West Visayas State University 2

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City NURSING CARE PLAN Name: K.L.C. Age: 13 y.o____ CLUSTERED CUES

8/28/08 @ 10AM S – “ Gawaras na siya bilog nga adlaw. Wala pahuway. Kaluoy man gani sa iya.”, as verbalized by the mother “Mas maayo nalang nga na higot siya subong, kay daan mahulog gid na siya sa iya nga katre.” “Hindi sya makabati, ukon makahambal. Maski ano mo pa na siya kaulo-ulo.” O – perceived discomfort due to restraints Inability to perform purposeful

Ward/ Bed Number: PSW B NURSING DIAGNOSIS

Impaired physical mobility r/t neuromuscular impairment secondary to status epilepticus

RATIONALE

OUTCOME CRITERIA

Alteration in 1. The patient will be mobility may able to perform be temporary activities that or more could promote permanent tissue integrity as problem. to positioning to Most disease different sides as and evidenced by rehabilitative recurrent states involve movement to sides some degree of infrequent use of immobility. after 4 hours (2PM) on 8/28/08. Status epilepticus 2. The patient will be patient have able to elicit alterations in decreased behavior such involuntary as sensorymovements as hallucinatory evidenced by phenomena, sedation or of by motor effects REM (sleeping) (eye provided by movements, efficacy of drug muscular administration contractions) after 2 hours (1030AM) on Source: 8/28/08. Maternal and Child Health

Attending Physician: Dr. G________ Impression/Diagnosis: Status Epilepticus____

NURSING INTERVENTIONS

RATIONALE

1. Stress out to folks about security of the patient; raise side rails (as possible) or give fitting restraints as prescribed.

Reduce risk of falls and further alimentation of current state.

2. Assess for proper positioning; assist in repositioning or by giving pillow support to elevate head for assumed semi-Fowler’s position.

Prevent bed sores. Immobility promotes clot formation thrombophlebitis.

3. Encourage folks to do ROM if sedation signs are elicited; perform ROM exercises accordingly without over-stimulating the patient.

a. Promote tissue integrity and provide a baseline measurement for future evaluation guide. b. Decreased stimulation of patient experiencing tonic-clonic seizure therefore

EVALUATION

8/28/08 @ 2PM 1. Goal partially met: The patient was able to transfer to different sides however this was done involuntarily and unconsciously.

8/28/08 @ 1030AM 2. Goal partially met: The patient was sedated but awake after administering of medication.

gross/ fine motor movements Generalized tense movements Inability to elicit a stance, absence of gait Cannot followthrough with instructions regarding proper positioning

Nursing, pp. 1102; Nursing 3. The patient will be Care Plans by able to passively Gulanick demonstrate correct posture as to lying on bed with support of restraints and appropriate sized pillows after 1 hour (11AM) during resting periods or after signs of sedation appears to promote REM (sleep) on 8/28/08. 4. The patient will be able to reactively participate on ROM exercises as evidenced by decrease unconscious guarding behavior to self after 2 hour (12PM) on 8/28/08.

prevent further eliciting of exaggerated involuntary movements that could further put the patient at risk for mechanical trauma. 4. Administer antiepileptic drugs and sedatives (Phenobarbital) as prescribed.

5. Monitor input and output record and nutritional pattern. Assess nutritional needs as they relate to continued bed rest or being flat on bed. 6. Use pressurerelieving devices (cotton bed linens). 7. Maintain limb in functional alignment (as possible) by changing location of restraints or by

Sedate and put patient to sleep and will temporarily prevent any involuntary movements that could lead to further damage of tissues. Possible hypocalcemia and negative nitrogen balance that could promote pressure sore development. Prevent tissue breakdown. Prevent contractures or excessive tightness of extremities.

8/28/08 @ 11AM 3. Goal partially met: The patient was sedated but awake after administering of medication however patient is mobile on bed with restraints making support pillows to displace.

8/28/08 @ 11AM 4. Goal unmet: The patient cannot further follow through with designated ROM exercises, and duration of effective ROM exercise cannot justify the baseline data for future evaluation. Patient is virtually uncooperative throughout the attempt for ROM.

temporarily untying restraints with precautions to avoid unconscious pulling out of any therapeutic contraptions attached.