Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:
The patients
mother stated
that, I brought
my daughter in
because of a
seizure episode
and I am scare
she might get
hurt.

Objective:
Patient is
experiencing
seizure attacks
lasting 10-20
seconds.
Observation of
extension of
upper and
lower
extremities,
abduction of
arms near the
chest,
clenching of
fist, fast
blinking of eyes
during seizure
attacks.
After seizure
attacks patient
falls asleep.

Temp: 36.0
Pulse: 84
Resp: 30

Impaired tissue
perfusion related
to reduction of
oxygen as
evidenced by low
hemoglobin mass
of 115 g/L


Short term:
After 8 hours
of nursing
intervention the
client will receive
adequate perfusion
and circulation
of well-oxygenated
blood.


Long term:
After 3 days
of nursing
interventions, the
client will improve
her hemoglobin
mass.

Independent:
Assessed general health



Provided safety by raising
bed side rails.
Provided care and
comfort by maintaining a
wrinkle free bed linen.
Monitor and document
neurological status
frequently and compare
with baseline
Monitor vital signs
noting: Hypertension or
hypotension






Elevate head on board
(maintain head/neck in
midline or neutral
position)


Dependent:
Drink medications as
indicated by the doctor
Administer supplemental
oxygen, as indicated

Collaboration:
Monitor blood gas
analysis of oxygen

To provide base line
data of nursing care.
To determine severity of
data.
To prevent patient from
falling/injury.
To keep the skin
integrity of the patient.

Assesses for potential
cerebral damage


Fluctuations in pressure
may occur because of
cerebral pressure or
injury in vasomotor area
of the brain.
Hypertension or
hypotension may have
been a precipitating
factor.
To promote circulation/
venous drainage





It may help to alleviate
episodes of seizures
Reduces hypoxia



The possibility of
acidosis accompanied by
Short term:
After 8 hours
of nursing
intervention the
client had receive
adequate perfusion
and circulation
of well-oxygenated
blood.


Long term:
After 3 days
of nursing
interventions, the
client had improve
her haemoglobin
mass.

Cbc:
Hemoglobin
mas: 115
RBC: 6.2
WBC: 11.1


delivery when needed.





the release of oxygen at
the cellular level may
lead to ischemic
cerebral.