nursing care plan seizure

7/25/2019 Nursing Care Plan Seizure

1/8

Problem Identifed: Risk or Trauma

Nursing Diagnosis: Risk or Trauma r/t weakness


2/8

ASSESSMENT PANNIN! INTER"ENTI#NS RATI#NAE E"A$ATI#NST#: Ater %& minutes o

nursing inter'ention t(e

)atient will be able to:

"erbali*e understanding

o a+tors t(at +ontribute

to )ossibilit, o trauma

and or su-o+ation and

take ste)s to +orre+t

situation.

T#: Ater (rs o nursing

inter'ention t(e )atient

and t(e amil, will be

able to:

Modi, en'ironment as

indi+ated to en(an+e

saet,.

Maintain treatment

regimen to +ontrol oreliminate sei*ure a+ti'it,.

Re+ogni*e need or

assistan+e to )re'ent

a++idents or in0uries.

1.2 As+ertain knowledge

o 'arious stimuli t(at ma,

)re+i)itate sei*ure a+ti'it,.

3.2Re'iew diagnosti+ studies

or laborator, tests or

im)airments and imbalan+es.

%.2 E4)lore and e4)ound

sei*ure warning signs 5ia))ro)riate2 and usual sei*ure

)attern. Tea+( S# to

determine and

amiliari*e warning signs and

(ow to +are or )atient during

and ater sei*ure atta+k.

6.2 $se and )ad side rails wit(

bed in lowest )osition7 or

)la+e bed u) against wall and)ad 8oor i rails not a'ailable

or a))ro)riate.

9.2 E'aluate need or or

)ro'ide )rote+ti'e (eadgear

1.2 Al+o(ol7 'arious drugs7

and ot(er stimuli 5loss o

slee)7 8as(ing lig(ts7

)rolonged tele'ision

'iewing2 ma, in+rease brain

a+ti'it,7 t(ereb, in+reasing

t(e )otential or sei*ure

a+ti'it,.

3.2 Su+( ma, result in ore4a+erbate +onditions7 su+(

as +onusion7 tetan,7

)at(ologi+al ra+tures7 et+.

%.2 Enables )atient to

)rote+t sel rom in0ur, and

re+ogni*e +(anges t(at

reuire notif+ation o

)(,si+ian and urt(er

inter'ention. ;nowing w(atto do w(en sei*ure o++urs

+an )re'ent in0ur, or

+om)li+ations and

de+reases S#


3/8

Reeren+e: (tt)://nurseslabs.+om/6=sei*ure=disorder=nursing=+are=)lans/

Problem Identifed:Risk or Ine-e+ti'e Airwa, >learan+e

Nursing Diagnosis:Risk for Ineective Airway Clearance r/t Neuromuscular impairment

ASSESSMEN

T

PANNIN! INTER"ENTI#NS RATI#NAE E"A$ATI#N


4/8

T(e )atient will be able to:

Maintain e-e+ti'e res)irator,

)attern wit( airwa, )atent or

as)iration )re'ented

1.2 Ensure )atient to em)t,

mout( o dentures or oreign

ob0e+ts i aura o++urs and to

a'oid +(ewing gum and su+king

lo*enges i sei*ures o++ur wit(out

warning.

3.2 Maintain in l,ing )osition7 8at

sura+e? turn (ead to side during

sei*ure a+ti'it,.

%.2 Loosen clothing from neck or

chest and abdominal areas.

4.) Suction as needed.

5.)Supervise supplemental oxygen

or bag ventilation as neededpostictally.

1.2 essens risk o as)iration or

oreign bodies lodging in

)(ar,n4.

3.2 @el)s in drainage o

se+retions? )re'ents tongue

rom obstru+ting airwa,.

%.2 Aids in breat(ing or +(est

e4)ansion

6.2 Redu+es risk o as)iration

or as)(,4iation. Note: Risk o

as)iration is low unless

indi'idual (as eaten wit(in t(e

last 6& min.

9.2 Ma, lessen +erebral(,)o4ia resulting rom

de+reased +ir+ulation or

o4,genation se+ondar, to

'as+ular s)asm during sei*ure.

Note: Artif+ial 'entilation

during general sei*ure a+ti'it,

is o limited or no beneft

be+ause it is not )ossible to

mo'e air in or out o lungs

during sustained +ontra+tion o

res)irator, mus+ulature. Assei*ure abates7 res)irator,

un+tion will return unless a


5/8

se+ondar, )roblem e4ists

5oreign bod, or as)iration2.

Reeren+e nurseslabs.+om

Problem Identifed: knowledge def+it

Nursing Diagnosis: knowledge def+it r/t inormation misinter)retation


6/8

ASSESSMEN

T


1.2re'iew )at(olog,/)rognosis o

+ondition and lielongneed or

treatments as indi+ated. dis+uss

)atient


7/8

Reeren+e: s+ribd.+om

Problem Identifed:

ASSESSMEN

T



8/8

Nursing Diagnosis:

Problem Identifed:

Nursing Diagnosis:ASSESSMENT PANNIN! INTER"ENTI#NS RATI#NAE E"A$ATI#N

nursing care plan seizure

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