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Nursing Care Plan

Name:
Date:
Section:
Patient:
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective Cues: Risk for trauma Goal: >Determine >Influences scope After the nursing
related to After the nursing factors related to and intensity of intervention the
Objective cues: neuromuscular intervention the individual interventions to client is free from
impairment(seizu client will be free situation, as manage threat to trauma during
re) from trauma listed in Risk safety. the shift
during the shift Factors, and
extent of risk. >Affects clients
Goal met
ability to protect
>Note clients self and others,
age, gender, and influences
developmental choice of
age, decision- interventions and
making ability, teaching.
level of cognition
or competence.

>Review >Such may result


diagnostic in or exacerbate
studies or conditions, such
laboratory tests as confusion,
for impairments tetany,
and imbalances. pathological
fractures, etc.

>Explore and >Enables patient


expound seizure to protect self
warning signs (if from injury and
appropriate) and recognize changes
Nursing Care Plan
Name:
Date:
Section:
Patient:
usual seizure that require
pattern. Teach SO notification of
to determine and physician and
familiarize warnin further
g signs and how intervention.
to care for Knowing what to
patient during do when seizure
and after seizure occurs can
attack. prevent injury or
complications and
decreases SOs
feelings of
>Use and pad helplessness.
side rails with
bed in lowest >Prevents or
position, or place minimizes injury
bed up against when seizures
wall and pad floor (frequent or
if rails not generalized) occur
available or while patient is in
appropriate. bed. Note: Most
individuals seize
in place and if in
the middle of the
bed, individual is
unlikely to fall out
of bed.
>Uphold strict
bed rest if >Patient may feel
Nursing Care Plan
Name:
Date:
Section:
Patient:
prodromal signs restless or need to
or aura ambulate or even
experienced. defecate during
Explain necessity aural phase,
for these actions. thereby
inadvertently
removing self from
safe environment
and easy
observation.
Understanding
importance of
providing for own
safety needs may
enhance patient
cooperation.
>Do not leave
the patient
during and after >Promotes safety
seizure. measures.
>Turn head to side
>Helps maintain
and suction airway
airway patency
as indicated. Insert and reduces risk
plastic bite block of oral trauma but
only if jaw relaxed. should not be
forced or
inserted when
teeth are clenched
Nursing Care Plan
Name:
Date:
Section:
Patient:
because dental
and soft-tissue
damage may
result.
Note: Wooden
tongue blades
should not be
used because they
may splinter and
break in patients
mouth.