Student Nurses Community

NURSING CARE PLAN ASSESSMENT SUBJECTIVE: Bigla na lang nanginig ang anak ko (Suddenly my
daughter started shaking uncontrollably) as

DIAGNOSIS

INFERENCE

PLANNING 6'ter 7 ho1rs o' n1rsing interventions2 the 5atient (ill de onstrate behaviors2 li'estyle %hanges to red1%e risk 'a%tors and 5rote%t sel' 'ro in41ry!

INTERVENTION Inde5endent: E85lore (ith the 5atient the vario1s sti 1li that ay 5re%i5itate seiz1re a%tivity!

RATIONALE ;a%k o' slee52 'lashing lights and 5rolonged television vie(ing ay in%rease brain a%tivity that ay %a1se 5otential seiz1re a%tivity! Enables the 5atient to 5rote%t sel' 'ro in41ry! 3ini izes in41ry sho1ld seiz1re o%%1r (hile 5atient is in bed! Use o' hel et ay 5rovide added 5rote%tion 'or individ1als d1ring a1ra or seiz1re a%tivity! +atient ay 'eel restless to a b1late or even de'e%ate d1ring a1ral 5hase2 that inadvertently re oving sel' 'ro sa'e environ ent and easy observation!

EVALUATION 6'ter 7 ho1rs o' n1rsing interventions2 the 5atient (as able to de onstrate behaviors2 li'estyle %hanges to red1%e risk 'a%tors and 5rote%t sel' 'ro in41ry!

.isk 'or tra1 a related to loss o' large 1s%le %oordination!

verbalized by the other! "BJECTIVE:

#eakness $a%ial gri a%e Irritability V&S taken as 'ollo(s: T: )*!) +: ,,.: /B+: ,/-&0-

Seiz1res are dist1rban%es in nor al brain '1n%tion res1lting 'ro abnor al ele%tri%al dis%harges in the brain2 (hi%h %an %a1se loss o' %ons%io1sness2 1n%ontrolled body ove ents2 %hanges in behaviors and sensation2 and %hanges in the a1tono i% syste ! 3a4ority o' seiz1res ha55en (ithin the 'irst years o' li'e!

9is%1ss seiz1re (arning signs and 1s1al seiz1re 5attern! :ee5 5added side rails 15 (ith bed in the lo(est 5osition! Eval1ate need 'or 5rote%tive head gear!

3aintain stri%t bed rest i' 5rodro al signs or a1ra e85erien%ed!

Student Nurses Community

T1rn head to side or s1%tion air(ay as indi%ated! Insert 5lasti% bite blo%k only i' 4a( are rela8ed! <el5 aintain air(ay and red1%es risk o' oral tra1 a b1t sho1ld not be 'or%ed or inserted (hen teeth are %len%hed be%a1se dental or so't= tiss1e ay da age! >entle g1iding o' e8tre ities red1%es risk o' 5hysi%al in41ry (hen 5atient la%ks vol1ntary 1s%le %ontrol! +atient ay be %on'1sed2 disoriented a'ter seiz1re and need hel5 to regain %ontrol and alleviate an8iety! S5e%i'i% dr1g thera5y de5ends on seiz1re ty5e2 (ith so e 5atients re?1iring 5olythera5y or 're?1ent edi%ations ad41st ent!

Cradle head2 5la%e on so't area2 or assist to 'loor i' o1t o' bed!

.eorient 5atient 'ollo(ing seiz1re a%tivity!

Collaborative: 6d inister edi%ations as indi%ated!