Student Nurses’ Community

NURSING CARE PLAN

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

• 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.