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Assessment S: -------------O: > Body weakness >loss of consciousness >With history of seizure that last for 5sec.

every minute >lack of sleep AEB dark circle around her eye >Oriented

Nursing Diagnosis
Risk for injury r/t seizure

Scientific explanation

Planning

Intervention

Rationale

Evaluation

After a series of >Assessed clients nursing level of disorientation interventions, pt. will to determine specific be able to remain requirements for free from physical safety. injury.

After a series of nursing >Knowledge of interventions, pt. remained free clients level of of from physical injury. disorientation to determine specific requirements for safety.

>Placed client in quiet private room. >Excessive stimuli increased client agitation. >Keep the bed side rails up at all times. >To prevent fall >Keep the bed in low position except when providing direct care. >To ease getting in and out of bed and to reduce the danger of falling

>Ensured that harmful objects such as knife >To reduce risk of etc. injury

Assessment S:----------------

Nursing Diagnosis

Scientific explanation

Planning

Intervention

Rationale

Evaluation

Impaired skin O: integrity r/t to effect of >skin warm to drugs. touch >presence of rashes on upper extremities >with dry scaly skin noted >with fair appetite > >

Skin is the After series of >Established rapport >To build trust with After series of nursing primary defense nursing the patient intervention pt. of the body, it intervention pt. >Allow pt. to express >Giving pt. a expresses feelings protects the body will be able to her feelings about skin chance to talk about changes in body against infection communicate problem. about her skin image. and diseases feelings about problem will help brought about by changes in alley anxiety and invasion of body image. develop coping microbes inside >Position patient for skills. the body. A comfort and minimal > This provides normal skin is pressure on bony evidence of the moist and intact prominences effectiveness of the dryness of skin is skin care regimen. prone to friction >Health teaching given that may result as follows: to impaired skin * Teach the client how integrity. to keep the affected *To prevent further area clean and dry. invasion of *Recommend the client microorganism to keep nail short. *To reduce risk of dermal injury when severe itching is *Instruct proper present. hygiene and self care. *Proper hygiene will prevent infection >maintain adequate and complication. nutrition and >To improve clients dehydration. immune system >Make sure other staff >

members are aware of patients condition.

Assessment

Nursing Diagnosis

Scientific explanation

Planning

Intervention

Rationale

Evaluation

S:

Disturbed thought O: with processes euthymic mood r/t >Nonpsychologic productive al causes speech noted > With good attention span > nystagmus (involuntary eye movement ) noted > with perceptual disturbances noted > lack of sleep noted AEB dark circles around her eye >oriented to 3 spheres

Within the shift, the patient will be able to participate in group activities.

> projected non>patient must have Within the shift the judgmental and trust to be able to patient was able to trusting attitude toward talk openly about participate in group patient through active delusions and activities. listening feelings >oriented patient to reality as needed -call patient by name -provide background information (place, time and date) frequently through out the day verbally and visually using a reality orientation board >reality orientation >oriented patient to techniques foster her environment patients awareness including sight, sounds of herself and her and smell environment >attempts to correct delusional > provided comfort andbeliefs and increase support anxiety >to understand the >refocused the patient condition conversation on patients underlying feeling