Ledesma, Annika Ysabelle S.

BSN III-M
09/16/22
Nursing Care Plan:

ASSESSME NURSING GOALS AND NURSING IMPLEMENTATIONS EVALUATION

NT DIAGNOSIS EXPECTED INTERVENTIONS
OUTCOMES

Risk for At the end of the 8 1.Monitor respiratory rate, - The vital signs of the
Subjective: Ineffective hours duty: rhythm, depth, and effort of patient is monitored every
“tumitirik ang airway respirations. four hours to get accurate
mata at clearance The patient's vital results and to be able to After 8 hours of nursing interventions the patient and her significant others
nanginginig related to signs are within determine the temperature were able to:
normal Rationale: Provides a if it is elevated or in normal
ang katawan benign febrile baseline data for evaluating baseline
nya” as convulsion as adequacy of ventilation
evidenced by The patients
verbalized by
significant others will
the upward rolling 2.Remove unnecessary 1. The patient's vital signs are within normal limits
be able to Verbalize - Removing the clothes from
Significant of the eyeball. clothing that could only 2. The patient does not have difficulty in breathing
understanding of the patient will help To
Others factors that contribute aggravate heat 3. The patient temperature are within normal limit
facilitate the effort to 4. The patients significant others verbalized the causative factors of
to the possibility of
Objective: breathe. why seizure occurs
trauma and/or Rationale:To decrease or
Vital signs: suffocation and take totally diminish pain 5. The patients significant others verbalized To know the
HR 120bmp steps to correct the medications needed when seizure occurs
RR 33 situation 3. Note the client's age, - The client is only two 6. The patients significant others verbalizedThe proper position
Temp: 37.3 years old and is with her when seizure occurs
gender, mother and significant
celsius developmental age, others. The patients
The patient's decision-making ability, level significant others are the
● muscle significant others will
contrac be able to
of cognition or competence. one making decisions as
well as with the assistance
tion demonstrate of the nurses on duty and
● shiverin behaviors and Rationale: Affects the the attending physician
g lifestyle changes to client’s ability to protect self
● Loss of reduce risk factors and others, and influences
● conscio and protect oneself
usness
the choice of interventions
from injury. and teaching.
● Febrile
● Hypert
ensive
● Genera The patients
lized significant others can 4.Place the client in a tilted - The patient is placed in a
Seizur now identify position, flat surface, tilt the side lying position when
es actions/measures to head during a seizure. seizure occurs so that the
● Weakn take when seizure patient won't have a risk
activity occurs for the occurence of
ess Rationale:Increasing flow ineffective breathing
(drainage) secret, pattern
preventing the tongue from
falling so clog the airway.
Maintain effective - The patient is
respiratory pattern
5.Administer IV fluids at administered with
with airway prescribed rate. Monitor Diazepam as needed in
regulation rate frequently. the dorsal metacarpal vein
patent/aspiration
to reduce the frequency of
prevented. seizure And
Rationale:To promote fluid
management. paracetamol to lessen
the fever
6..Monitor CBC,
electrolytes, glucose levels.
- The patients CBC was
Rationale: Identifies factors monitored
that aggravate or decrease
the seizure threshold.

7. Perform suction as - The patient will under

indicated go aspiration in order to
remove excess saliva in
Rationale: Reduce the risk the mouth in order to
of aspiration or asphyxia. avoid asphyxia

8. Prepare / aids intubation - The nurse must be

if indicated. quick and check for
the presence of
Rationale: The emergence prolonged apnea
of prolonged apnea in postictally may
postictal state, requiring require ventilatory
mechanical ventilator support.
support.
 9. Use a tympanic
thermometer when - Tympanic
necessary to take a thermometer was
temperature. used to assess if the
patient still has fever
Rationale: Reduces the since having elevated
risk of patient biting and temperature can
breaking glass indicate a sign for
thermometer or seizure
suffering injury if
sudden seizure activity
should occur

10Do not leave the patient - The patient was not

during and after seizure. left alone when
seizure occurs in
Rationale: Promotes safety
order for the nurse to
measures.
assist as well as
educate and assist
the significant others
when seizure occurs

References:

Carpenito, L. J. (2017). Nursing diagnosis: application to clinical practice. 15th edition. Philadelphia, PA, Wolters Kluwer

N/A, R. (2017, July 3). Seizure Disorder Nursing Care Plan & Management. RNpedia. Retrieved September 16, 2022, from

https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/seizure-disorder/
Doenges, M.E., Moorhouse, M.F. and Murr, A.C. (2016) Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales (Nurse’s Pocket

Guide: Diagnoses, Interventions & Rationales). 14th Edition.