KATHLEEN PARKS I HUMAN CASE 26YEARS OLD REASON FOR ENCOUNTER: MORE FREQUENT SEVERE HEADACHES WITH LATEST QUESTIONS AND 100% CORRECT ANSWERS () ALREADY GRADED A+

KATHLEEN PARKS I HUMAN CASE 26YEARS OLD REASON FOR ENCOUNTER: MORE FREQUENT SEVERE HEADACHES WITH LATEST QUESTIONS AND 100% CORRECT ANSWERS () ALREADY GRADED A+ Outcomes (NOC) Interventions (NIC) and Rationales Pain Control Pain Management eNursing Care Plan 63-1 • Balance • Coordination • Muscle movement • Joint movement Walking Measurement Scale 1 = Severely compromised 2 = Substantiallycompromised 3 = Moderatelycompromised 4 = Mildly compromised 5 = Not compromised • Apply/provide assistive device (e.g., cane, walker, or wheelchair) for ambulation if the patient is unsteady to decrease fatigue and enhance independence, comfort, and safety. • Encourage independent ambulation within safe limits to maintain mobility and promote independence. Exercise Therapy: Joint Mobility • Teach patient and caregiver(s) how to perform passive, assisted, or active ROM exercises, as indicated, to prevent contractures and minimize muscle atrophy. Exercise Promotion: Stretching • Teach patient to slowly extend muscle/joint to point of full stretch (or reasonable discomfort) and hold for specified time and slowly release the stretched muscles to relieve spasms and contracted muscles. eNursing Care Plan 63-2 Patient with Seizure Disorder or Epilepsy Clinical Problem* Impaired Respiratory Function Etiology: Neuromuscular impairment from tonic-clonic status epilepticus and/or postictal fatigue Supporting data: Altered respiratory rate, rhythm, and/or depth Patient Goal Has breathing pattern adequate to meet oxygen needs Outcomes (NOC) Interventions (NIC) and Rationales Respiratory Status: Ventilation Airway Management • Respiratory rate • Respiratory rhythm • Depth of inspiration _ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range • 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 airway patency as necessary. • Perform endotracheal or nasotracheal suctioning to clear airway passages. Seizure Management • Loosen clothing to prevent restricted breathing. • Apply O2 as appropriate to maintain oxygenation and prevent hypoxemia. • Monitor postictal period duration and characteristics because neurologic damage can affect postictal breathing pattern. *Clinical problems listed in order of priority. Clinical Problem Risk for Injury Risk factors: Loss of consciousness during seizure activity and postictal physical weakness Patient Goal Has no seizure-related injury Outcomes (NOC) Interventions (NIC) and Rationales Seizure Self-Control Seizure Precautions • 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 Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated • Monitor adherence to taking antiseizure medications to determine risk for seizures. • Remove potentially harmful objects from the environment to prevent injury during a seizure. • Keep suction, bag valve mask, oral or nasopharyngeal airway at bedside to maintain patent airway, if needed. • Use padded side rails to prevent injury during a seizure. • Teach patient to carry medication alert card/identification to provide information in case of emergency. Seizure Management • Remain with patient during seizure to protect patient from injury. • Guide movements to prevent injury during a seizure. • Monitor neurologic status to identify any deficits resulting from seizure. • Record seizure characteristics (e.g., body parts involved, motor activity, and seizure progression). • Monitor postictal period duration and characteristics to plan appropriate interventions as needed. Clinical Problem Difficulty Coping Etiology: Perceived loss of control, threat to physical and social well-being Supporting data: Denial of diagnosis, lack of truth-telling about seizure frequency Patient Goals 1. Expresses acceptance of seizure disorder by admitting presence of epilepsy and adhering to therapeutic regimen 2. Maintains therapeutic serum levels of antiseizure medications Outcomes (NOC) Interventions (NIC) and Rationales Seizure Self-Control Coping Enhancement • Maintains positive attitude toward seizure disorder • Maintains role performance • Maintains social relationships Acceptance: Health Status • Recognizes reality of health situation • Copes with health situation • Adjusts to change in health status • Reports sense of life being worth living Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated • Assess patient’s adjustment to changes in body image. • Assess impact of patient’s life situation on roles and relationships to determine extent of problem and to plan appropriate interventions. • Assess and discuss alternative responses to situation. • Provide factual information concerning diagnosis, treatment, and prognosis to clarify changes required. • Encourage verbalization of feelings, perceptions, and fears to enable patient to deal with emotional responses to seizure disorder. • Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes. • Arrange situations that encourage patient’s autonomy to promote effective coping by providing correct information. Teaching: Disease Process • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process. • Describe possible chronic complications. • Describe reason behind management/treatment recommendations. Clinical Problem Deficient Knowledge Etiology: Lack of knowledge about management of seizure disorder Supporting data: States lack of knowledge, inaccurate perception of health status, nonadherence to prescribed health behavior Patient Goals 1. Describes factorsinvolved in effective management ofseizure disorder 2. Makes decisions about health and lifestyle modifications necessary for management ofseizure disorder Outcomes (NOC) Interventions (NIC) and Rationales Knowledge: Disease Process Teaching: Disease Process • Characteristics of specific disease process • Signs and symptoms of disease complications • Strategies to minimize disease progression • Available support groups Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge • Assess 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 avoiding hazardous activities) that may be required to prevent future complications and/or control the disease process. • Discuss therapy/treatment options and describe reason behind management/treatment options so patient and family can make lifestyle modifications to manage a chronic disease. eNursing Care Plan 63-3