beddings/ drape
- provide sponge bath/ use
cooling material
- monitor body temperature
 8. *Impaired Urinary elimination
(incontinence or retention) related to
impairment in neurologic sensing and
control
9.* bowel incontinence r/t impairment in
neurologic sensing and control and also
r/t to changes in nutritional delivery
methods*
Promote Bowel Function
- assessed foR distention, listen to bowel
sounds
-stool softeners
-
10. * Disturbed sensory perception r/t
neurologic impairment*
Provide Sensory Stimulation
- communicate with the client
- provide frequent orientation
- minimize stimulation
11 * Interrupted family processes related
to health crisis*
Meeting the Family Needs
- provide time for the family, assistance,
support
- reinforce/ clarify information
- encouraged family to be involved in
providing care, listen and encourage
ventilation of feelings