Student Nurses’ Community

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
SUBJECTIVE: Seizures are After 8 hours of  Explore with the  Lack of sleep, After 8 hours of
Risk for trauma disturbances in nursing patient the various flashing lights and nursing
“Bigla na lang related to loss of normal brain interventions, the stimuli that may prolonged interventions, the
nanginig ang large muscle function resulting patient will precipitate seizure television viewing patient was able to
anak ko” coordination. from abnormal demonstrate activity. may increase demonstrate
(Suddenly my electrical discharges behaviors, lifestyle brain activity that behaviors, lifestyle
daughter started in the brain, which changes to reduce may cause changes to reduce
shaking can cause loss of risk factors and risk factors and
potential seizure
uncontrollably) as consciousness, protect self from protect self from
activity.
verbalized by the uncontrolled body injury. injury.
mother. movements,  Discuss seizure  Enables the
changes in warning signs and patient to protect
OBJECTIVE: behaviors and usual seizure self from injury.
sensation, and pattern.
 Weakness changes in the
 Facial autonomic system.  Keep padded side  Minimizes injury
grimace Majority of seizures rails up with bed in should seizure
 Irritability happen within the the lowest position. occur while patient
 V/S taken as first years of life. is in bed.
follows:
 Evaluate need for  Use of helmet may
T: 37.3 protective head provide added
P: 110 gear. protection for
R: 20 individuals during
BP: 120/90 aura or seizure
activity.

 Maintain strict bed  Patient may feel

rest if prodromal restless to
signs or aura ambulate or even
experienced. defecate during
aural phase, that
inadvertently
removing self from
safe environment
and easy
Student Nurses’ Community

observation.
 Turn head to side or  Help maintain
suction airway as airway and
indicated. Insert reduces risk of
plastic bite block oral trauma but
only if jaw are should not be
relaxed. forced or inserted
when teeth are
clenched because
dental or soft-
tissue may
damage.

 Cradle head, place  Gentle guiding of

on soft area, or extremities
assist to floor if out reduces risk of
of bed. physical injury
when patient lacks
voluntary muscle
control.

 Reorient patient  Patient may be

following seizure confused,
activity. disoriented after
seizure and need
help to regain
control and
alleviate anxiety.
Collaborative:
 Administer  Specific drug
medications as therapy depends
indicated. on seizure type,
with some patients
requiring
polytherapy or
frequent
medications
adjustment.