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Transcript of com +Nursing+Care+Plan+Seizure
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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.
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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.