NURSING CARE PLAN

Name:________________________ Diagnosis:________________
Age: _________ Attending Physician:______________
NURSING PLANNING/NURSING NURSING EXPECTED
CUES RATIONALE RATIONALE
DIAGNOSIS OBJECTIVES INTERVENTION OUTCOME

S -“mg Risk for trauma r/t to Seizures are disturbances After 8 hrs of nursing Independent: Goals Met:
seseizure and loss of large muscle in normal brain function intervention the patient  Discuss seizure  Enables the patient  The patient is
aki koh coordination resulting from abnormal will: warning signs to protect self form able to
aroaldaw electrical discharges in the o Demonstrate and usual seizure injury. demonstrate
nalng” as
brain, which can cause loss behavior and pattern. behaviors,
verbalized by
of consciousness, lifestyle changes to  Keep siderails in  Minimizes injury lifestyle changes
uncontrolled body reduce risk factors place. should seizure to reduce risk
the mother. movements, changes in and protect self from occur while patient factor and
O - weak and behavior and sensation and injury. protect self form
is in bed.
pale in changes in the autonomic o Be free from seizure injury.
 Evaluate need  Use of helmets
appearance system. activity. may provide added  The patient is
for protective
-restlessness headgear. protection for calm and no
and rolling of individuals during signs of seizure
eyeballs aura or seizure activity.
noted activity.
-muslce  Maintain strict  Patient may feel
contractions bed rest when restless to
on both side prodromal signs ambulate or even
of extremities or aura defecate during
noted experienced. aural phase that
-irritability inadvertently
noted removing self
-V/S fromsafe
BP- 100/80 environment and
mmHg easy observation.
T- 36.40C  Keep the airway  To prevent the
P- 90 bpm patent. patient from
R- 26 cpm suffocation.
Name:________________________ Diagnosis:________________
Age: _________ Attending Physician:______________
 Do not put  To prevent oral
anything by soft tissue injury.
mouth.
 Cradle head or  Gentle guiding of
put on soft area, extremities reduces
or assist to floor risk of physical
if out of bed. injury when patient
lacks voluntary
muscle control.
 Reorient patient  Patient may be
following confused,
seizure activity. disoriented after
seizure and need
help to regain
control and
alleviate anxiety.
Collaborative:  To provide
 Administer therapeutic
medication as regimen
indicated. management.