Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention

Objective Risk for Injury is a After 1 hour of 1. Independent Influences the Goal met.
Trauma common nursing scope and Patient
T-36.8 problem in intervention, a. Assessment intensity of
verbalized
understanding
RR- 12 patients patient control Determine interventions to in compliance
with and will factors related to manage the to prevent
PR- 65 epilepsy. prevent from the individual threat to safety. trauma.
Dental and injury or situation, as
BP- 110/80 mmHg Affects the Goal met.
tongue trauma. listed in Risk client’s ability to Patient
Weakness, injury was Factors, and identify
protect self and
balancing the most extent of risk. actions and
common others, and measures to
difficulties Patient will
Note client’s age, influences the do when
seizure- verbalize
Cognitive related gender, choice of seizure
understanding interventions occurs.
limitations/altered injury. The developmental
of factors that
consciousness risk factors age, decision- and teaching.
contribute to Goal met.
were the possibility making ability, may increase
Patient
Loss of large or demonstrated
generalized level of cognition
small muscle of trauma and brain activity, modification
tonic-clonic or suffocation or competence. thereby
coordination of behaviors
seizures, and take steps increasing the
Ascertain that prevent
Emotional and high to correct the potential for her from
knowledge
difficulties frequency situation. seizure activity. injury.
of various stimuli
of seizures.
Patient will that may Such may result
Patients
precipitate
with identify actions in or exacerbate
or measures to seizure activity. conditions
epilepsy can
lead normal take when
seizure activity Use of helmet
lives but Review may provide
occurs.
certain Patient will diagnostic added
precautions demonstrate studies or protection
are needed behaviors, laboratory tests
Reduces risk of
to prevent lifestyle for impairments
seizure- changes to and imbalances. patient biting
and breaking
related reduce risk
injuries. factors and Evaluate the glass
need for or thermometer or
protect self
from injury. provide suffering injury
protective if sudden
Patient will headgear. seizure activity
modify should occur.
Use a tympanic
environment as
indicated to thermometer Promotes safety
when necessary measures.
enhance safety.
to take the
Patient will temperature. Documents
postictal state
maintain
treatment Do not leave the and time or
patient during completeness of
regimen to
control or and after a recovery to a
seizure. normal state. 
eliminate
seizure activity. Provide May be a result
neurological or of repetitive
Patient will
recognize the vital sign check muscle
after seizure  contractions or
need for
assistance to symptom of
Investigate injury incurred
prevent reports of pain.
accidents or Immediate
injuries. Detect status intervention is
epilepticus required to
control seizure
b. Health activity and
Teachings prevent
Teach SO to permanent
determine and injury or death. 
familiarize HEALTH EDUC
warning signs
and how to care Knowing what
for the patient to do when a
during and after seizure occurs
seizure attack. can prevent
injury or
Use and pad side complications
rails with the bed and decreases
in lowest SO’s feelings
position, helplessness.

Prevents or
2. Dependent minimizes injury
when seizures 
Administer
Phenobarbital DEPENDENT
(Luminal) The goal is
as ordered. optimal
suppression of
Administer seizure activity
Antiepileptic with the lowest
drugs (AEDs):  as possible dose of
a drug and with
ordered. fewest side
effects.

Potentiates and
Prepare enhances the
for surgery or effects of AEDs
electrode and allows for
implantation as lower dosage to
indicated. reduce side
Lorazepam effects.
(Ativan) Used to abort
Glucose, status seizure
thiamine activity

May be given to
restore
3. Collaborative\ metabolic
balance if a
Psychiatrists
seizure is
Radiologists or induced
neuroradiologists by hypoglycemia

Physical and
rehabilitation
COLLA
medicine
Diagnosis,
assessment,
treatment, and
management of
physical
 disabilities and
limitations,
which could be
the result of a
seizure,

Treatment and
management of
patients with
seizure-like
events with a
psychological
basis

Neuroimaging
services that aid
in diagnosis,
treatment, and
determination
of candidacy for
epilepsy-related
surgery

Cues Nursing Rationale Goal/Outcome Criteria Nursing Intervention Rationale Evaluation

1. Risk for When the Goal: 1. Independen Provides a baseline data for Goal met.
Subjective ineffectiv breathing t evaluating adequacy Patient
pattern is After hour of nursing
e airway of ventilation. identify
clearance ineffective, th intervention, Patient a. Assessment behaviors
e body will will maintain effective An ineffective cough compromises
2. Objective to
likely not get respiratory pattern airway clearance and prevents achieve
Pale enough with airway patent Monitor respiratory secretions to expel freely. effective
oxygen to or aspiration prevented rate, rhythm, depth, airway.
Restlessnes the cells. . Lessens risk of aspiration or
and effort of foreign bodies lodging in the
s respirations.
Outcome criteria pharynx.
Assess client’s ability Goal met.
Helps in the drainage of
to cough effectively. Patient
secretions; prevents the tongue display
Client will be proficient from obstructing the airway.
in using effective Ensure patient to and
the empty mouth of maintain
airway clearance when Aids in breathing or chest
seizure occurs. dentures or foreign expansion. patent
objects if aura airway
occurs HEALTH EDUC and
effective
Client will maintain Maintain in lying Patient/floks may be initially dis
clearance
clear and open airway position, flat oriented requiring repeated
.
as evidenced by normal surface; turn head explanations.
breath sounds, normal to side during
rate and depth of seizure activity.
respirations. DEPENDENT
Loosen clothing
from neck or chest
Reduces risk of aspiration
and abdominal
areas. or asphyxiation.
b. Health Teachings

explain and help the

Suction as COLLA
needed.
Specialist will provide mots
Get ready for or accurate specific care plan
assist with for the patient.
intubation, if
indicated.

2. Collaborativ
e

Refer to a
respiratory
therapist.
Cues Nursing Diagnosis Rationale Goal/Outcome Nursing Rationale Evaluation
Criteria Intervention

OBJECTIVE  Situational Living with a Goal: 1. Independent Verbalization of concerns Goal met.
Low Self- chronic about future implications can Patient
T Esteem medical After 1 hour a. Assessment help the patient begin to verbalize
related to condition is nursing
RR Determine accept or deal with the increased
Stigma often intervention, situation. sense of self
individual
PR associate accompanied the patient will esteem in
by low self- gain self situation condition affects acceptance
d with the related to low relation to
BP esteem, a esteem and of therapeutic regimen.
condition self-esteem in diagnosis.
diminished acceptance to
Change in usual sense of the present Provides an opportunity to
condition Goal met.
patterns of personal circumstances. problem-solve response, and Patient
responsibility worth, and Outcome provides a measure of
Explore demonstrate
lower self- criteria control over the situation.
Lack of follow- feelings about behaviors on
efficacy, a
through or Patient will diagnosis, the help patient begin to accept acceptance to
diminished
nonparticipation verbalize an perception of manageability of the condition.
sense of
in therapy one's ability increased threat to self. condition. Goal met.
to influence sense of self- Encourage
Expressions of Participation in as many Patient
helplessness or behavioral esteem in expression of experiences as possible can participated in
uselessness outcomes. relation to feelings. lessen depression about treatment
diagnosis. limitations. regimen and
Analyze nursing
Patient will possible or may affect a patient’s sense intervention.
demonstrate anticipated of competency and self-
SUBJECTIVE behaviors to public reaction esteem and interfere with
restore to the support received from SO,
“wala ko lately positive self- condition. limiting the potential for
naobra akon esteem. optimal management and
usual nga daily Discuss with personal growth.
activity” Patient will patient current
verbalized by participate in and past HEALTH EDUC
the patient. the treatment successes and
regimen or strengths. Patient/floks may be initially
dis oriented requiring
activities to
correct factors encourage repeated explanations.
activities,
that DEPENDENT
precipitated a providing
supervision Taking your medicine as
crisis.
and monitoring prescribed or medication
when adherence is important
indicated. for controlling chronic
conditions, treating
Know the temporary conditions,
attitudes or and overall long-term
capabilities of health and well-being. 
SO.

b. Health COLLA
Teachings
Provides an opportunity to
explain and gain information, support,
help the folks and ideas for dealing with
understand all problems from others who
the share similar experiences. 
interventions
Counseling can help
and
treatments overcome feelings of
inferiority and self-
2. Dependent consciousness.

Administer
medications as
ordered.

3.
Collaborative

Refer patient
and SO to
support group

Talk over and