Student Nurses Community

NURSING CARE PLANASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

Bigla na lang nanginig ang anak ko (Suddenly my daughter started shaking uncontrollably) as verbalized by the mother.

OBJECTIVE:

Weakness Facial

grimace Irritability V/S taken as

follows:

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

Risk for trauma related to loss of large muscle coordination.

Seizures are disturbances in normal brain function resulting from abnormal electrical discharges in the brain, which can cause loss of consciousness, uncontrolled body movements, changes in behaviors and sensation, and changes in the autonomic system. Majority of seizures happen within the first years of life.

After 8 hours of nursing interventions, the patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Independent: Explore with the

patient the various stimuli that may precipitate seizure activity.

Discuss seizure warning signs and usual seizure pattern.

Keep padded side rails up with bed in the lowest position.

Evaluate need for protective head gear.

Maintain strict bed rest if prodromal signs or aura experienced.

Lack of sleep, flashing lights and prolonged television viewing may increase brain activity that may cause potential seizure activity.

Enables the patient to protect self from injury.

Minimizes injury should seizure occur while patient is in bed.

Use of helmet may provide added protection for individuals during aura or seizure activity.

Patient may feel restless to ambulate or even defecate during aural phase, that inadvertently removing self from safe environment and easy observation.

After 8 hours of nursing interventions, the patient was able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Student Nurses Community

Turn head to side or suction airway as indicated. Insert plastic bite block only if jaw are relaxed.

Cradle head, place on soft area, or assist to floor if out of bed.

Reorient patient following seizure activity.

Collaborative: Administer

medications as indicated.

Help maintain airway and reduces risk of oral trauma but should not be forced or inserted when teeth are clenched because dental or soft-tissue may damage.

Gentle guiding of extremities reduces risk of physical injury when patient lacks voluntary muscle control.

Patient may be confused, disoriented after seizure and need help to regain control and alleviate anxiety.

Specific drug therapy depends on seizure type, with some patients requiring polytherapy or frequent medications adjustment.