Mio Franco S.

Quilit

ETD:

Nursing Care Plan No. 1

Patients initial:

Pavilion:

ASSESSMENT
SUBJECTIVE DATA

PLAN
SHORT TERM GOAL

INTERVENTIONS

Bigla na lang
nanginig ang anak
ko (Suddenly my
daughter started
shaking
uncontrollably) as
verbalized by the
mother.

After 8 hours of
nursing
interventions, the
patient will
demonstrate
behaviors, lifestyle
changes to reduce
risk factors and
protect self from
injury.

Independent:
Explore with the
patient the
various stimuli
that may
precipitate
seizure activity.

Discuss seizure
warning signs
and usual
seizure pattern.
Keep padded
side rails up
with bed in the
lowest position.
Evaluate need

RATIONALE

Lack of sleep,
flashing lights
and prolonged
television
viewing may
increase brain
activity that
may cause
potential seizure
activity.

Enables the
patient to
protect self from
injury.

Minimizes injury
should seizure
occur while

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.

for protective
head gear.

patient is in
bed.

Use of helmet
may provide
added
protection for
individuals
during aura or
seizure activity.

Patient may feel

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

Help maintain
airway and
reduces risk of
oral trauma but

Maintain strict
bed rest if
prodromal signs
or aura
experienced.

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.

should not be
forced or
inserted when
teeth are
clenched
because dental
or soft-tissue
may damage.

Reorient patient
following
seizure activity.

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

Patient may be
confused,
disoriented after
seizure and
need help to
regain control
and alleviate
anxiety.

Collaborative:
Administer
medications as
indicated.

Specific drug
therapy depends
on seizure type,
with some patients

requiring
polytherapy or
frequent
medications
adjustment.
LONG TERM GOAL
OBJECTIVE DATA

NURSING
DIAGNOSIS

Risk for trauma

related to loss of
large muscle
coordination.

Weakness
Facial grimace
Irritability
V/S taken as
follows:

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