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Nursing Diagnosis and Interventions Risk for Injury - Seizures

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Risk for Injury - Seizures

Nursing Care Plan for Epilepsy

Nursing Diagnosis : Risk for Injury

Risk for Injury related to uncontrolled seizure activity (balance disorder).

Goal:
  • Clients can identify the precipitation of an attack and to minimize / avoid it, creating a state that is safe for the client, avoid any physical injury, avoid falling.

Expected outcomes:
  • no physical injury to the client, 
  • client is in a safe condition, 
  • no bruises, 
  • no fall.

Nursing Diagnosis and Interventions Risk for Injury - Seizures

Observation:

1. Identification of environmental factors that allow the risk of injury.
Rational:
The stuff around the patient may be harmful during the seizure.

2. Monitor neurological status every 8 hours
Rational:
Identify deviations of development or expected results

Independent :

3. Keep objects that could cause injury to the patient during a seizure.
Rational:
Reduce the occurrence of injury as a result of uncontrolled seizure activity.

4. Install the barrier the patient's bed.
Rational:
Safeguards for security, to prevent injury or fall

5. Place the patient in a low and flat.
Rational:
Areas of low and flat to prevent injury to the patient.

6. Together with the patient in some time after the seizure.
Rational:
Providing safeguards for patient safety for the possibility of back spasms.

7. Prepare a soft cloth to prevent biting the tongue occurs during seizures.
Rational:
Potentially bitten tongue during seizures because of sticking out.

8. Ask the patient if there are unusual feelings experienced just before a seizure.
Rational:
To identify early manifestation before the occurrence of seizures in patients.

Collaboration:

9. Provide anti-convulsive fit your doctor's advice.
Rational:
Reduce prolonged seizure activity, which could reduce the supply of oxygen to the brain

Education:

10. Instruct patient to tell if there is something that does not feel comfortable, or experience something unusual for a start having seizures.
Rational:
For information on the nurses to take immediate action before the seizures continued.

11. Provide information to the family about what to do during the patient's seizures.
Rational:
Involving families to reduce the risk of injury.

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