8/8/2019 com +Nursing+Care+Plan+Seizure

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Student Nurses Community

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

Bigla na langnanginig anganak ko(Suddenly mydaughter startedshaking

uncontrollably)asverbalized by themother.

OBJECTIVE:

Weakness

Facial

grimace

Irritability

V/S taken as

follows:

T: 37.3P: 110R: 20BP: 120/90

Risk for trauma

related to loss oflarge musclecoordination.

Seizures are

disturbances innormal brainfunction resultingfrom abnormalelectrical dischargesin the brain, whichcan cause loss ofconsciousness,uncontrolled bodymovements,changes in

behaviors andsensation, andchanges in theautonomic system.Majority of seizureshappen within thefirst years of life.

After 8 hours ofnursing

interventions, thepatient willdemonstratebehaviors, lifestylechanges to reducerisk factors andprotect self frominjury.

Independent:

Explore with the

patient the various

stimuli that mayprecipitate seizureactivity.

Discuss seizure

warning signs andusual seizure

pattern.

Keep padded side

rails up with bed inthe lowest position.

Evaluate need for

protective headgear.

Maintain strict bed

rest if prodromalsigns or auraexperienced.

Lack of sleep,

flashing lights and

prolongedtelevision viewingmay increasebrain activity thatmay causepotential seizureactivity.

Enables the

patient to protectself from injury.

Minimizes injury

should seizureoccur while patientis in bed.

Use of helmet may

provide addedprotection forindividuals during

aura or seizureactivity.

Patient may feel

restless toambulate or evendefecate duringaural phase, thatinadvertentlyremoving self fromsafe environmentand easy

observation.

After 8 hours ofnursing

interventions, thepatient was able todemonstratebehaviors, lifestylechanges to reducerisk factors andprotect self frominjury.

http://nursingcrib.com/http://nursingcrib.com/

8/8/2019 com +Nursing+Care+Plan+Seizure

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Student Nurses Community

Turn head to side or

suction airway asindicated. Insertplastic bite blockonly if jaw are

relaxed.

Cradle head, place

on soft area, orassist to floor if outof bed.

Reorient patient

following seizureactivity.

Collaborative:

Administermedications asindicated.

Help maintain

airway andreduces risk oforal trauma butshould not be

forced or insertedwhen teeth areclenched becausedental or soft-tissue maydamage.

Gentle guiding of

extremitiesreduces risk ofphysical injurywhen patient lacksvoluntary musclecontrol.

Patient may be

confused,disoriented afterseizure and needhelp to regaincontrol andalleviate anxiety.

Specific drugtherapy dependson seizure type,with some patientsrequiringpolytherapy orfrequentmedicationsadjustment.