Student Nurses Community

NURSING CARE PLAN ASSESSMENT SUBJECTIVE: Bigla na lang nanginig ang anak ko (Sudde
nly my
daughter started shaking uncontrollably) as
DIAGNOSIS
INFERENCE
PLANNING After 8 hours of nursing interventions, the patient will demonstrate be
haviors, lifestyle changes to reduce risk factors and protect self from injury.
INTERVENTION Independent: Explore with the patient the various stimuli that may
precipitate seizure activity.
RATIONALE Lack of sleep, flashing lights and prolonged television viewing may in
crease brain activity that may cause potential seizure activity. Enables the pat
ient to protect self from injury. Minimizes injury should seizure occur while pa
tient is in bed. Use of helmet may provide added protection for individuals duri
ng aura or seizure activity. Patient may feel restless to ambulate or even defec
ate during aural phase, that inadvertently removing self from safe environment a
nd easy observation.
EVALUATION After 8 hours of nursing interventions, the patient was able to demon
strate behaviors, lifestyle changes to reduce risk factors and protect self from
injury.
Risk for trauma related to loss of large muscle coordination.
verbalized by the mother. OBJECTIVE:

Weakness Facial grimace Irritability V/S taken as follows: T: 37.3 P: 110 R: 20
BP: 120/90
Seizures are disturbances in normal brain function resulting from abnormal elect
rical discharges in the brain, which can cause loss of consciousness, uncontroll
ed body movements, changes in behaviors and sensation, and changes in the autono
mic system. Majority of seizures happen within the first years of life.

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

Maintain strict bed rest if prodromal signs or aura experienced.

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Turn head to side or suction airway as indicated. Insert plastic bite block only
if jaw are relaxed. Help maintain airway and reduces risk of oral trauma but sh
ould not be forced or inserted when teeth are clenched because dental or softtis
sue may damage. Gentle guiding of extremities reduces risk of physical injury wh
en patient lacks voluntary muscle control. Patient may be confused, disoriented
after seizure and need help to regain control and alleviate anxiety. Specific dr
ug therapy depends on seizure type, with some patients requiring polytherapy or
frequent medications adjustment.

Cradle head, place on soft area, or assist to floor if out of bed.

Reorient patient following seizure activity.

Collaborative: Administer medications as indicated.