NURSING DIAGNOSIS

Risk for injury related to seizure activity

ANALYSIS
Risk for injury as a result of environmental conditions interacting with individuals adaptive and defensive. Fundamentals of nursing page 414

GOAL AND OBJECTIVES

Goal After an hour of nursing intervention clients vital sign will regain normal and will promote clients safety Objectives After 15 mins of rendering nursing care client will be free from injury

INTERVENTION

RATIONALE

EVALUATION
Met Partially met Unmet After nursing intervention client was free from injury, vital sign did not regain normal and client was admitted.

I tumitirik ang mata at nanginginig ang katawan nya as verbalized by the Significant Others O muscle contraction shivering Loss of consciousness Febrile Hypertensive Generalized seizures

>provided privacy >loosen constrictive clothing >raised side rails >placed in side lying position >suctioned saliva or drainage >kept patient on one side

>patients right >for patient comfort >for client safety >for draining secretions >to clear airway >for patient airway it allows tongue to fall forward and prevent aspiration >to give sufficient O2 >to prevent further injury in the

M BP-160/110 mmHg Temp.-37.9 P-120 pbm R-33 cpm

>oxygen given at 2-4 Lpm via nasal cannula >provided mouth gag

After 30 mins of providing care and administering medication clients vital sign will regain normal.

>iced rubbing done

>prevented adverse effect of magnesium sulfate

>administered prescribed medications as ordered by physician Hydralazine Phenytoin Furosemide Ceftriaxone Diazepam Magnesium sulfate

>lowers BP >treatment for seizures >diuretics >kills bacteria >tranquilizer, hypnotic >to prevent seizures activities