RISK FOR TRAUMA

A Nursing Care Plan presented to

The Faculty of the Nursing Department

In Partial Fulfillment of
The Requirements in NCM 209-RLE

DELIVERY ROOM ROTATION

Submitted to:

Mrs. Ariane Mae Soriano, RN

Clinical Instructor

Submitted by:

Joven Keith A. Suelto

BSN 2E-GROUP 3

April 25, 2020

 Name of Patient: S. M. L.________________________________________________ Age/Sex: 4 years old/Female_ Rm & Bed No.:_403-1___
Chief Complaint: _Seizure and loss of consciousness_____________________________________________ Physician: Dr. Madayag_______
Diagnosis (if discharged):______________________________________________________________________________________________

Date & Nursing

Time Cues Need Nursing Diagnosis Goal of Care Nursing Interventions Impleme Evaluations
ntation
A Subjective: H Risk for trauma related After 7 hours of  Determine risk factors and 1 April 25, 2020 @
P E
to weakness nursing care, the the extent of the risk. 3:00 pm
R “kalit lang ug kirig A
I kirig akong anak L parents of the patient ® Influences the scope and “Goal was met”
L ug nag lisod ug T
® Seizures are changes will be able to: intensity of interventions to a. demonstrated
breath” as H
verbalized by the in the brains activity. a. demonstrate manage the threat to safety lifestyle changes
2 P
mother
5 These changes can behaviors,  Note client’s age, gender, 2 such as putting
E
, R cause dramatic, lifestyle developmental age, carpet on the floor
2 C
noticeable symptoms, changes to decision-making ability, and putting baby
0 E
2 P or in other cases no reduce risk level of cognition or mats on edges in
0 T
symptoms at all. factors and competence. order to protect self
I
@ O Seizures can only lead protect self from ® Affects the client’s ability to from injury
Objective: N
to injury, such as falls injury protect self and others, and b. maintained treatment
-
8
 Facial M or trauma to the body. b. maintain influences the choice of through medication
A A
grimace Reference: treatment interventions and teaching. and therapy to
M N
 Weakness
 Loss of A Nall, R. (2016, May 3). What regimen to  Review diagnostic studies 3 eliminate seizure
awareness G You Should Know
control or or laboratory tests for activity
E About Seizures.
 Stiffening
M Retrieved April 23, eliminate impairments and c. modified environment
and
E 2020, from
shaking of seizure activity imbalances. such as putting baby
N healthline.com:
 muscles T https://www.healthl c. modify ® Such may result in or mats, carpet floors,
 Irritability ine.com/health/seiz
environment as exacerbate conditions, such and ventilated rooms
 V/S taken; P ures
 T= 37.1°C A indicated to as confusion, tetany, in order to enhance
 P=110 T
enhance safety pathologic fractures, etc. good environment
 R=11 T
BP= 120/80 E  Explore and expound
R
seizure warning signs and 6
N
seizure patterns. Teach
patient’s parents to
determine and familiarize
warning signs and how to
care for the patient during
and after seizure attack.
® Enables patient to protect
self from injury and recognize
changes that require
notification of physician and
further intervention. Knowing
what to do when a seizure
occurs can prevent injury or
complications and decreases
the clients feeling of
helplessness.
 Side rails up or place bed
 against the wall and pad
floor if rails are not 9
available or appropriate
® prevents or minimize injury
when seizures occur while the
patient is in bed.
 Do not leave the patient
during and after a seizure
® promotes safety measure 8
 Carry out medication as
indicated
® specific drug therapy 4
depends on seizure type, with
some patients requiring
polytherapy or frequent
medication adjustment
 Monitor CBC, electrolytes,
glucose level
® Identifies factors that 5
aggravate or decrease the
seizure threshold.
 Investigate reports of pain
® May be a result of repetitive
 muscle contraction or
symptoms of injury incurred,
requiring further evaluation. 7
 Support head, place on
soft area or assist to the
floor if out of bed. Do not
attempt to restrain
® Supporting the extremities 10
lessens the risk of physical
injury when the patient lacks
voluntary muscle control.

Bibliography
Herdman, T. &. (2017). NANDA International Nursing Diagnosis: Definition and Classification, 2015-2017. Oxford: Wiley Backwell.

MayoClinicStaff. (2019, August 10). Epilepsy. Retrieved from mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/epilepsy/symptoms-causes/syc-20350093

Nall, R. (2016, May 3). What You Should Know About Seizures. Retrieved April 23, 2020, from healthline.com: https://www.healthline.com/health/seizures

Vera, M. (2020, January 2). 5 Seizure Disorder Nursing Care Plans. Retrieved April 23, 2020, from nurseslabs.com: https://nurseslabs.com/4-seizure-disorder-nursing-care-plans/

RISK FOR INEFFECTIVE AIRWAY CLEARANCE

A Nursing Care Plan presented to

The Faculty of the Nursing Department
 In Partial Fulfillment of
The Requirements in NCM 209-RLE

DELIVERY ROOM ROTATION

Submitted to:

Mrs. Ariane Mae Soriano, RN

Clinical Instructor

Submitted by:

Joven Keith A. Suelto

BSN 2E-GROUP 3

April 25, 2020

Name of Patient: S. M. L.________________________________________________ Age/Sex: 4 years old/Female_ Rm & Bed No.:_403-1___
Chief Complaint: _Seizure and loss of consciousness_____________________________________________ Physician: Dr. Madayag_______
Diagnosis (if discharged):______________________________________________________________________________________________

Date & Cues Need Nursing Diagnosis Goal of Care Nursing Interventions Nursing Evaluations
Time Impleme
ntation
A Subjective: H Risk for ineffective After 7 hours of  Assess airway for 1 April 25, 2020 @
P E
airway clearance nursing care, the patency 3:00 pm
R “kalit lang ug kirig A
I kirig akong anak L related to cognitive parents of the patient ® Maintaining patent airway is “Goal was partially met”
L ug nag lisod ug T
impairment will be able to: always the first priority, especially a. maintained effective
hinga” as H
verbalized by the ® The autonomic a. maintain in cases like trauma, acute respiratory pattern
2 P
mother
5 nervous system effective neurological decompensation, or with the help of nasal
E
, R regulates body respiratory cardiac. cannula
2 C
functions like breathing. pattern with  Monitor respiratory 3 b. demonstrated slow
0 E
2 P Seizure can disrupt the airway patent or rate, rhythm, depth, increase in
0 T
respiratory system, aspiration and effort of respiration rate
I
@ O causing breathing to prevented respirations c. modified environment
Objective: N
temporarily stop. b. demonstrate ® Provides a baseline data for such as ventilated
-
8
 Facial M Interruptions in increased air evaluating adequacy of rooms in order to
A A
grimace breathing due to exchange ventilation. enhance good
M N
 Weakness
 Loss of A seizures can lead to c. modify  Assess decreased or 2 environment and
awareness G
abnormally low oxygen environment as absent breath sounds, calm surroundings
E
 Stiffening
M levels, and may indicated to or wheezing
and
E
shaking of contribute to sudden enhance safety ® These may indicate presence
N
muscles
T death in epilepsy. of mucous plug or other major
 Irritability
 V/S taken; Reference: obstruction.
P
 T= 37.1°C A 5
 Ensure client to empty
 P=110 T
  R=11 T the mouth of dentures
BP= 120/80 E
or foreign objects if
R
N aura occurs and to
avoid chewing gum
and sucking lozenges
if seizure occur
without warning.
® Lessens risk of aspiration of
foreign bodies sheltering in the
pharynx. 6
 Loosen clothing from
neck or chest and
abdominal areas.
® Aids in breathing or chest
expansion. 4
 Maintain in lying
position, flat surface;
turn head to side
during seizure activity.
® Helps in drainage of
secretions; prevents the tongue
from obstructing the airway. 8
 Provide and insert
 plastic airway or soft
roll as indicated and
only if the jaw is
relaxed.
® If inserted before the jaw is
tightened, these devices may
prevent biting of the tongue and
facilitate suctioning or respiratory
support if needed. Airway adjunct
may be indicated after cessation
of seizure activity if the patient is
unconscious and unable to
maintain a safe position of the
tongue. 9
 Suction as needed.
® Reduce risk of aspiration or
asphyxiation 7
 Supervise
supplemental oxygen
or bag ventilation as
needed postictal.
® May lessen cerebral hypoxia
resulting from decreased
 circulation or oxygenation
secondary to vascular spasm
during a seizure. 10
 Ready for assist in
intubation if needed.
® Presence of prolonged apnea
postictally may need ventilator
support.

Bibliography
Herdman, T. a. (2018). NANDA International, Inc. Nursing Diagnosis Definition and Classification 2018-2020 Eleventh Edition. New York: Thieme.

Vera, M. (2020, January 2). 5 Seizure Disorder Nursing Care Plans. Retrieved April 23, 2020, from nurseslabs.com: https://nurseslabs.com/4-seizure-disorder-nursing-care-plans/2/

Watson, S. (2017, August 15). The Effects of Epilepsy on the Body. Retrieved April 23, 2020, from healthline.com: https://www.healthline.com/health/epilepsy/effects-on-body#1