Pediatric Care Plan -Seizures PDF

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Summary

Care plan in a 13 years old boy who has Seizures...

Description

Nursing Plan of Care

Student’s Name ______ Date: __________ Patient’s Initials ___

Age _13 months__

Gender _Male__

Medical diagnosis _Seizure Activity________ Diet __Regular__ Activity _As tolerated_________ VS/Pain level (scale used) __BP 78/42, Respirations 36, Pulse 126, Oxygenation 100%, Temperature 38.6 C, Pain 5/10 (FLACC scale) Immunizations ___Up to date per CDC guidelines________________________ Brief/Significant Medical History Only The patient is a 13-month-old male that presented to the emergency department for possible seizure activity by ambulance. He is alert but fussy with signs of mild distress. The patient has reached all developmental milestones without delays.

Assessment Data Subjective data: The patient’s mother stated that the patient had a fever the day prior and she administered ½ teaspoon of Tylenol at home. Later that night she was holding him at home when he started to shake and then experienced a brief loss of consciousness. She also stated that he has had poor appetite lately. The patient has pain 5/10 according to FLACC scale. Objective data: The patient’s vitals are BP 78/42, Respirations 36, Pulse 126, Oxygenation 100%, Temperature 38.6 C. His skin is hot to touch and flushed, cheeks are reddened. Tonsils are enlarged, bright red and swollen. Lymphatic nodes are enlarged in the cervical, axillary, and inguinal chains. The patient is alert and interacts with others appropriately. Lab results were positive for influenza A virus.

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Nursing Diagnosis (NANDA): Hyperthermia related to infection as evidenced by temperature 38.6 C, loss of appetite, irritability.

Expected Outcomes Short term: The patient’s temperature will be within normal limits within 12 hours. Long Term: The patient will be influenza free between 4 to 7 days.

Nursing Actions (At least 3 of each) Assess    

Vitals and neurological status every hour Palpate lymph nodes every 4 hours Auscultate lung sounds and possible aspiration every hour Monitor for seizure activity

Assist     

Set up suction equipment and oral airway at bedside Lower the bed in lowest position Refer to HCP for follow up Refer to pediatric neurologist for evaluation Administer medications acetaminophen and lorazepam as prescribed

Teach   

Educate caregiver on seizure safety measures to take at home Educate caregiver on medication regimen to continue after discharge Educate caregiver on signs and symptoms of infection

Evaluations of Nursing Actions:

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    

Patient is able to maintain vital signs and temperature within normal limits. Lymph nodes regress to normal size and functionality Lung sounds clear bilaterally with no signs of aspiration Patient’s pain is decreased to 1/10 according to FLACC scale Seizure activity is being continually monitored

Evaluations of Outcomes:   

The patient is demonstrating temperature within normal limits, with no skin flushing Throat culture is being processed for presence of influenza type A The patient’s caregiver demonstrated understanding of seizure precautions and signs and symptoms of infection

Modifications of Plans: Continue with current Plan of Care, no modifications needed at this moment.

List additional appropriate Nursing diagnosis:  

Risk for aspiration related to decreased LOC Impaired comfort related to acute pain as evidenced by pain 5/10 on FLACC scale

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