1. Risk for Injury related to: loss of consciousness during seizure activity and postical physical weakness.
- Outcomes:
- Describes precipitating seizure factors Avoids seizure triggers/risk factors.
- Uses medications as prescribed.
- Obtains medical attention immediately if seizure frequency increases.
- Implements safety practices in environment.
- Interventions:
- Monitor compliance in taking antiseizure medications to determine risk for seizures.
- Remove potentially harmful objects from the environment.
- Keep suction, Ambu bag, oral or nasopharyngeal airway at bedside to maintain airway and oxygenation if needed.
- Use padded side rails to prevent injury during a seizure.
- Instruct patient to carry medication alert card to provide information in case of emergency.
- Remain with patient during seizure to protect patient from injury.
- Guide movements to prevent injury during a seizure.
- Monitor neurological status to identify any deficits resulting from seizure.
- Record seizure characteristics: body parts involved, motor activity, and seizure progression.
- Monitor postictal period duration and characteristics to plan appropriate interventions as needed.
2. Ineffective airway clearance related to: blockage of the tongue, endotracheal,increased secretion of saliva
- Outcomes:
- Demonstrate effective coughing and clear breath sounds.
- Maintain a patent airway at all times.
- Undertake appropriate measures to prevent suffocation
- Interventions:
- Auscultate breath sounds every 1 to 4 hours
- Monitor respiratory patterns, including rate, depth, and effort. Monitor blood gas values and pulse oxygen saturation levels as available.
- Position person to optimize respirations: head of bed elevated 30-45 degrees
- Teaching:
- Instruct the person in the importance of reporting effectiveness of current medications to physician.
- Outcomes:
- Respiratory rate
- Respiratory rhythm
- Depth of inspiration
- Interventions:
- Monitor respiratory and oxygenation status to determine presence and extent of breathing problem and to initiate appropriate interventions.
- Position patient (side-lying) to maximize ventilation potential and decrease risk of aspiration.
- Identify patient requiring actual/potential airway insertion to facilitate intubation as necessary.
- Perform endotracheal or nasotracheal suctioning to maintain airway.
- Loosen clothing to prevent restricted breathing.
- Apply oxygen as appropriate to maintain oxygenation and prevent hypoxia.
- Monitor postictal period duration and characteristics because neurologic damage can affect postictal breathing pattern.
4. ineffective self-health management related to drug therapy and lifestyle adjustments.
- Outcomes:
- Knowledge of specific disease process
- Precautions to prevent complications of disease
- Available support groups
- Interventions:
- Appraise the patient’s current level of knowledge related to specific disease process to establish learning needs.
- Discuss lifestyle changes (e.g., avoidance of precipitating factors, driving restrictions, wearing medical ID tags, moderation in drinking and eating, exposure to stress, and avoidance of hazardous activities) that may be required to prevent future complications and/ or control the disease process.
- Discuss therapy/treatment options and describe rationale behind management/treatment options so patient and family can make lifestyle modifications to manage a chronic disease.
5. Risk for Ineffective cerebral Tissue Perfusion related to: decreased oxygen supply to the brain.
- Outcomes:
- Demonstrate appropriate orientation to person, place, time, and situation.
- Demonstrate ability to follow simple commands.
- Demonstrate equal bilateral motor strength.
- Demonstrate adequate swallowing ability.
- Interventions:
- Maintain euvolemia.
- Maintain head of bed flat or less than 30 degrees.
Sources:
Lewis, M.S., Dirksen, S., & Heitkemper, M.M. et al. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). St. Louis: Mosby. (LDH-9th)
Ladwig,G.B., Ackley, B.J., 2014 Mosby’s Guide to Nursing Diagnosis 4th ed.
