Adrian Enrico B.

Mansalay July 27, 2010

4D3a Nursing Care Plan
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for injury for After 8 hours of nursing Independent: After 8 hours of nursing
interventions, the  Pad side rails, placed in  Precautions taken to interventions, the
injury related to
raised position, tape prevent injury during
Objective: internal chemical patient will have patient had an absence
padded tongue blade or seizure.
 Patient is hooked regulatory function absence of injury during away to bed, remove of injury after the
to a mechanical the seizure evidenced by harmful objects from seizure evidenced by
caused by seizure
ventilator inspection revealing no immediate inspection revealing no
activity (uncontrolled
damage to mouth or environment, O2 and damage to mouth or
 Arm twitching movements) resulting tongue, bone or soft suction available. tongue, bone or soft
in musculoskeletal, tissue breaks or tissue breaks or
oral tissue trauma.  Stay until seizure is  Provides support and
bruising; control of over, speak calmly
bruising; control of
prevents injury.
 Weakness seizures. without restraining seizures.
unless may be injured.
 Facial grimace
 Avoid restraining,  Prevents possible injury
forcing object between damage to mouth and
 Irritability teeth if clenched; insert teeth.
padded blade if safe to
 V/S taken as do so.
follows:

T: 37.3  Loosen tight clothing,  Prevents aspiration.

P: 105 roll to side to drain
R: 20 secretions from mouth
BP: 120/80 during relaxation, or
suction secretions if
needed.

 Reorient to events,  Promotes comfort and

provide rest and relaxation following
reassurance, cleanse seizures.
oral cavity.

Collaborative:
Administer medications as
indicated.