there\'s 2 pages. just fill in don\'t need to get crazy 2-24 THE PAIENT WITH A S
ID: 138491 • Letter: T
Question
there's 2 pages. just fill in don't need to get crazy
2-24 THE PAIENT WITH A SEIZURE DISORDER 181 2-24 THE PATIENT WITH A SEIZURE DISORDER 1600 Transfer Handoff Report: S Mr. M, 20 years old, fell at home and lost consciousness. He was just transferred to the neurology unit from the emergency department. He is aware and alert, VS at 1530 are T 97.8°E, P 76, R 20, BP 120/76, pulse ox 98%, pain level 0, The MD orders include seizure precautions, bed rest, soft diet, VS, and neu rologic checks q4h. He has a saline lock on the left hand. He is anxious about being admitted. 20-year-old male fell at home and was brought to the emergency department after it was noticed that he had lost consciousness for a few seconds. In the emergency department he indicated that he did not remember falling. His family history is significant for seizure disorders. Diagnostic studies included an electroencephalogram, magnetic resonance imaging, serum blood glucose, complete blood cell count, electrolytes, blood urea nitrogen, and urinalysis drug screening. B You begin your assessment by following the recommended nursing interventions. Prioritize the following five recommended nursing interventions as you would do them to initially take care of Mr. M. Write a number in the box to identify the order ofyour interventions (#1 = first intervention, #2 second intervention, etc.), and state a rationale for each intervention INTERVENTIONS PRIORITY # RATIONALE . Orient Mr. M to his room . Assess neurologic status . Implement seizure precautions Obtain admitting history Inform patient of pertinent MD orders KEY POINTS TO CONSIDERExplanation / Answer
Interventions according to priority
1) Orient Mr M to his room
Rationale- As Mr M is anxious about admission orientation may help to relieve some anxiety
2) Obtain admitting history
Rationale- To identify any risk factor, family history of seizure disorder, so can be prepared accordingly.
3) Assess neurological status
Rationale- To rule out any abnormalities
4) Inform patient about pertinent MD orders
Rationale- To reduce anxiety during implementation of orders
5) Implement seizure precautions
Rationale- To prevent seizures
Key points
- Mr M has family history of seizure disorder
- Loss of consciousness after fall
Priority nursing diagnosis identified in second situation is
Readiness for enhanced knowledge: Seizure disorder
Rationale - As Mr M is saying that he had this episodes prior also but has hidden it from others, Also he says he see something floating prior to seizure activity.
Intervention
Assess patient level of knowledge about the condition to plan teaching accordingly.
Assess the preferable method of learning
Tell the patient various sources available for more information.
Decision making diagram
Priority problems
1) Risk for aspiration (Excessive salivation)
2) Risk for injury related to seizure activity
3) Anxiety
4) Fear
5) Social isolation
Priority nursing interventions
1) Check airway patency ( due to back fall of tongue during seizure activity)
2) Turn to side (to prevent aspiration)
3) Assess for injury
4) Maintain quiet environment
5) Reorient patient
6) Record findings
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