Assessment Subjective data: Report of seizure.

. Objective data: Altered level of consciousness (+) Seizure activity (+) Right sided weakness GCS 11

Risk for self-directed injury related to seizures secondary to brain injury. . Diagnosis Planning Nursing Interventions Rationale Risk for falls related to impaired physical mobility secondary to altered level of consciousness. Short term goal: After 30 minutes of effective nursing intervention, the client and watcher will develop and follow risk control strategies as manifested by verbalization of understanding. Long term goal: After 8 hours of effective nursing intervention, the client will have no incidence of injury-causing events such as falls. Independent: 1. Observed individuals general health status, noticing factors that might affect safety such as chronic or debilitating conditions. 2. Assessed muscle strength, gross and fine motor coordination. 3. Reviewed history of prior falls associated with immobility, weakness, or prolonged bed rest. 4. Recognized clients cognitive status including extent of brain injury and neurological disorders. 5. Considered environmental hazards in the care setting.

Evaluation Short term: Goal met.

To evaluate source or degree of risk.

To evaluate the degree of risk. To predict current risk for falls. Long term: Goal met.

To evaluate the clients ability to perceive own limitations or recognize danger. To provide opportunities for intervention and instruction.

6. Maintained side rails raised.

To protect the patient from rolling and falling out of bed. To ensure the clients safety.

7. Advised the clients relative to maintain a safe environment.

8. Advised the clients relative to never leave the client unattended. Dependent: 9. Administered medications as ordered. Collaborative: 12. Assisted in treatments and provided information regarding clients conditions that may result in increased risk of falls. 13. Referred to rehabilitation team, physical or occupational therapist as appropriate.

To ensure clients safety. To treat the underlying condition. To assist caregiver to reduce or correct individual risk factors. To improve clients balance, strength, or mobility and to improve or relearn ambulation.