No.

5 : Risk for Injury Cues Nursing Diagnosis Scientific Explanation Objectives Intervention Rationale Expected Outcome

S: O: The patient has history of multiple seizure attacks that last for 30 seconds with intervals of 5-10 mins

Risk for Injury related to occurrence of seizure

Seizure is a sudden, explosive, disorderly discharge of cerebral neurons and is characterized by a sudden, transient alteration in brain function usually involving motor, sensory, autonomic, or psychic clinical manifestations

Short term: nursing interventions the patients SO will verbalize understanding of the preventive measures to avoid injury during seizure attacks. Long term: After 3 days of

>Monitor and assessment >Place pillow on the head part >Raise side rails during episode of seizures. >Remove unnecessary objects during seizure episodes

>To have a

Short term: Goal met, the patients SO verbalized

After 8 hours of record neurological baseline data

> To prevent head injury. >To prevent patient from falling >To prevent any further injury

understandin g of the preventive measures to avoid injury during seizure attacks.

Long term: >Administer >To stop seizure Goal met, the

and an alteration in level of arousal. This is brought about by the meningeal irritation caused by the released of bacterial toxins.

nursing intervention, the patient will be free from risk of injury during seizure attacks.

anticonvulsant such as ordered.

attack and prevent any untoward complications.

patient remained free from risk of injury during seizure attacks.

: Hyperthermia Cues Nursing Diagnosis Scientific Explanation Objectives Intervention Rationale Evaluation

S: O: The patient manifested: >body temperature of 37.8o C/axilla >flushed skin and warm to touch

Hyperthermia The presence of microorganisms which cause inflammation of the meninges, which also affects the heat-regulating center in the brain. Temperature elevation is caused by the action of the pyrogen on the hypothalamus. This chemical

Short term: nursing intervention the patients body temperature of 37.8oC/axilla will decrease within normal limits. Long term: After 2 days of nursing interventions, the patient will

>Monitor and

>To have a baseline data

Short term: Goal met as evidenced by decreased in

After 8 hours of record VS

>Perform TSB

>To release the heat in the body through evaporation

body temperature from 37.8

oC/axilla

to 37

oC/axilla.

>Encourage SO to increase patients fluid intake >Ask the SO to loosen clothes of the patient

>To promote heat loss

Long term: Goal met as evidenced by temperature

>To give comfort and for easy dispersion of heat

of normal level and absence of

affects the hypothalamus by resetting the thermostat at a normal.

maintain normothermia and will not manifest any such as seizure. >Promote rest and provide stress free environment. >Administer antipyretic, as ordered > To decrease metabolic requirements >Pharmacologica l intervention to decrease the patients body temperature to normal level.

any complications such as convulsions.

higher level than complications