Serial
number
1
2
Nursing
diagnosis
Short term
Seizures related
to C.N.S
dysfunction
secondary to
infectious
process.
Nursing
objectives
Potential for
asphyxiation
related to
seizures.
To prevent
asphyxiation
during spasms.
To control
seizures within
period of
hospitalization.
Nursing interventions






We nursed patient in a
dark and quiet room.
We administered
diazepam 1amp IV, and
Penicillin G 2million
I.U as ordered, while
watching for side
effects such as
lethargy,
hallucinations,
sedation, confusion etc.
We maintained a patent
airway by placing a
spatula between the
upper and lower teeth.
We tried to place
patient’s head in a
lateral position.
We administered
diazepam and penicillin
G as ordered,while
watching for effects
such as hallucination,
sedation, confusion etc.
Rationale





Light and noise
will cause
stimulation of the
C.N.S that will
lead to spasms.
Muscle relaxant
will control tonic
spasms while
penicillin will
treat the underline
cause.
To prevent the
tongue from
falling back and
blocking the
trachea.
To encourage
postural drainage
from the mouth.
Diazepam will
cause relaxation
of the intercostals
muscle, while
penicillin will
treat the underline
cause.
Expected
outcome
Evaluation
Seizures should
be brought
under control
and gradually
reduce within
hospitalization
period.
On observation
patient presented
with 8 episodes of
spasms.
Patient should
not go into
asphyxiation
during spasms.
No signs of
asphyxiation were
observed.
3
Potential for
injuries related
to involuntary
spasms.
To prevent
patient from
sustaining
injuries during
spasms.



4
Long term
Back pain
related to
abnormal
posture.
To minimize
pain by
restoring
normal posture.
We put up bed rails
which we padded with
cloth.
We adviced patient’s
mother to give nil per
os.
We administered
diazepam 1 amp IV
8hourly as ordered,
while watching for side
effects such as
confusion, sedation,
hallucination etc.
We repositioned patient to a
sitting position with pillows at
his back to lean on, and also
advised the mother to sit
behind him and support him in
sitting.
In performing range of motion
exercise we were gentle in
flexing and extending the
joints, being careful not to
exceed the angle permitted by
the joint.
We did the exercises just for a
few minutes.



To prevent patient
from falling off
the bed, and
sustaining any
wounds.
To prevent patient
from choking.
To control spasms
thereby
preventing
injuries.
To maintain the spinal
cord’s anatomical
position, and to prevent
deformity.
Performing exercises
gently and slowly
minimizes pain.
Remaining within the
range prevents pain and
dislocation.
Doing this for a few
minutes prevents
exhaustion and
discomfort.
Patient should
be well
protected from
any source of
injuries during
spasms.
On inspection,
there were no
injuries sustained.
Patient should
report little or
no pain, and
should maintain
a normal
posture during
hospitalization
period.
Patient
complained of
less pain and
could sit up with
assistance.
5
Potential formal
nutrition related
to poor feeding
To provide
nutritional
education to the
patient before
discharge.
We advice patient’s mother to
prepare foods that contain
basic nutrients such as protein,
carbohydrate, vitamin, and
fats.
This we specified foods such
as rice and beans, vegetables
and ripe plantain; these of
course would be mashed, fruits
e.g. paw-paw and oranges, to
name a few.
Balanced meals will
prevent mal-nourishment,
thereby, building then
immune system.
It also provides energy
and repair of tissues.
Patient should
have an idea on
basic nutrition
before
discharge.
Patient’s mother
understood the
need for a
balanced diet.
She could list the
basic food
nutrients.
6
Self care deficit
syndrome
related to
muscle
weakness.
Care giver role
strain related to
24hours role of
responsibility.
To improve on
patient’s care
and comfort
during
hospitalization.
To reduce the
burden on the
mother.
We gave patient bed bath.
We did his mouth touilet
We made up his bed and kept
his bed side clean.
To improve on skin
integrity.
To prevent oral thrush.to
keep patient comfortable.
Patient still needs
assistance to carry
out activities of
daily living.
To help her understand
the situation, hence
bringing about her
compliance with the
patient.
To reduce her anxiety.
To lessenherburden and
to allow her have some
rest.
Potential for
To watch for
We assessed for causative and
contributing factors such as
poor understading of the
situation, insufficient leisure
and resources.
We encouraged themother to
discuss her difficulties.
We assisted her in caring for
the child so that she could go
home and clean up her self.
We advised her to ask for help
from relatives.
We monitored vital signs twice
Patient should
be able to care
for himself
during
hospitalization.
The care giver
should be able
to care for her
ownself and
should not be
exhausted as a
result of
24hours
responsibility.
Changes in V/s show
Patient should
No signs of
7
8
The burden on the
mother was
reduced as she
expressed relief
from the
assistance given.
development for
complications
e.g. atelectasis,
pulmonary
embolism
early signs of
complications
such as
cyanosis,
increase pulse
rate etc
daily.
We observed for signs of
complications such as
cyanosis, increase pulse rate
etc.
We administered penicillin G
as prescribed, while watching
for side effects such as
hallucinations, lethargy.
earliest signals of
impending
complications.
Early diagnosis and
intervention controls the
evolution of
complications.
be closely
monitored to
prevent
complication
within
hospitalization
period.
complications
were observed
ASSESSMENT FINDINGS
DAY 4
a. Patient’s problems
i)short term
 Seizures related to C.N.S dysfunction.
 Potential for asphyxiation related to seizures.
 Potential for the development of injuries related to tonic spasms.
ii) Long term
 Pains related to range of motion exercises.
 Self care deficit syndrome related to muscle weakness.
 Care giver role strain related to 24hours role of responsibility.
 Financial constraints.
 Potential for the development of complications.
b. Patient’s needs
Following maslow’s heirachy we have;
 Physiologic needs
 Safety and security .
 Self esteem.
 Self actualization.
Serial
Nursing
number diagnosis
Short term
Seizures
1
related to
C.N.S
dysfunction
secondary to
infectious
process.
Nursing
objectives
Nursing interventions
Rationale
Expected
outcome
Evaluation
To control
seizures during
hospitalization
period.
On
observation
patient
presents with
8 episodes of
spasms.
To prevent
asphyxiation
during seizures.
Light and noise will cause
stimulations of the CNS
that will lead to tonic
spasms.
Muscle relaxants to
control and stop tonic
spasms.
Antibiotic will treat the
underline cause.
To prevent the tongue
from falling back and
blocking the trachea.
To encourage postural
drainage fom the mouth.
Diazepam will cause the
intercostal muscles and
diaphragm to relax , to
ease breathing.
Seizures should
bebrought uder
controland
gradually reduce
within
hospitalization
period.
2
We nursed patient in a dark
and quiet room.
We administered diazepam
1amp IV 8hourly,
And penicillin G 2million IU
6hourly as prescribed; while
watching for side effects such
as lethargy, confusion,
hallucination, and sedation.
We maintained a patent
airway i.e. we placed a
spatula between the upper and
lower teeth.
We tried to place patient’s
head in a lateral position.
We administered prescribed
medications(diazepam and
penicillin), while watching for
side effects such as sedation,
lethargy etc.
Patient should not
go into
asphyxiation
during spasms.
No signs of
asphyxiation
were
observed.
Potential for
asphyxiation
related to
seizures.
3
4
5
Risk of
injuries
related to
seizures.
Long term
Pain related to
range of
motion
exercises.
Self care
deficit
syndrome
related to
muscle
weakness.
To prevent
patient from
sustaining
injuries during
spasms.
We put up bed rails which we
padded with cloth.
We advised patient’s mother
to give nil per os during
seizures.
We administered diazepam
1amp IV 8hourly and watched
for signs of sedation, lethargy
etc.
To prevent patient from
falling off the bed, and
sutaining any wounds.
To prevent patient from
choking.
To control spasms,
thereby avoiding injuries.
To minimize
pain during
range of motion
exercise.
In performing range of motion
exercises, we were gentle and
slow in flexing and extending
the joints.
We were careful not to exceed
the range permitted by the
joints.
We did these exercises just
for a few minutes.
Performing exercises
gently and slowly
minimizes pain.
Remaining within the
range prevents pain and
dislocation.
Doing the exercises for a
few minutes prevents
exhaustion and
discomfort.
To improve on
patient’s care
and comfort
during
hospitalization.
We gave patient bed bath.
We gave him mouth wash.
We made up his bed and
cleaned his bed side.
To improve on skin
integrity.
To prevent oral thrush.
To keep patient
comfortable.
Patient should be
well protected
from any source
of injury during
spasms.
On
inspection, no
injuries were
sustained.
Patient should
report little or no
pain during
exercises.
Patient
reports less
pain during
exercises.
Patient should be
able to ccare for
himself during
hospitalization.
Patient still
needs
assistance to
carryout
activities of
daily living.
6
Caregiver role
strain related
to 24hours
role of
responsibility.
To reduce the
burden on the
caregiver.
7
Potential for
To watch for
development
early signs of
complications. complications.
8
Financial
constraints.
To restore
psychological
homeostasis
during
hospitalization
period.
We encourage the mother to
discuss her difficulties.
We assisted her in caring for
the child so that she could go
home and clean herself.
We advised her to ask for help
from her relatives.
To reduce her anxiety.
To lessen her burden and
To allow her have some
rest.
The care giver
should be able to
care for herself,
and should not be
exhausted as a
result of 24hours
role
responsibility.
The burden
on the mother
was reduced
due to the
assistance
from the St
Francis
nurses.
We monitored V/s twice
daily.
We observed for signs of
complications such as
cyanosis, increased pulse, and
seizures.
We administered prescribed
medications (penicillin and
diazepam) as we watched for
side effects such as sedation,
hallucination, lethargy and
confusion.
We discussed the need for
financial support with the
patient’s parents,and they
promised to solve it.
Changes iin V/s show
earliest signals of
impending complication.
Early diagnosis and
intervention controls the
evolution of
complications.
Patient should be
closely monitored
to prevent
complications
within the
hospitalization
period.
No signs of
complications
were noticed.
Understanding the need
for financial support will
bring about compliance.
Patient should be
able to afford all
his medications
during
hospitalization.
Patient’s
glucose
infusion
remained
pending.
ASSSESSMENT FINDINGS
DAY 5 – 20
Due to lack of space and time, and for the fact that patient’s problems for day 5to day 20
remained unchanged and our interventions were similar for these days, we decided to
produce a care plan for day 5 to day 20.
a. Patient’s problems
i)
short term
 Seizures related to C.N.S dysfunction.
 Potential for asphyxiation related to tonic spasms.
 Risk of injury related to spasms.
ii)
Long term
 Pain related to range of motion exercises.
 Self care deficit syndrome related to muscle weakness.
 Financial constraints
 Potential for development of complications.
b. Patient’s need
 Physiologic need.
 Safety and security.
 Self esteem.
 Self actualization
Nursing diagnosis
Nursing objective
Nursing intervention.
Rationale
Expected
outcome.
Evaluation
To control
seizures within
period of
hospitalization.
We nursed patient in a dark
and quiet room.
We administered diazepam
1amp IV 8hourly,
Penicillin 2million IU 6hourly
as prescribed, while watching
for signs of sedation, lethargy,
hallucinations etc.
Photo stimulations and
noise will cause
stimulations of the CNS,
which leads to tonic
spasms.
Muscle relaxant to control
and stop tonic spasms.
Penicillin will treat the
underline cause.
Seizures should
be brought under
control and
gradually stop
during
hospitalization.
On
observation,
patient
presented
with 7
episodes of
spasms.
To prevent
asphyxiation
during spasms.
We maintained a patent
airway, by placing a spatula
between the upper and lower
teeth.
We tried to place the patient’s
head in a lateral position.
We administerd medications as
ordered(diazepam and
penicillin.
To prevent the tongue from
falling back and blocking
the trachea.
To encourage postural
drainage from the mouth.
Diazepam will cause
relaxation of the
intercostals and diaphragm
muscles.
Patient should not
go into
asphyxiation
during spasms.
No signs of
asphyxiation
were
observed.
Serial
number
1
2
Short term
Seizures related
to CNS
dysfunction
secondary to
infectious
process.
Potential for
asphyxiation
related to
seizures.
Potential for
injuries related to
seizures.
To prevent patient
from sustaining
injuries during
spasms.
We put up bed rails which we
padded with cloth.
We advised patient mother to
give nil per os during spasms.
We administered diazepam
1amp IV 8hourly as
prescribed, while watching for
signs of sedation, lethargy, and
drowsiness.
To prevent patient from
falling off the bed, and
from sustaining any
wounds.
To prevent the patient from
choking.
To control spasms thereby
avoiding injuries.
Patient should be
well protected
from any source
of injury during
spasms.
On inspection,
no injuries
were noticed.
Long term
Pain related to
range of motion
exercises.
To minimize pain
during range of
motion exercises.
We were gentle in extending
and flexing the joints.
We were also careful not to
exceed the range permitted by
the joint.
We did the exercises just for
few minutes.
Performing exercises
gently and slowly
minimizes pain.
Remaining within the
range permitted prevents
pain and dislocation.
Doing this for a few
minutes prevents
exhaustion and discomfort.
Patient should
report little or no
pain during range
of motion
exercise.
Patient
complains of
less pain
during
exercises.
Self care deficit
syndrome related
to muscle
weakness.
To improve on
patient’s care
during
hospitalization.
We gave patient bed bath.
We also gave him mouth wash.
We made up patient’s bed and
kept his bed side clean.
To maintain skin integrity.
To prevent mouth wash.
To keep patient
comfortable.
Patient should be
able to maintain
personal body
hygiene.
Patient still
needs
assistance to
carry out
activities of
daily living.
3
4
5
6
Financial
constraints.
To restore
psychological
homeostasis
within patient’s
stay in the
hospital.
We discussed with patient’s
parents about the need for
financial assistance from
relatives and friends.
Understanding the need for
financial aid brings about
compliance from
significant others.
Anxiety should be
relieved and
patient should be
able to receive all
his drugs.
Patient could
afford most of
the prescribed
drugs.
7
Potential for the
development of
complications.
To watch for
early signs of
complications,
such as cyanosis,
increased pulse
etc.
We monitored V/s twice a
shift.
We observed for signs of
complications such as
cyanosis.
We administered prescribed
medications(penicillin and
diazepam) while watching for
signs such as sedation,
hallucination, confusion etc.
Changes in V/s show
earliest signals of
impending complication.
Early diagnosis and
intervention controls the
evolution of complications.
Prescribed medications
will treat the underline
cause.
Patient should be
closely monitored
to prevent
complications
during
hospitalization.
No signs of
complications
were
observed.
ASSESSMENT FINDINGS
DAY 21
a. Patient’s problems
i) short term
 Patient no longer presents with these problems.
ii)Long term
 Knowledge deficit.
 Financial constraints.
c. Patient’s needs
 Self esteem
 Self actualization.
Serial
number
Nursing diagnosis.
Nursing objectives.
Nursing interventions.
Rationale.
Expected
outcome.
Evaluation.
1
Knowledge deficit
related to lack of
information.
Patient should
acquire sufficient
knowledge on
tetanus.
We explained to the patient
and significant others the
cause of tetanus which is
Clostridium tetani and its
mode of transmission (e.g.
through septic wounds).
We also explained the need
for immunization, which is
to provide antibodies to fight
against the bacillus.
Awareness brings
about compliance to
treatment, and knowing
the cause and mode of
transmission helps in
prevention.
Immunization helps to
fight against any
tetanus toxins.
Patient should
acquire basic
knowledge on
tetanus.
Patient and
his relations
showed much
understanding
and asked a
lot of
questions
which we
answered.
2
Slight deformity at
the back related to
abnormal posture.
To restore normal
anatomical posture.
We repositioned patient from
a lying to a sitting position.
We did range of motion
exercises.
We encouraged patient to
gradually resume an upright
posture.
To avoid stiffness and
loss of function of the
back muscles.
To promote flexion and
relaxation of the
muscles.
Patient should
recover the
normal
anatomical
posture, when
standing.
Back
deformity was
greatly
reduced on
observation.