Problem Identified: Risk for Trauma

Nursing Diagnosis: Risk for Trauma r/t weakness

ASSESSMENT

PLANNING
STO: After 30 minutes of
nursing intervention the
patient will be able to:
Verbalize understanding
of factors that contribute
to possibility of trauma
and or suffocation and
take steps to correct
situation.
LTO: After 8hrs of nursing
intervention the patient
and the family will be
able to:
Modify environment as
indicated to enhance
safety.
Maintain treatment
regimen to control or
eliminate seizure activity.
Recognize need for
assistance to prevent
accidents or injuries.

INTERVENTIONS

1.) Ascertain knowledge

of various stimuli that may
precipitate seizure activity.
2.)Review diagnostic studies
or laboratory tests for
impairments and imbalances.
3.) Explore and expound
seizure warning signs (if
appropriate) and usual seizure
pattern. Teach SO to
determine and
familiarize warning signs and
how to care for patient during
and after seizure attack.
4.) Use and pad side rails with
bed in lowest position, or
place bed up against wall and
pad floor if rails not available
or appropriate.
5.) Evaluate need for or
provide protective headgear

RATIONALE

1.) Alcohol, various drugs,

and other stimuli (loss of
sleep, flashing lights,
prolonged television
viewing) may increase brain
activity, thereby increasing
the potential for seizure
activity.
2.) Such may result in or
exacerbate conditions, such
as confusion, tetany,
pathological fractures, etc.
3.) Enables patient to
protect self from injury and
recognize changes that
require notification of
physician and further
intervention. Knowing what
to do when seizure occurs
can prevent injury or
complications and
decreases SOs feelings of
helplessness.
4.) Prevents or
minimizes injury
when seizures (frequent or
generalized) occur while
patient is in bed. Note: Most
individuals seize in place
and if in the middle of the
bed, individual is unlikely to
fall out of bed.
5.) Use of helmet may

EVALUATION

Reference: http://nurseslabs.com/4-seizure-disorder-nursing-care-plans/

Problem Identified: Risk for Ineffective Airway Clearance

Nursing Diagnosis: Risk for Ineffective Airway Clearance r/t Neuromuscular impairment
ASSESSMEN
T

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

The patient will be able to:

Maintain effective respiratory
pattern with airway patent or
aspiration prevented

1.) Ensure patient to empty

mouth of dentures or foreign
objects if aura occurs and to
avoid chewing gum and sucking
lozenges if seizures occur without
warning.
2.) Maintain in lying position, flat
surface; turn head to side during
seizure activity.
3.) Loosen clothing from neck or
chest and abdominal areas.
4.) Suction as needed.
5.) Supervise supplemental oxygen
or bag ventilation as needed
postictally.

1.) Lessens risk of aspiration or

foreign bodies lodging in
pharynx.
2.) Helps in drainage of
secretions; prevents tongue
from obstructing airway.
3.) Aids in breathing or chest
expansion
4.) Reduces risk of aspiration
or asphyxiation. Note: Risk of
aspiration is low unless
individual has eaten within the
last 40 min.
5.) May lessen cerebral
hypoxia resulting from
decreased circulation or
oxygenation secondary to
vascular spasm during seizure.
Note: Artificial ventilation
during general seizure activity
is of limited or no benefit
because it is not possible to
move air in or out of lungs
during sustained contraction of
respiratory musculature. As
seizure abates, respiratory
function will return unless a

secondary problem exists

(foreign body or aspiration).

Reference nurseslabs.com

Problem Identified: knowledge deficit

Nursing Diagnosis: knowledge deficit r/t information misinterpretation

ASSESSMEN
T

PLANNING

INTERVENTIONS

RATIONALE

1.)review pathology/prognosis of
condition and lifelongneed for
treatments as indicated. discuss
patients particular trigger
factors (e.g., flashing
lights,hyperventilation, loud
noises,video games, tv viewing).

1.) provides opportunity to

clarify/dispel misconceptions
and present condition as
something that is manageable
withina normal lifestyle

2.)discuss significance of
maintaining good general
health,e.g., adequate diet, rest,
moderate exercise, and
avoidanceof exhaustion, alcohol,
caffeine, and stimulant drugs.
3.)review importance of good
oral hygiene and regular dental
care.
4.)identify necessity/promote
acceptance of actuallimitations;
discuss safety measures
regarding driving,using
mechanical equipment, climbing
ladders,swimming, and hobbies.
5.)discuss local laws/restrictions
pertaining to persons
withepilepsy/seizure disorder.
encourage awareness but
notnecessarily acceptance of
these policies

2.) regularity and moderation

in activities may aid
inreducing/controlling
precipitating factors,
enhancingsense of general
well-being, and strengthening
copingability and self-esteem.
note:
too little sleep or too
muchalcohol can precipitate
seizure activity in some people
3.) reduces risk of oral
infections and gingival
hyperplasia.
4.) reduces risk of injury to self
or others, especially if seizures
occur without warning
5.) although legal/civil rights
of persons with epilepsy
haveimproved during the past
decade, restrictions still exist
insome states pertaining to
obtaining a drivers
license,sterilization, workers
compensation, and
requiredreportability to state
agencies.

EVALUATION

Reference: scribd.com

Problem Identified:
ASSESSMEN
T

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Nursing Diagnosis:

Problem Identified:
ASSESSMENT

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Nursing Diagnosis: