Nursing Care Plan

Nursing Care Plan
Nutrition imbalanced less than body requirements related to

inadequate food intake
Delayed growth and development: language r/t inadequate
stimulation.
Knowledge deficit related to cognitive limitation as evidence by
questions and statements of concern
Risk for injury related to sudden, abnormal, and excessive electrical

discharges from the brain.
Risk for aspiration related to sudden, abnormal, and excessive

electrical discharges from the brain.
Ineffective Family Coping related to Seasonal Work

Assessment
Subjective:

-“saging lang iya ginakaon”as verbalized by the mother.

Objective:

Weight: 10.3 kg
Height: 32 inches
BMi: 16.6 (underweight)
Hgb=127(dehydration)
dry and blonde hair
pale conjunctiva
irritable
restless

NCP
Planning
After 2-3 hours of nursing intervention:

The mother will verbalize understanding of
nutritional needs
The mother will demonstrate selection or meals that
will achieve a cessation of weight loss.
NCP
Nursing
Intervention
Nursing Interventions (Independent and Rationale
Dependent)
Independent Independent
Document actual weight and height. Patient mother may be unaware of
the actual height and weight loss of
his child due to estimating weight.
Obtain nutritional history Patient Mother perception of actual
intake may differ
Monitor or explore attitudes toward Proper assessment guides
eating and food. information
Advice the mother to serve food and To stimulate appetite and promote
fluids those are appealing to the client. interest in eating.
NCP
Nursing
Intervention
Dependent)
Therapeutic Therapeutic
Discourage beverages that are These may decrease appetite and
caffeinated or carbonated. lead to early satiety.
Engage the patient to a healthy Metabolism and utilization of
physical activities nutrients are enhanced by
activity.
NCP
Evaluation

The mother verbalized understanding her son’s
nutritional needs.
The mother made a resolve to prepare nutritious yet
affordable food or meals.
NCP
stimulation.
Assessment
Subjective:
 “Bale Mama, Papa, Dede kag Wewe palng sina iya
namitlangan gha”as verbalized by the mother.

Objective:
3 year-old older sibling.
Lack of time by the mother.
Pointing on something he wants.
NCP
stimulation.
Planning
Within the hospitalization days the patient
will achieve realistic developmental and
growth milestone based on existing abilities,
extent of disability, and functional age.
NCP
stimulation.
Nursing
Intervention
Dependent)
Provide meaningful stimulation by Initiating a conversation is a type of

initiating conversation to the client. stimulation and it is essential to the
development of the language of the
Engage the child in appropriate play child.
activities and offer them the appropriate Play is essential for learning in
toys. children and it is also a means of
communicating to them.
Enlist and encourage involvement of the Frequent and consistent family
parents and/or family as participants in the contact and care promotes emotional
care of the child particularly in the assurance to the child and thus
hospital. promotes conversation.
NCP
stimulation.
Nursing
Intervention
Dependent)
Provide emotional support for family Parents may be distress by the

members in their reactions to potential for development delay
evidence of developmental delay. of the child.
Instruct the mother with regard to Parents are then better equipped
age-appropriate activities and play, to promote the growth and
nutrition, discipline, and safety, and development of the child.
hoe to support growth and
development.
NCP
stimulation.
Evaluation
Goal was not met.

The patient still unable to utter other words beside
Mama, Papa, wewe, and dede.
NCP
Assessment
Subjective:
“Ano inang seizure nga gina tawag nila man?” as

verbalized by the mother.
NCP
Planning

The mother can verbalize understanding of
disorder and various stimuli that may
increase seizure activity.
The mother can express a desire for
necessary lifestyle/behavior changes as
indicated.
NCP
Nursing
Intervention
Nursing Interventions (Independent and
Dependent)
Rationale
Independent
Discuss the pathology/ prognosis of Provides opportunity to clarify/dispel
condition and lifestyle need for treatment misconception and present condition
as indicated. as something that is manageable
within a normal lifestyle.
Discuss patient particular trigger factors Regularity and moderation in
(e.g. flashing lights, hyperventilation, loud activities may aid in reducing/
noises, and video games. And Explain the controlling precipitate factors,
importance of maintain good general enhancing sense of general well
health. being, and strengthening coping
ability and self esteem.
Emphasize the importance of good oral Reduces risk of oral infections and
hygiene and regular dental care. gingival hyperplasia.
NCP
Evaluation
Goal met


The mother verbalized understanding of disorder
and various stimuli that may increase seizure activity.
The mother expressed a desire for necessary
lifestyle/behavior changes as indicated.
NCP
Assessment
Subjective:

“Gin hilanat siya kag nag turong iya mata” as verbalized by
the mother.

Objective:

History of seizure episodes.
NCP
Planning
The patient will be free from injury within the
succeeding days of hospitalization as manifested by:
Intact skin
No pain, bruises or fractures present.
No limitation in movement.
NCP
Nursing
Intervention
Dependent)
Independent:
Seizure precautions
Prepare a tongue depressor at A tongue depressor will prevent
bedside oral trauma.
Pad the side of the crib w/ blankets or To avoid patient from injury and
pillows. promote safety.
Maintain bed in lowest position with To promote client safety.
wheels locked.
Turn head to side. To maintain patent airway.
Encouraged bed rest. To prevent fatigue and promote
healing.
NCP
Nursing
Intervention
Nursing Interventions (Independent and
Dependent)
Rationale
During the seizure  Seizure activity should be

 Remain w/ patient. Observe for, record, and documented in detail to aid in
report type, duration, and characteristic of management and differentiation of
seizure activity and any post seizure seizure type and identifying of
response. triggering factors. Characteristic of
seizure and post seizure response
should include, as appropriate,
precipitating event, aura, initial
location and progression.
 Do not restraint the patient but rather To prevent injury caused by flailing.
guide patient movements gently.
 Roll patient into a side-lying position. Used To maintain patent airway.
head-chin-lift maneuver. To prevent injury caused by
 Loosen tight clothing. constrictive clothing.
NCP
Nursing
Intervention
Dependent)
Dependent
 Administer Phenobarbital 5mg/pptab May be given in emergent
1pptab q 12 hours as ordered by the situation to potentiate/enhance
physician. affects of other Anti-epileptic
drugs, and allow for lower
dosage to reduce side effects.
 Monitor complete blood count, May be given in emergent
electrolytes and glucose levels. situation to potentiate/enhance
affects of other Anti-epileptic
drugs, and allow for lower
dosage to reduce side effects.
NCP
Evaluation
Goal met

As manifested by :
 Intact skin
No pain, bruises or fractures present.
No limitation in movement.
NCP
Assessment
Subjective:

“ Gin hilanat siya kag nag turong iya mata” as verbalized by
the mother.

Objective :
History of seizure episodes.
NCP
Planning
The patient will be free from aspiration within the
succeeding days of hospitalization as manifested
By:
Noiseless respirations
Clear breath sounds
No secretion noted.
NCP
Nursing
Intervention
Dependent)
Independent :
Elevate client to highest or best To reduce risk
possible position for eating and For aspiration.
drinking.(high fowlers position)
Assess pulmonary status for Aspiration of small amounts
clinical sign of aspiration. can occur w/o coughing or
Auscultate breath sounds for sudden onset of respiratory
development of crackles and/ distress, especially in patients
wheezes. w/ a decreased level of
consciousness
Provide soft foods. To prevent aspiration.
NCP
Evaluation
Goal met

As manifested by:
Noiseless
Respirations
 Clear breath sounds
No secretions noted
NCP
Assessment
Subjective:

 “Wala permanente nga ubra akon bana. Kulang pa
gid sa amon iya sweldo. Housewife man lang ko.” As
verbalized by the mother.
Objective:
Monthly income is below P5,000
NCP
Planning
After 2 hours of Nursing intervention, the family
should be able to express understanding of the
problem and identify resources.
NCP
Nursing
Intervention
Dependent)
Assess family members’ perception of Depending on the stressor, a

problem. Resolution is possible only variety of strategies may be
if each person’s perception is required to facilitate coping.
understood.
Evaluate strengths coping skills, and This facilitates the use of
current support systems. previously successful
techniques.
Provide opportunities to express This promotes communication
concerns, fears, expectations, or and support.
questions.
NCP
Evaluation
Goal met.
The family was able to express and understand the
problem and identified resources.

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Nursing Care Plan

Nutrition imbalanced less than body requirements related to

Risk for injury related to sudden, abnormal, and excessive electrical

Risk for aspiration related to sudden, abnormal, and excessive

Ineffective Family Coping related to Seasonal Work

Provide meaningful stimulation by Initiating a conversation is a type of

Provide emotional support for family Parents may be distress by the

“Ano inang seizure nga gina tawag nila man?” as

During the seizure  Seizure activity should be

Assess family members’ perception of Depending on the stressor, a

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