West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Name: K.L.C. Attending Physician: Dr. G________
Age: 13_y.o____ Ward/ Bed Number: PSW B Impression/Diagnosis: Status Epilepticus____

CLUSTERED CUES RATIONALE OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE EVALUATION

NURSING
DIAGNOSIS

8/28/08 @ Self-care The deficit may 1. The patient will be 1. Do sponge bath Soap helps 8/28/08 @ 1030AM
830AM deficit: be the result of able to elicit as necessary or if remove dirt on 1. Goal met: The
bathing/hygiene transient decreased patient is sedated (as skin. Promotes patient was
/dressing/groom limitations, involuntary indicated). Use soap tissue integrity by sedated but awake
S – “ Halin sang ing/feeding/ patient’s with movements as suds with dampen providing after
pag-admit sa iya toileting r/t physical evidenced by towels. Apply lotion adequate moisture administering of
wala gid siya agi neuromuscular limitations sedation or of by after sponge bath on skin. medication.
paliguan, mu na impairment (mental REM (sleeping) and after adequate
eh sibin sibin secondary to disorders) or provided by rinsing of skin.
lang.”as status lack of efficacy of drug
verbalized by the epilepticus available administration 2. Implement a. After the
mother materials to after 2 hours meticulous mouth feeding via NGT,
perform (1030AM) on care regimen after the patient will
“Kabudlay man optimum care 8/28/08. every NGT feeding have decrease
daan siya di for oneself. to have a systematic saliva production
paliguan, te asta 2. The patient will be and grouped which could be 8/28/08 @ 1130AM
sibin lang e Status able to show signs procedures to be prone to 2. Goal partially
anay.” epilepticus of comfort done without over- infection. met: The patient
patient have passively after 3 stimulating the comfort level
O – Not well alterations in hours (1130AM) patient. b. Decreased could not be
groomed behavior such on 8/28/08. stimulation of justified however
as sensory- patient patient was calm
Disheveled hallucinatory experiencing after sponge bath.
appearance phenomena, tonic-clonic
motor effects seizure therefore
Restless (eye prevent further 8/28/08 @ 1130AM
movements, 3. The patient will be eliciting of 3. Goal partially met:
Body odor noted muscular able to show exaggerated The patient comfort
contractions) decreased signs of involuntary level could not be
restlessness due to movements that justified however
Untrimmed Source: perceived could further put patient was calm
fingernails Maternal and discomfort after 3 the patient at risk after sponge bath;
Child Health hours (1130AM) for trauma reduced level of
Dry buccal Nursing, pp. on 8/28/08. especially to the restlessness, as sign
mucosa 1102; Nurse’s oral mucosa. of efficacy of
Pocket Guide sedative.

3. Changing of bed Reduce friction.

linens as necessary Provide a
and changing of comfortable
clothes accordingly environment as to
every after sponge wearing of clean
bath. clothes.

4. Grooming Promote scalp

(combing) after integrity and
performing bed promote healthy
shampoo (as hair.
indicated). Prevention of
Application of baby offensive body
oil on scalp and hair. odor related to
oily scalp
secretion.

Sedate and put

5. Administer patient to sleep
antiepileptic drug and will
and sedatives temporarily
(Phenobarbital) as prevent any
prescribed. You can involuntary
movements that
could lead to
further damage of
tissues.

Cleansing the
5. Rinse the mouth mouth with water
with water as to prevent dryness
necessary with of the buccal
aspiration precaution. mucosa and of the
While doing so lips. Aspiration
position client to side- precaution is
lying position (if considered.
tolerated or sedated).