ASSESSMEN DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIO

T N
OBJECTIVES:
Risk for trauma Seizures are After 8 hours of INDEPENDENT: After 8 hours
• Facial related to loss of disturbances in nursing • Lack of sleep, of
grimace large muscle normal brain interventions, the • Explore with the flashing lights nursing
• irritabilit coordination. function patient will patient the various may increase interventions
resulting demonstrate stimuli that may brain activity , the
y
from abnormal behaviors, precipitate seizure that may patient was
electrical to reduce activity. cause potential able to
discharges risk factors and seizure demonstrate
in the brain, protect self from activity. behaviors,
which injury. • Discuss to mother or lifestyle
can cause loss relatives the seizure • Enables the changes to
of warning signs and significant reduce
consciousness, usual seizure pattern. others to risk factors
uncontrolled protect the and
body patient to protect self
movements, • Keep padded side protect from
changes in rails up with bed in from injury. injury.
behaviors and the lowest position.
sensation, and
• Minimizes
changes in the
injury should
autonomic • Evaluate need for seizure occur
system. protective head gear. while patient is
Majority of
in bed.
seizures
happen within
the • Use of helmet
first years of may provide
life. added
Turn head to side or protection for
suction airway as individuals
indicated. during aura or
seizure
activity.

• Help maintain
airway and
reduces risk of
oral trauma but
should not be
• Cradle head, place forced or
on soft area. inserted when
 teeth are
clenched
because dental
or soft tissue
may damage.
COLLABORATIVE: • Gentle guiding of
extremities
• Administer reduces risk of
medications as physical injury
indicated. when patient lacks
voluntary muscle
control.
.
• Specific drug
therapy
depends on
seizure type,
with some
patients
requiring
polytherapy or
frequent
medications
adjustment.