Nursing Care Plan for Seizure | Seizure Disorders Overview; the Main Causes for Seizures; Classifications of Seizures
Seizures (convulsions) are the result of uncontrolled electrical discharges from the nerve cells of the cerebral cortex and are characterized by sudden, brief attacks of altered consciousness, motor activity, and/or sensory phenomena. Seizures can be associated with a variety of cerebral or systemic disorders as a focal or generalized disturbance of cortical function. Sensory symptoms arise from the parietal lobe; motor symptoms arise from the frontal lobe.
The phases of seizure activity are prodromal, aural, ictal, and postictal. The prodromal phase involves mood or behavior changes that may precede a seizure by hours or days. The aura is a premonition of impending seizure activity and may be visual, auditory, or gustatory. The ictal stage is characterized by seizure activity, usually musculoskeletal. The postictal stage is a period of confusion/somnolence/irritability that occurs after the seizure.
The main causes for seizures can be divided into six categories:
Toxic agents: Poisons, alcohol, overdoses of prescription/nonprescription drugs (with drugs the leading cause).
Chemical imbalances: Hyperkalemia, hypoglycemia, and acidosis.
Fever: Acute infections, heatstroke.
Cerebral pathology: Resulting from head injury, infections, hypoxia, expanding brain lesions, increased intracranial pressure.
Eclampsia: Prenatal hypertension/toxemia of pregnancy.
Idiopathic: Unknown origin.
Seizures can be divided into two major classifications (generalized and partial).
Generalized seizure types include tonic-clonic, myoclonic, clonic, tonic, atonic, and absence seizures.
Partial (focal) seizures are the most common type and are categorized as either (1) simple (partial motor, partial sensory) or (2) complex.
Nursing Care Plan for Seizure | Nursing Priorities; Discharge Goals
Nursing Priorities |Nursing Care Plan for Seizure
Prevent/control seizure activity.
Protect patient from injury.
Maintain airway/respiratory function.
Promote positive self-esteem.
Provide information about disease process, prognosis, and treatment needs.
Discharge Goals|Nursing Care Plan for Seizure
Seizures activity controlled.
Capable/competent self-image displayed.
Disease process/prognosis, therapeutic regimen, and limitations understood.
Plan in place to meet needs after discharge.
Nursing Care Plan for Seizure | Nursing Diagnosis for Seizure
Nursing Care Plan for Seizure | Nursing Diagnosis for Seizure; Risk factors; Desired Outcomes
Nursing Diagnosis for Seizure:
Trauma/Suffocation, risk for
Risk factors may include
Weakness, balancing difficulties
Cognitive limitations/altered consciousness
Loss of large or small muscle coordination
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Verbalize understanding of factors that contribute to possibility of trauma and/or suffocation and take steps to correct situation.
Risk Control (NOC)
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/eliminate seizure activity.
Knowledge: Personal Safety (NOC)
Identify actions/measures to take when seizure activity occurs.
Nursing Care Plan for Seizure | Nursing Interventions for Seizure
Nursing Care Plan for Seizure | Nursing Interventions for Seizure and Rationale;
Nursing Interventions for Seizures and Rationale
Seizure Precautions (NIC)
Nursing Interventions for Seizures (Independent) | Nursing Care Plan for Seizure
Explore with patient the various stimuli that may precipitate seizure activity. Rationale: Alcohol, various drugs, and other stimuli (e.g., loss of sleep, flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity.
Discuss seizure warning signs (if appropriate) and usual seizure pattern. Teach SO to recognize warning signs and how to care for patient during and after seizure. Rationale: Enables patient to protect self from injury and recognize changes that require notification of physician/further intervention. Knowing what to do when seizure occurs can prevent injury/complications and decreases SO’s feelings of helplessness.
Keep padded side rails up with bed in lowest position, or place bed up against wall and pad floor if rails not available/appropriate. Rationale: Minimizes injury should seizures (frequent/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.
Encourage patient not to smoke except while supervised. Rationale: May cause burns if cigarette is accidentally dropped during aura/seizure activity.
Evaluate need for/provide protective headgear. Rationale: Use of helmet may provide added protection for individuals who suffer recurrent/severe seizures.
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.
Maintain strict bedrest if prodromal signs/aura experienced. Explain necessity for these actions. Rationale: Patient may feel restless/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.
Stay with patient during/after seizure. Rationale: Promotes patient safety.
Turn head to side/suction airway as indicated. Insert plastic bite block only if jaw relaxed. Rationale: Helps maintain airway 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. (Refer to ND: Airway Clearance/Breathing Pattern, ineffective, risk for)
Cradle head, place on soft area, or assist to floor if out of bed. Do not attempt to restrain. Rationale: Gentle guiding of extremities reduces 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.
Document preseizure activity, presence of aura or unusual behavior, type of seizure activity (e.g., location/duration of motor activity, loss of consciousness, incontinence, eye activity, respiratory impairment/cyanosis), and frequency/recurrence. Note whether patient fell, expressed vocalizations, drooled, or had automatisms (e.g., lip-smacking, chewing, picking at clothes). Rationale: Helps localize the cerebral area of involvement.
Seizure Management (NIC)
Nursing Interventions for Seizures (Independent) | continuation
Perform neurological/vital sign check after seizure, e.g., level of consciousness, orientation, ability to comply with simple commands, ability to speak; memory of incident; weakness/motor deficits; blood pressure (BP), pulse/respiratory rate. Rationale: Documents postictal state and time/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/irrelevant for time and place. Attempts to control or prevent activity may result in patient becoming aggressive/combative.
Investigate reports of pain. Rationale: May be result of repetitive muscle contractions or symptom of injury incurred, requiring further evaluation/intervention.
Observe for status epilepticus, i.e., 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/death. Note: Although absence seizures may become static, they are not usually life-threatening.
Administer medications as indicated. Rationale: Specific drug therapy depends on seizure type, with some patients requiring polytherapy or frequent medication adjustments.
Antiepileptic drugs (AEDs), e.g., 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/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 postseizure 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.
Nursing Interventions for Seizures (Collaborative) – continuation| Nursing Care Plan for Seizure
Monitor/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.
Prepare for surgery/electrode implantation as indicated. Rationale: Vagal nerve stimulator, magnetic beam therapy, or other surgical intervention (e.g., 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.