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DIAGNOSIS
RATIONALE
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.
During episodes of
seizure, patients
are prone to injuries
since they may
strike different
objects due to
uncontrollable
muscle spasms.
GOALS AND
OBJECTIVES
After 2 hours of nursing
intervention, patient will be able to
attain or sustains no injury during
seizure activity
Will adhere with safety measures
and identifies hazards of noncompliance.
Will verbalize the importance of
lifestyle changes to reduce risk
factors and protect self from
injury.
INTERVENTIONS
RATIONALE
INDEPENDENT
Provide privacy and protect patient from curious
onlookers.
Triage in observation room on bed. Keep padded
side rails up with bed in lowest position.
COLLABORATIVE
Administered medications as ordered to stop
seizures:
a.)
Diazepam
b.)
Dilantin
EVALUATION
After 2 hours of nursing intervention,
goals were fully met as evidenced
by:
Patient sustains no injury during
seizure activity
Adheres with safety measures and
identifies hazards of noncompliance.
Verbalize the importance of lifestyle
changes to reduce risk factors and
protect self from injury.