Convulsion Nursing Care Plan

 

Nursing Diagnosis
  • Risk for Trauma
  • Risk for Suffocation

Risk factors may include

  • Weakness, balancing difficulties; reduced muscle, hand or eye coordination
  • Poor vision
  • Reduced sensation
  • Cognitive limitations or altered consciousness
  • Loss of large or small muscle coordination
  • Emotional difficulties

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Verbalize understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to correct the situation.
  • Identify actions or measures to take when seizure activity occurs.
  • Identify and correct potential risk factors in the environment.
  • Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
  • Modify environment as indicated to enhance safety.
  • Maintain treatment regimen to control or eliminate seizure activity.
  • Recognize the need for assistance to prevent accidents or injuries.
Nursing Interventions
  • Determine factors related to individual situation, as listed in Risk Factors, and extent of risk.
    • Rationale: Influences scope and intensity of interventions to manage threat to safety.
  • Note client’s age, gender, developmental age, decision-making ability, level of cognition or competence.
    • Rationale: Affects client’s ability to protect self and others, and influences choice of interventions and teaching.
  • Ascertain knowledge of various stimuli that may precipitate seizure activity.
    • Rationale: Alcohol, various drugs, and other stimuli (loss of sleep, flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity.
  • Review diagnostic studies or laboratory tests for impairments and imbalances.
    • Rationale: Such may result in or exacerbate conditions, such as confusion, tetany, pathological fractures, etc.
  • Explore and expound seizure warning signs (if appropriate) and usual seizure pattern. Teach SO to determine and familiarize warning signs and how to care for patient during and after seizure attack.
    • Rationale: Enables patient to protect self from injury and recognize changes that require notification of physician and further intervention. Knowing what to do when seizure occurs can prevent injury or complications and decreases SO’s feelings of helplessness.
  • Use and pad side rails with bed in lowest position, or place bed up against wall and pad floor if rails not available or appropriate.
    • Rationale: Prevents or minimizes injury when seizures (frequent or generalized) occur while patient is in bed. Note: Most individuals seize in place and if in the middle of the bed, individual is unlikely to fall out of bed.
  • Educate patient not to smoke except while supervised.
    • Rationale: May cause burns if cigarette is accidentally dropped during aura or seizure activity.
  • Evaluate need for or provide protective headgear.
    • Rationale: Use of helmet may provide added protection for individuals who suffer recurrent or severe seizures.
  • Avoid using thermometers that can cause breakage. Use tympanic thermometer when necessary to take temperature.
    • Rationale: Reduces risk of patient biting and breaking glass thermometer or suffering injury if sudden seizure activity should occur.
  • Uphold strict bedrest if prodromal signs or aura experienced. Explain necessity for these actions.
    • Rationale: Patient may feel restless or need to ambulate or even defecate during aural phase, thereby inadvertently removing self from safe environment and easy observation. Understanding importance of providing for own safety needs may enhance patient cooperation.
  • Do not leave the patient during and after seizure.
    • Rationale: Promotes safety measures.
  • Turn head to side and suction airway as indicated. Insert plastic bite block only if jaw relaxed.
    • Rationale: Helps maintain airway patency and reduces risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Wooden tongue blades should not be used because they may splinter and break in patient’s mouth.
  • Support head, place on soft area, or assist to floor if out of bed. Do not attempt to restrain.
    • Rationale: Supporting the extremities lessens the risk of physical injury when patient lacks voluntary muscle control. Note: If attempt is made to restrain patient during seizure, erratic movements may increase, and patient may injure self or others.
  • Note preseizure activity, presence of aura or unusual behavior, type of seizure activity (location or duration of motor activity, loss of consciousness, incontinence, eye activity, respiratory impairment or cyanosis), and frequency or recurrence. Note whether patient fell, expressed vocalizations, drooled, or had automatisms (lip-smacking, chewing, picking at clothes).
    • Rationale: Helps localize the cerebral area of involvement.
  • Provide neurological or vital sign check after seizure (level of consciousness, orientation, ability to comply with simple commands, ability to speak; memory of incident; weakness or motor deficits; blood pressure (BP), pulse and respiratory rate).
    • Rationale: Documents postictal state and time or completeness of recovery to normal state. May identify additional safety concerns to be addressed.
  • Reorient patient following seizure activity.
    • Rationale: Patient may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety.
  • Allow postictal “automatic” behavior without interfering while providing environmental protection.
    • Rationale: May display behavior (of motor or psychic origin) that seems inappropriate or irrelevant for time and place. Attempts to control or prevent activity may result in patient becoming aggressive or combative.
  • Investigate reports of pain.
    • Rationale: May be result of repetitive muscle contractions or symptom of injury incurred, requiring further evaluation or intervention.
  • Detect status epilepticus (one tonic-clonic seizure after another in rapid succession).
    • Rationale: This is a life-threatening emergency that if left untreated could cause metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased intracranial pressure, airway obstruction, and respiratory arrest. Immediate intervention is required to control seizure activity and prevent permanent injury or death. Note: Although absence seizures may become static, they are not usually life-threatening.

Carry out medications as indicated: Specific drug therapy depends on seizure type, with some patients requiring polytherapy or frequent medication adjustments.

  • Antiepileptic drugs (AEDs): phenytoin (Dilantin), primidone (Mysoline), carbamazepine (Tegretol), clonazepam (Klonopin), valproic acid (Depakene), divalproex (Depakote), acetazolamide (Diamox), ethotoin (Peganone), methsuximide (Celotin), fosphenytoin (Cerebyx);
    • Rationale: AEDs raise the seizure threshold by stabilizing nerve cell membranes, reducing the excitability of the neurons, or through direct action on the limbic system, thalamus, and hypothalamus. Goal is optimal suppression of seizure activity with lowest possible dose of drug and with fewest side effects. Cerebyx reaches therapeutic levels within 24 hr and can be used for nonemergent loading while waiting for other agents to become effective. Note: Some patients require polytherapy or frequent medication adjustments to control seizure activity. This increases the risk of adverse reactions and problems with adherence.
  • Topiramate (Topamax), ethosuximide (Zarontin), lamotrigine (Lamictal), gabapentin (Neurontin);
    • Rationale: Adjunctive therapy for partial seizures or an alternative for patients when seizures are not adequately controlled by other drugs.
  • Phenobarbital (Luminal);
    • Rationale: Potentiates and enhances effects of AEDs and allows for lower dosage to reduce side effects.
  • Lorazepam (Ativan);
    • Rationale: Used to abort status seizure activity because it is shorter acting than Valium and less likely to prolong post seizure sedation.
  • Diazepam (Valium, Diastat rectal gel);
    • Rationale: May be used alone (or in combination with phenobarbital) to suppress status seizure activity. Diastat, a gel, may be administered rectally, even in the home setting, to reduce frequency of seizures and need for additional medical care.
  • Glucose, thiamine.
    • Rationale: May be given to restore metabolic balance if seizure is induced by hypoglycemia or alcohol.
  • Monitor and document AED drug levels, corresponding side effects, and frequency of seizure activity.
    • Rationale: Standard therapeutic level may not be optimal for individual patient if untoward side effects develop or seizures are not controlled.
  • Monitor CBC, electrolytes, glucose levels.
    • Rationale: Identifies factors that aggravate or decrease seizure threshold.
  • Prepare for surgery or electrode implantation as indicated.
    • Rationale: Vagal nerve stimulator, magnetic beam therapy, or other surgical intervention (temporal lobectomy) may be done for intractable seizures or well-localized epileptogenic lesions when patient is disabled and at high risk for serious injury. Success has been reported with gamma ray radio surgery for the treatment of multiple seizure activity that has otherwise been difficult to control.
Nursing Diagnosis
  • Risk for Ineffective Airway Clearance
  • Risk for Ineffective Breathing Pattern

Risk factors may include

  • Neuromuscular impairment
  • Tracheobronchial obstruction
  • Perceptual or cognitive impairment

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Maintain effective respiratory pattern with airway patent or aspiration prevented.
Nursing Interventions
  • Ensure patient to empty mouth of dentures or foreign objects if aura occurs and to avoid chewing gum and sucking lozenges if seizures occur without warning.
    • Rationale: Lessens risk of aspiration or foreign bodies lodging in pharynx.
  • Maintain in lying position, flat surface; turn head to side during seizure activity.
    • Rationale: Helps in drainage of secretions; prevents tongue from obstructing airway.
  • Loosen clothing from neck or chest and abdominal areas.
    • Rationale: Aids in breathing or chest expansion.
  • Provide and insert plastic airway or soft roll as indicated and only if jaw is relaxed.
    • Rationale: If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning or respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue.
  • Suction as needed.
    • Rationale: Reduces risk of aspiration or asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min.
  • Supervise supplemental oxygen or bag ventilation as needed postictally.
    • Rationale: May lessen cerebral hypoxia resulting from decreased circulation or oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in or out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists (foreign body or aspiration).
  • Get ready for or assist with intubation, if indicated.
    • Rationale: Presence of prolonged apnea postictally may need ventilatory support.
Nursing Diagnosis
  • Low Self-Esteem

May be related to

  • Stigma associated with condition
  • Perception of being out of control
  • Social role changes
  • Feelings of abandonment
  • Inconsistent behavior

Possibly evidenced by

  • Verbalization about changed lifestyle
  • Fear of rejection; negative feelings about body
  • Change in self-perception of role
  • Change in usual patterns of responsibility
  • Lack of follow-through or nonparticipation in therapy
  • Expressions of helplessness or uselessness
  • Evaluation of self as unable to deal with situations or events
Desired Outcomes
  • Identify feelings and methods for coping with negative perception of self.
  • Verbalize increased sense of self-esteem in relation to diagnosis.
  • Verbalize realistic perception and acceptance of self in changed role or lifestyle.
  • Express positive self-appraisal
  • Demonstrate behaviors to restore positive self-esteem.
  • Participate in treatment regimen or activities to correct factors that precipitated crisis.
Nursing Interventions
  • Determine individual situation related to low self-esteem in the present circumstances.
    • Rationale: Verbalization of concerns about future implications can help patient begin to accept or deal with situation.
  • Explore feelings about diagnosis, perception of threat to self. Encourage expression of feelings.
    • Rationale: Reactions vary among individuals, and previous knowledge or experience with this condition affects acceptance of therapeutic regimen.
  • Analyze possible or anticipated public reaction to condition. Encourage patient to refrain from concealing problem.
    • Rationale: Provides opportunity to problem-solve response, and provides measure of control over situation. Concealment is destructive to self-esteem (potentiates denial), blocking progress in dealing with problem, and may actually increase risk of injury or negative response when seizure does occur.
  • Discuss with patient current and past successes and strengths.
    • Rationale: Concentrating on positive aspects can help alleviate feelings of guilt and self- consciousness and help patient begin to accept manageability of condition.
  • Refrain from over protecting the patient; encourage activities, providing supervision and monitoring when indicated.
    • Rationale: Participation in as many experiences as possible can lessen depression about limitations. Observation and supervision may need to be provided for such activities as gymnastics, climbing, and water sports.
  • Know the attitudes or capabilities of SO. Help individual realize that his or her feelings are normal; however, guilt and blame are not helpful.
    • Rationale: Contradictory or unfavorable expectations from SO may affect patient’s sense of competency and self-esteem and interfere with support received from SO, limiting potential for optimal management and personal growth.
  • Elaborate the positive effect of staff and SO remaining calm during seizure activity.
    • Rationale: Tension and anxiety among caregivers is contagious and can be conveyed to the patient, increasing or multiplying individual’s own negative perceptions of situation or self.
  • Refer patient and SO to support group (Epilepsy Foundation of America,National Association of Epilepsy Centers, and Delta Society’s National Service Dog Center).
    • Rationale: Provides opportunity to gain information, support, and ideas for dealing with problems from others who share similar experiences. Note: Some service dogs have ability to sense or predict seizure activity, allowing patient to institute safety measures, increasing independence and personal sense of control.
  • Talk over and explain referral for psychotherapy with patient and SO.
    • Rationale: Seizures have a profound effect on personal self-esteem, and patient or SO may feel guilt over perceived limitations and public stigma. Counseling can help overcome feelings of inferiority and self-consciousness.
Nursing Diagnosis
  • Knowledge Deficit

May be related to

  • Lack of exposure, unfamiliarity with resources
  • Information misinterpretation
  • Lack of recall; cognitive limitation

Possibly evidenced by

  • Questions, statement of concerns
  • Increased frequency or lack of control of seizure activity
  • Lack of follow-through of drug regimen
Desired Outcomes
  • Verbalize understanding of disorder and various stimuli that may increase potentiate seizure activity.
  • Participate in learning process.
  • Exhibit increased interest or assume responsibility for own learning by beginning to look  for information and ask questions.
  • Adhere to prescribed drug regimen.
  • Identify relationship of signs and symptoms to the disease process and correlate symptoms with causative factors.
  • Initiate necessary lifestyle or behavior changes as indicated.
Nursing Interventions
  • Ascertain level of knowledge, including anticipatory needs.
    • Rationale: To assess readiness to learn
  • Determine client’s ability or readiness and barriers to learning.
    • Rationale: Individual may not be physically, emotionally, or mentally capable at this time.
  • Review pathology and prognosis of condition and lifelong need for treatments as indicated. Discuss patient’s particular trigger factors (flashing lights, hyperventilation, loud noises,video games, TV viewing).
    • Rationale: Provides opportunity to clarify or dispel misconceptions and present condition as something that is manageable within a normal lifestyle.
  • Review possible effects of hormonal changes.
    • Rationale: Alterations in hormonal levels that occur during menstruation and pregnancy may increase risk of seizures.
  • Discuss significance of maintaining good general health, (adequate diet, rest, moderate exercise, and avoidance of exhaustion, alcohol, caffeine, and stimulant drugs).
    • Rationale: Regularity and moderation in activities may aid in reducing or controlling precipitating factors, enhancing sense of general well-being, and strengthening coping ability and self-esteem. Note: Too little sleep or too much alcohol can precipitate seizure activity in some people.
  • Know and instill the importance of good oral hygiene and regular dental care.
    • Rationale: Lessens risk of oral infections and gingival hyperplasia.
  • Identify necessity and promote acceptance of actual limitations; discuss safety measures regarding driving, using mechanical equipment, climbing ladders, swimming, and hobbies.
    • Rationale: Lessens risk of injury to self or others, especially if seizures occur without warning.
  • Review local laws and restrictions pertaining to persons with epilepsy and seizure disorder. Encourage awareness but not necessarily acceptance of these policies.
    • Rationale: Although legal and civil rights of persons with epilepsy have improved during the past decade, restrictions still exist in some states pertaining to obtaining a driver’s license, sterilization, workers’ compensation, and required reportability to state agencies.
  • Review medication regimen, necessity of taking drugs as ordered, and not discontinuing therapy without physician supervision. Include directions for missed dose.
    • Rationale: Lack of cooperation with medication regimen is a leading cause of seizure breakthrough. Patient needs to know risks of status epilepticus resulting from abrupt withdrawal of anticonvulsants. Depending on the drug dose and frequency, patient may be instructed to take missed dose if remembered within a predetermined time frame.
  • Recommend taking drugs with meals, if appropriate.
    • Rationale: May reduce incidence of gastric irritation, nausea and vomiting.
  • Discuss nuisance and adverse side effects of particular drugs (drowsiness, fatigue, lethargy, hyperactivity, sleep disturbances, gingival hypertrophy, visual disturbances, nausea and vomiting, rashes, syncope and ataxia, birth defects, aplastic anemia).
    • Rationale: May indicate need for change in dosage or choice of drug therapy. Promotes involvement and participation in decision-making process and awareness of potential long-term effects of drug therapy, and provides opportunity to minimize or prevent complications.
  • Provide information about potential drug interactions and necessity of notifying other healthcare providers of drug regimen.
    • Rationale: Knowledge of anticonvulsant use reduces risk of prescribing drugs that may interact, thus altering seizure threshold or therapeutic effect. For example, phenytoin (Dilantin) potentiates anticoagulant effect of warfarin (Coumadin), whereas isoniazid (INH) and chloramphenicol (Chloromycetin) increase the effect of phenytoin (Dilantin), and some antibiotics (erythromycin) can cause elevation of serum level of carbamazepine (Tegretol), possibly to toxic levels.
  • Familiarize proper use of diazepam rectal gel (Diastat) with patient, SO and caregiver as appropriate.
    • Rationale: Useful in controlling serial or cluster seizures. Can be administered in any setting and is effective usually within 15 min. May reduce dependence on emergency department visits.
  • Encourage patient to wear identification tag or bracelet stating the presence of a seizure disorder.
    • Rationale: Expedites treatment and diagnosis in emergency situations.
  • Stress need for routine follow-up care and laboratory testing as indicated (CBC should be monitored biannually and in presence of sore throat or fever, signs of other infection).
    • Rationale: Therapeutic needs may change and or serious drug side effects (agranulocytosis or toxicity) may develop.
Other Possible Nursing Care Plans
  • Injury, risk for—weakness, balancing difficulties, cognitive limitations or altered consciousness, loss of large or small muscle coordination.
  • Self-Esteem (specify)—stigma associated with condition, perception of being out of control, personal vulnerability, negative evaluation of self or capabilities.
  • Therapeutic Regimen: ineffective management—social support deficits, perceived benefit (versus side effects of medication), perceived susceptibility (possible long periods of remission).