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NURSING CARE PLAN assessment SUBJECTIVE: (Suddenly my daughter started shaking uncontrollably) asverbalized by the mother.

OBJECTIVE: Weakness Facial grimace Irritability V/S taken as follows: T: 100.8 F P: 110 R: 20 BP: 120/90 diagnosis Risk for trauma related to loss of large muscle coordination as evidenced by uncontrollable shaking goal Child will demonstrate normal behaviours and free from trauma. intervention Explore with thepatient the variousstimuli that may precipitateseizureactivity. Discussseizure warning signs andusualseizurepatternwith parents. Keep padded siderails up with bed in the lowest position. Evaluate need forprotective headgear. Maintain strict bedrest if prodromal signs or aura experienced. -Administer medications as indicated rationale Lack of sleep, flashing lights and prolonged television viewing may increase brain activity that may cause potential seizure activity. -Enables the patient to protect self from injury. Minimizes injury should seizure occur while patientis in bed. -Patient may feel implimentation Explored the patient with various stimuli Discussed the warning signs and usual pattern with parents Kept padded side rails Evaluation After nursing interventions, the patient was able to demonstrate behaviors, lifestyle changes to reduce risk factors of injury.

Maintained strict bed rest

Administered medications as per doctors order.

Assess the condition of the child Instruct the mother to ,in the event of seizure place child in side liying position in flat surface. 2)subjective data:decrased respiratory rate as verbalizesd by mother Objective data:R-20/mt Ineffective breathing pattern related to neuromuscular impairment as evidenced by decreased respiration Remain with the child Child will maintain normal breathing pattern as evidenced by normal respiratory pattern. Remove food,secretions and liquids from the mouth. Administer oxygen if needed Administer medications as per doctors order

restless to ambulate or even defecate during aural phase, that inadvertently removing self fromsafe environment and easy observation . Specific drug therapy depends on seizure type,

Assessed the condition of tehchild. Instructed the mother to place the child in side slying position in a flat surface Instructed the mother to stay with the child. Removed secreations from mouth The child maintained normal breathing pattern ad evidenced by normal respiratory pattern.

Assess the anxiety level of the parents Allow the parents to remain with the child during seizure activity.

assessment will help to proper planning

Provide information

to prevent aspiration and protect air way

Administered medications as per

regarding the condition of the child Encourage the family involment in daily care of child with goal of normalization and promotion of optimal growth and development of child Parent will cope up with the child condition and receive adequate support.

doctors order

To detemune the need of emergency. To prevent chocking and aspiration To prevent hypoxia

3)subjective data; asking so many questions related to child condition Objective data; mother looks worry and her facial expression shows she was anxious

Anxiety /fear (parent) related to child having life threatening and in capacitating seizure activity.

Assessed the anxiety level of the child Instructed the parents to stay with the child while seizure activity

Parent coping up with the child condition.

Assess the nutritional intake of the child

Instruct the parents regarding the proper intake of diet. Instruct to give small and frequent diet.

To prevent Provided continued information seizure activity regarding the condition of the child To plan the care based on the assessment To decrease the fear of unknown and allow parents Encouraged family involment.

Assess the weight daily

Assess the knowledge level of the parent Imbalanced nutrition less than body requirement realed to less intake of food as evidenced by weight loss. Instruct the parents about the disease condition Provide written instructions, and shedules for activity ,medication and treatmen

to see measures to taken to protect the child To promote the knowledge of condition.

Assessed the nutritional intake of the child Instructed the parents regarding proper intake of diet

4)subjective data: mother verbalises as child not taking proper diet Objective data:wt loss

Child will maintain normal nutritional status as evidenced by weigt gain

To provide hope and promote family coping and functioning

Instructed to give small and frequent diet

The child maintains normal nutritional status asevidenced by increase in weight.

Educate the parents regarding in the events of seizure palce the child in aside lying position. Remove secretions foods and liquid from mouth when seizure subside If the child is vomiting place in one side.ifte child is in

Assesd the weight daily

5)Subjective

Parental knowledge deficit regarding disease condition,prognosis

Small and frequent diet increase the

Assessed the knowledge level of the parents

data:mother asking somany doubts Objective data:mother is anxious

As evidencd by asking so many doubts and frequent quiestioning

post ictal state administer oxygen. administer medication intended to stop seizure

intake of food To check the nutritional status

Instructed the parents regarding the child condition

Parents verbalizes understanding of condition and its treatment

Provided written instruction This will help proper planning of the care Protect the child during seizure. Remove hazards in immediate environment. Talk in a calm voice and reassuring manner. Proper diet is necessary for goorwth and development

Parents parcticipate in child care

Educated the parents regarding in the events of seizure palce the child in aside lying position. Removedsecretions foods and liquid from mouth when seizure subside If the child is vomiting place in one side.ifte child

Risk for aspiration related


Objective data During seizure activity child is losing his consciousness. to impaired motor activity as evidenced by apnea

Instruct the parents to protect the child after seizure.

Assessment will help proper planning of care.

Child have effective ventilation.

To improve the parents

knowledge.
Child will have effective ventilation

is in post ictal state administer oxygen. administer medication intended to stop seizure.

Protected the child during seizure. To prevent asp Irationand Removed hazards protect in immediate airway. environment. Talk in a calm voice and reassuring manner. To prevent choking and aspiration.
child will not experience any physical injury and will remain calm.

Objective data: During convulsion child losses consciousness.

Risk for injury related to impaired consciousness and automatism as evidenced by loss of consciousness during convulsion

Instructed the parents to protect the child after seizure.

Child is free from injury.

To prevent chocking and

aspiration

to prevent seizure activity

To prevent injury to the child or self To prevent injury

To prevent further agitation

To provide

support ,because child may be confused and agitated.

NURSING DIAGNOSIS ACTUAL NURSING DIAGNOSIS y y y y y Ineffective breathing pattern related to neuromuscular impairment as evidenced by decreased respiration Anxiety /fear (parent) related to child having life threatening and in capacitating seizure activity. Imbalanced nutrition less than body requirement realed to less intake of food as evidenced by weight loss. Parental knowledge deficit regarding disease condition,prognosisAs evidencd by asking so many dou bts and frequent questioning self-esteem related to stigma associated with condition

POTENTIAL NURSING DIAGNOSIS y y y y

Risk for aspiration related to impaired motor activity as evidenced by apnea


Risk for injury related to impaired consciousness and automatism a s evidenced by loss of consciousness during convulsion Risk for trauma related to loss of large muscle coordination as evidenced by uncontrollable shaking Risk for ineffective airway clearence/breathing pattern related to neuromuscular impairment.