Risk for Injury NCP Seizures

GOALS AND  NURSING

RATIONALE

OBJECTIVES

Seizures are disturbances in normal brain function resulting from abnormal electrical discharges in the brain, which can cause loss of  consciousness, uncontrolled body movements, changes in behaviors and sensation, and changes in the autonomic system.

 After  hours of nursing intervention, patient will be able to attain or sustains no injury during seizure activity

INTERVENTIONS

RATIONALE

EVALUATION

DIAGNOSIS

Risk for injury related to loss of large or small muscle coordination secondary to seizure

During episodes of seizure, patients are prone to injuries since they may strike different objects due to uncontrollable muscle spasms.

!ill adhere with safety measures and identifies hazards of non" compliance. !ill verbalize the importance of lifestyle changes to reduce risk factors and protect self from injury.

#$D%&%$D%$' &rovide privacy and protect patient from curious onlookers.

'he patient who has an aura/warning of impending seizure0 may have time to seek a safe, private place.

'riage in observation room on bed. (eep padded side rails up with bed in lowest position.

)inimizes injury should fre-uent or generalized seizures occur while client is on bed

&roper history taking from %)'. Document pre seizure activity, presence of aura, or unusual behaviour, type of seizure activity, such as location and duration of motor activity, and *+, incontinence eye activity, respiratory impairment and cyanosis, and fre-uency of recurrence. $ote whether patient fell, epressed vocalization, drooled, or had automatisms such as lip smacking, chewing, and picking at clothes.

 Apply tag /neon pink0 for high risk of fall.

5elps localize the cerebral area of involvement and may be useful in chronic conditions in helping patient and significant other prepare for  or manage seizure activity.

'he most immediate concern when it comes to epileptic seizures is to prevent traumatic injury resulting from falls due to uncontrolled violent movements of the entire body that may lead to fracture and internal bleeding with damage to vital organs.

$o attempt should be made to restrain the patient during seizure.

)uscular contractions are strong and restrain can produce injury.

)aintain strict bed rest if prodromal signs or aura is eperienced. %plain necessity for this actions

lient may feel restless, need to ambulate or even defecate during aural phase, thereby inadvertently removing self from safe environment and easy observation. 6nderstanding importance of providing for own safety needs may enhance patient cooperation.

Stay with the client during and after seizure.

&romotes patient safety and reduces sense of isolation during the event.

&erform neurological and vital signs check post seizure1 *+, orientation, ability to comply with simple commands, ability to speak, memory of incident, weakness or motor deficits, 2&, &R &R 3 RR.

Document postictal state 3 time and completeness of recovery to normal state. )ay identify additional safety concerns to be addressed.

Reorient patient following seizure acitivit y.

&atient may be confused, disoriented, and possibly amnesic after seizure and need help to regain control and alleviate aniety.

+**A2+RA'#4%  Administered medications as ordered to stop seizures1 a.0

Diaze pa pam

b.0

Dilantin

Diazepam may be given #4 at 7mg8min rate to control seizure activity by enhancing neurotransmitter 9A2A. ardiovascular and respiratory depression may occur if diazepam is used in conjunction with phenobarbital.

Dilantin may be given at 7:mg8min rate to decrease cellular influ of sodium and calcium and blocking neurotransmitter release. aution

 After  hours of nursing intervention, goals were fully met as evidenced by1 &atient sustains no injury during seizure activity  Adheres with safety measures and identifies hazards of non" compliance. 4erbalize the importance of lifestyle changes to reduce risk factors and protect self from injury.

any faster than prescribed rate because of its p5, and %9 must be monitored for dysrhythmias while administering this drug.

5%A*'5 %6A'#+$1 %plain to the patient the various stimuli that may precipitate seizure activity.

Discuss seizure warning signs, if appropriate, and usual seizure pattern. 'each significant other to recognize warning signs and how to care for patient during and after seizure.

 Alcohol, various drugs, and other stimuli, such as loss of sleep, flashing lights, and prolonged '4 viewing may increase potential for seizure activity. &atient may or may not have control over many precipitating factors, but may benefit from becoming aware of these risks. an enable patient or significant other to protect individual from injury and to recognize changes that re-uire notification of physician and further intervention. (nowing what to do when seizure occurs can prevent injury or complications.