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Student Nurses’ Community

NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Bigla na lang nanginig ang anak ko” (Suddenly my

daughter started shaking uncontrollably) as

DIAGNOSIS

INFERENCE

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

INTERVENTION Independent: • Explore with the patient the various stimuli that may precipitate seizure activity. •

RATIONALE 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.

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

Risk for trauma related to loss of large muscle coordination.

verbalized by the mother. OBJECTIVE: •

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Weakness Facial grimace Irritability V/S taken as follows: T: 37.3 P: 110 R: 20 BP: 120/90

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.

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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.

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Maintain strict bed rest if prodromal signs or aura experienced.

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Student Nurses’ Community

• Turn head to side or suction...