Question

Mr. Mitchell, 20 years old, fell at home and was brought to the emergency room after it was noticed he had lost consciousness for a few seconds. In the emergency room indicated that he did not remember falling. His family history is significant for seizure disorders. Diagnostic studies were ordered and included an EEG, MRI, serum blood glucose, CBC, BUN, and UA drug screening. He was just transferred to the neurological unit from the emergency room. The current MD orders include: seizure precautions, bed rest, soft diet, saline lock, vital signs, and neuro checks q4h.  

Prioritize the five nursing interventions as you would do them to take care of Mr. Mitchell. Write in the number in the box to identify the order of your interventions (#1=first intervention, #2=second intervention, etc.) and state an evidence-based rational for each intervention (cite your source)

INTERVENTIONS PRIORITY # RATIONALE

Orient Mr. Mitchell to his room
Assess neurovascular status
Implement seizure precautions
Obtain admitting history
Inform pt of MD pertinent orders

Mr. Mitchell is diagnosed with a seizure disorder and is started on Depakote. In speaking with Mr. Mitchell, you gather the following:

1. Mr. Mitchell says he has had similar episodes but never told anyone.
2. He remembers seeing “spots” before the episode.
3. No one in his family talked much about the relative who had seizures

            All of the following nursing diagnosis may apply to Mr. Mitchell

Ineffective coping, Ineffective airway clearance, Risk for injury, Deficient knowledge, disturbed self-concept, Social Isolation, Fear, Anxiety, Disturbed thought processes, Risk for aspiration

1. Select the ONE nursing diagnosis above that is of priority at this time
2. Provide a rationale for your selection
3. List three nursing interventions that meet the needs of Mr. Mitchell

Several hours after admission, you hear a “cry” coming from Mr. Mitchell’s room. You assess the following as you walk into the room:

Tonic-clonic movements of the body, loss of consciousness, excessive salivation, some cyanosis, urinary incontinence, teeth clenched with cessation of tonic-clonic movements after 3 minutes.

Based on situation above, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing intervention for this situation and identify your follow-up action plan for Mr. Mitchell. What is priority problem? What is a new action plan?

Priority Problem # 1 # 2 # 3 # 4 # 5 # 6

Nursing Interventions                                                                    New Action Plan

1. Maintain a quiet environment
2. Assess for injury
3. Check patency of airway
4. Document findings
5. Turn to side
6. Reorient patient

Answer 1

#. Prioritization of Nursing interventions :-

1. Assess neurovascular status

Rationale - to find out any abnormal assessment as early as possible and avoid complications.

2. Obtain admitting history

Rationale - it is the part of assessment and to know about his previous medical , famiy history as a guide for diagnosis.

3. Orient Mr. Mitchell to his room

Rationale - orientation of the environment to the patient will help to avoid falls and injuries

4. Implement seizure precautions

Rationale - to prevent seizures

5. Inform pt of MD pertinent orders

Rationale - for compliance to the treatment and cooperation in the treatment plan

#. Most important Nursing diagnosis :-

Ineffective airway due to secretions that get produced during seizures .

Interventions :-

- place the patient in side lying position

- don't swipe the tongue

- suctioning of the secretions

- oxygen administration

- vital assessment hrly and strict monitoring

#. Prioritization :-

1. Check patency of airway - to maintain airway

2. Turn to side - for lung expansion and excretion of secretions

3. Assess for injury - for early management and avoid complications

4. Maintain a quiet environment - to prevent episodes of seizure

5. Reorient the patient - orientation to the environment to avoid injury and to ensure safety

6. Document findings - as a part of Nursing care plan document findings .