West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Name: K.L.C. Attending Physician: Dr. G________
Age: 13 y.o____ Ward/ Bed Number: PSW B Impression/Diagnosis: Status Epilepticus____

CLUSTERED CUES RATIONALE OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE EVALUATION

NURSING
DIAGNOSIS

8/28/08 @ 10AM Impaired Alteration in 1. The patient will be 1. Stress out to folks Reduce risk of 8/28/08 @ 2PM
physical mobility may able to perform about security of the falls and further 1. Goal partially met:
mobility r/t be temporary activities that patient; raise side alimentation of The patient was
S – “ Gawaras na neuromuscular or more could promote rails (as possible) or current state. able to transfer to
siya bilog nga impairment permanent tissue integrity as give fitting restraints different sides
adlaw. Wala secondary to problem. to positioning to as prescribed. however this was
pahuway. Kaluoy status Most disease different sides as done involuntarily
man gani sa iya.”, epilepticus and evidenced by 2. Assess for proper Prevent bed and unconsciously.
as verbalized by rehabilitative recurrent positioning; assist in sores. Immobility
the mother states involve movement to sides repositioning or by promotes clot
some degree of infrequent use giving pillow formation
“Mas maayo of immobility. after 4 hours support to elevate thrombophlebitis.
nalang nga na (2PM) on 8/28/08. head for assumed
higot siya subong, Status semi-Fowler’s
kay daan mahulog epilepticus 2. The patient will be position. 8/28/08 @ 1030AM
gid na siya sa iya patient have able to elicit 2. Goal partially
nga katre.” alterations in decreased 3. Encourage folks a. Promote tissue met: The patient
behavior such involuntary to do ROM if integrity and was sedated but
“Hindi sya as sensory- movements as sedation signs are provide a awake after
makabati, ukon hallucinatory evidenced by elicited; perform baseline administering of
makahambal. phenomena, sedation or of by ROM exercises measurement for medication.
Maski ano mo pa motor effects REM (sleeping) accordingly without future evaluation
na siya kaulo-ulo.” (eye provided by over-stimulating the guide.
movements, efficacy of drug patient.
O – perceived muscular administration b. Decreased
discomfort due to contractions) after 2 hours stimulation of
restraints (1030AM) on patient
Source: 8/28/08. experiencing
Inability to Maternal and tonic-clonic
perform purposeful Child Health seizure therefore
gross/ fine motor Nursing, pp. prevent further
movements 1102; Nursing 3. The patient will be eliciting of 8/28/08 @ 11AM
Care Plans by able to passively exaggerated 3. Goal partially
Generalized tense Gulanick demonstrate involuntary met: The patient
movements correct posture as movements that was sedated but
to lying on bed could further put awake after
Inability to elicit a with support of the patient at risk administering of
stance, absence of restraints and for mechanical medication
gait appropriate sized trauma. however patient is
pillows after 1 mobile on bed
Cannot follow- hour (11AM) 4. Administer Sedate and put with restraints
through with during resting antiepileptic drugs patient to sleep making support
instructions periods or after and sedatives and will pillows to
regarding proper signs of sedation (Phenobarbital) as temporarily displace.
positioning appears to promote prescribed. prevent any
REM (sleep) on involuntary
8/28/08. movements that
could lead to
4. The patient will further damage 8/28/08 @ 11AM
be able to of tissues. 4. Goal unmet:
reactively The patient cannot
participate on 5. Monitor input Possible further follow
ROM exercises and output record hypocalcemia through with
as evidenced by and nutritional and negative designated ROM
decrease pattern. Assess nitrogen balance exercises, and
unconscious nutritional needs as that could duration of
guarding they relate to promote pressure effective ROM
behavior to self continued bed rest sore exercise cannot
after 2 hour or being flat on bed. development. justify the
(12PM) on baseline data for
8/28/08. Prevent tissue future evaluation.
6. Use pressure- breakdown. Patient is virtually
relieving devices uncooperative
(cotton bed linens). throughout the
Prevent attempt for ROM.
7. Maintain limb in contractures or
functional excessive
alignment (as tightness of
possible) by extremities.
changing location
of restraints or by
temporarily untying
restraints with
precautions to avoid
unconscious pulling
out of any
therapeutic
contraptions
attached.