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Nursing Care for Seizure Management

The document summarizes the health care provider's notes and orders for a 39-year old male patient who experienced multiple seizures over a few days. It notes the patient's subjective reports and objective symptoms observed during the seizures. The assessment determined the patient had a CVD bleed and seizures. The nursing intervention goals were to control the patient's pain, educate them on seizure warning signs and management, and prevent accidents. After 8 hours the goals were met as the patient's pain was reduced and they understood how to manage seizures and ask for assistance.

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Shelvin Jules Layva
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125 views3 pages

Nursing Care for Seizure Management

The document summarizes the health care provider's notes and orders for a 39-year old male patient who experienced multiple seizures over a few days. It notes the patient's subjective reports and objective symptoms observed during the seizures. The assessment determined the patient had a CVD bleed and seizures. The nursing intervention goals were to control the patient's pain, educate them on seizure warning signs and management, and prevent accidents. After 8 hours the goals were met as the patient's pain was reduced and they understood how to manage seizures and ask for assistance.

Uploaded by

Shelvin Jules Layva
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSING SERVICES DIVISION

HEALTH CARE PROVIDER’S NOTES AND ORDER SHEET

PATIENT NAME
Patient X

BIRTHDATE AGE SEX ROOM NO.


03/23/1979 39 years old  MALE
 FEMALE
MM/DD/YYYY

DATE/ HEALTH CARE PROVIDER’S NOTE ORDER/S NURSE/S


TIME Subjective, Objective, Assessment and Plan of Care PRINTED NAME
& SIGNATURE
DATE AND TIME
SUBJECTIVE: seizures
05/26 OBJECTIVE:
12:30 pm - pt seen lying on the floor
- upward rolling eyeballs,
-extension of extremities
- Confusion afterwards. Pt fefused to go to
hospital.
05/26 S: 2nd onset of seizure, last for 1 min.
7pm
05/26 S:
9pm - slurring of speech
- they decided to go to hospital,
-3rd onset of seizure occurred.

O:
- while on ER the pt reoccurred seizures for 4
times.
- known for hypertensive and have DM type 2,
taking meds:
- metformin 1g OB
- losartan 100 mg/tb 1table OB
- sertide
-piolitazone 1 OD
05/29 S:
-C/O headache, dizziness
-pain with 8/10,
-facial grimace
-normocephalic
-no masses or lumps
-blurring vision
- BP 150/100

O:
- Able recognize who’s with her
- Fear verbalized in the outcome of the
surgery.
- Moist skin with stretch marks
-

ASSESSMENT:
-CVD bleed
- seizure
OUTCOME:
After 8 hrs of nursing intervention, the:
- Patient will report pain is controlled or
relieved by less than 4 out of 10.
- Patient will identify actions or measures
to take when seizure activity occurs.
- Patient will maintain treatment regimen
to control or eliminate seizure activity.
- Patient will recognize the need for
assistance to prevent accidents or
injuries.

INTERVENTION:
- Determine factors related to the
individual situation, as listed in Risk
Factors, and extent of risk.
- Explore and expound seizure warning
signs (if appropriate) and usual seizure
pattern. Teach SO to determine and
familiarize warning signs and how to
care for the patient during and after
seizure attack.
- Use and pad side rails with the bed in
lowest position, or place bed up against
wall and pad floor if rails not available or
appropriate.
- Evaluate the need for or provide
protective headgear.
- Note pre-seizure activity, presence of
aura or unusual behavior, type of
seizure activity (location or duration of
motor activity, and frequency or
recurrence. Note whether the patient
fell, expressed vocalizations, drooled, or
had automatisms (lip-smacking,
chewing, picking at clothes).
- Investigate reports of pain.
EVALUATION:
After 8 hrs of nursing intervention, the
GOALwas met:
- Patient reported pain is controlled or
relieved by less than 4 out of 10.
- Patient identified actions or measures to
take when seizure activity occurs.
- Patient maintained treatment regimen
to control or eliminate seizure activity.
- Patient recognized the need for
assistance to prevent accidents or
injuries.

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