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    Risk For Injury

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    andycamille7
    1. The patient is at risk for injury during a seizure due to uncontrolled movements that could cause musculoskeletal or oral tissue trauma. 2. After 8 hours of nursing interventions including padding side rails, removing harmful objects, staying with the patient until the seizure ended, and speaking calmly, the patient had no injuries as evidenced by an inspection. 3. The nursing interventions were aimed at preventing injury during the seizure and promoting comfort and relaxation afterwards.

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    Risk For Injury

    Uploaded by

    andycamille7
    425 views1 page
    1. The patient is at risk for injury during a seizure due to uncontrolled movements that could cause musculoskeletal or oral tissue trauma. 2. After 8 hours of nursing interventions including padding side rails, removing harmful objects, staying with the patient until the seizure ended, and speaking calmly, the patient had no injuries as evidenced by an inspection. 3. The nursing interventions were aimed at preventing injury during the seizure and promoting comfort and relaxation afterwards.

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    Risk for Injury

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    1. The patient is at risk for injury during a seizure due to uncontrolled movements that could cause musculoskeletal or oral tissue trauma. 2. After 8 hours of nursing interventions including padding side rails, removing harmful objects, staying with the patient until the seizure ended, and speaking calmly, the patient had no injuries as evidenced by an inspection. 3. The nursing interventions were aimed at preventing injury during the seizure and promoting comfort and relaxation afterwards.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    425 views1 page

    Risk For Injury

    Uploaded by

    andycamille7
    1. The patient is at risk for injury during a seizure due to uncontrolled movements that could cause musculoskeletal or oral tissue trauma. 2. After 8 hours of nursing interventions including padding side rails, removing harmful objects, staying with the patient until the seizure ended, and speaking calmly, the patient had no injuries as evidenced by an inspection. 3. The nursing interventions were aimed at preventing injury during the seizure and promoting comfort and relaxation afterwards.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Adrian Enrico B.

    Mansalay July 27, 2010


    4D3a Nursing Care Plan
    Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
    Subjective: Risk for injury for After 8 hours of nursing Independent: After 8 hours of nursing
    interventions, the  Pad side rails, placed in  Precautions taken to interventions, the
    injury related to
    raised position, tape prevent injury during
    Objective: internal chemical patient will have patient had an absence
    padded tongue blade or seizure.
     Patient is hooked regulatory function absence of injury during away to bed, remove of injury after the
    to a mechanical the seizure evidenced by harmful objects from seizure evidenced by
    caused by seizure
    ventilator inspection revealing no immediate inspection revealing no
    activity (uncontrolled
    damage to mouth or environment, O2 and damage to mouth or
     Arm twitching movements) resulting tongue, bone or soft suction available. tongue, bone or soft
    in musculoskeletal, tissue breaks or tissue breaks or
    oral tissue trauma.  Stay until seizure is  Provides support and
    bruising; control of over, speak calmly
    bruising; control of
    prevents injury.
     Weakness seizures. without restraining seizures.
    unless may be injured.
     Facial grimace
     Avoid restraining,  Prevents possible injury
    forcing object between damage to mouth and
     Irritability teeth if clenched; insert teeth.
    padded blade if safe to
     V/S taken as do so.
    follows:

    T: 37.3  Loosen tight clothing,  Prevents aspiration.


    P: 105 roll to side to drain
    R: 20 secretions from mouth
    BP: 120/80 during relaxation, or
    suction secretions if
    needed.

     Reorient to events,  Promotes comfort and


    provide rest and relaxation following
    reassurance, cleanse seizures.
    oral cavity.

    Collaborative:
    Administer medications as
    indicated.

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