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Student Nurses Community

NURSING CARE PLAN


ASSESSMENT

DIAGNOSIS

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

Risk for trauma


related to loss of
large muscle
coordination.

INFERENCE

PLANNING

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.

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.

Discuss seizure
warning signs and
usual seizure
pattern.

Enables the
patient to protect
self from injury.

Keep padded side


rails up with bed in
the lowest position.

Minimizes injury
should seizure
occur while patient
is in bed.

Evaluate need for


protective head
gear.

Use of helmet may


provide added
protection for
individuals during
aura or seizure
activity.

Maintain strict bed


rest if prodromal
signs or aura
experienced.

Patient may feel


restless to
ambulate or even
defecate during
aural phase, that
inadvertently
removing self from
safe environment
and easy

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.

Student Nurses Community


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

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.

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

Reorient patient
following seizure
activity.

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.

Collaborative:
Administer
medications as
indicated.