West Visayas State University 3

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 @ 830AM S – “ Halin sang pag-admit sa iya wala gid siya agi paliguan, mu na eh sibin sibin lang.”as verbalized by the mother “Kabudlay man daan siya di paliguan, te asta sibin lang e anay.” O – Not well groomed Disheveled appearance Restless Body odor noted

Ward/ Bed Number: PSW B NURSING DIAGNOSIS

Self-care deficit: bathing/hygiene /dressing/groom ing/feeding/ toileting r/t neuromuscular impairment secondary to status epilepticus

RATIONALE

OUTCOME CRITERIA

The deficit may be the result of transient limitations, patient’s with physical limitations (mental disorders) or lack of available materials to perform optimum care for oneself.

1. The patient will be able to elicit decreased involuntary movements as evidenced by sedation or of by REM (sleeping) provided by efficacy of drug administration after 2 hours (1030AM) on 8/28/08.

Status epilepticus patient have alterations in behavior such as sensoryhallucinatory phenomena, motor effects (eye movements, muscular contractions)

2. The patient will be able to show signs of comfort passively after 3 hours (1130AM) on 8/28/08.

3. The patient will be able to show decreased signs of restlessness due to

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

NURSING INTERVENTIONS

RATIONALE

EVALUATION

1. Do sponge bath as necessary or if patient is sedated (as indicated). Use soap suds with dampen towels. Apply lotion after sponge bath and after adequate rinsing of skin.

Soap helps 8/28/08 @ 1030AM remove dirt on 1. Goal met: The skin. Promotes patient was tissue integrity by sedated but awake providing after adequate moisture administering of on skin. medication.

2. Implement meticulous mouth care regimen after every NGT feeding to have a systematic and grouped procedures to be done without overstimulating the patient.

a. After the feeding via NGT, the patient will have decrease saliva production which could be prone to infection. b. Decreased stimulation of patient experiencing tonic-clonic seizure therefore prevent further eliciting of exaggerated involuntary movements that

8/28/08 @ 1130AM 2. Goal partially met: The patient comfort level could not be justified however patient was calm after sponge bath. 8/28/08 @ 1130AM 3. Goal partially met: The patient comfort level could not be justified however

Untrimmed fingernails Dry buccal mucosa

Source: Maternal and Child Health Nursing, pp. 1102; Nurse’s Pocket Guide

perceived discomfort after 3 hours (1130AM) on 8/28/08.

could further put the patient at risk for trauma especially to the oral mucosa. 3. Changing of bed linens as necessary and changing of clothes accordingly every after sponge bath.

Reduce friction. Provide a comfortable environment as to wearing of clean clothes.

4. Grooming (combing) after performing bed shampoo (as indicated). Application of baby oil on scalp and hair.

Promote scalp integrity and promote healthy hair. Prevention of offensive body odor related to oily scalp secretion.

5. Administer antiepileptic drug and sedatives (Phenobarbital) as prescribed. You can

5. Rinse the mouth with water as necessary with

Sedate and put patient to sleep and will temporarily prevent any involuntary movements that could lead to further damage of tissues. Cleansing the mouth with water to prevent dryness of the buccal

patient was calm after sponge bath; reduced level of restlessness, as sign of efficacy of sedative.

aspiration precaution. While doing so position client to sidelying position (if tolerated or sedated).

mucosa and of the lips. Aspiration precaution is considered.