Nursing Diagnosis for Seizures and Care Plan

SimpleNursing Editorial Team Dec 27, 2023
Young pretty brunette female nurse studying nursing diagnoses for seizures and care plans.

Seizure pathophysiology

Seizures occur due to over-excitation of the nerve cells in the brain, leading to a sudden, uncontrolled discharge of electrical activity.

There are two types of seizures:

  • Focal (partial) seizures that originate in one area of the brain
  • Generalized seizures that begin in both sides of the brain

The type of seizure a person experiences depends on the location and extent of the abnormal electrical activity.

Remember: Not all seizures are the same and can vary in duration, severity, and manifestations depending on where in the brain they originate.

Risk factors

  • Alcohol abuse or withdrawal
  • Brain injury or head trauma
  • Brain lesions or tumors
  • Cardiovascular disease
  • Drug abuse or withdrawal
  • Electrolyte and metabolic disorders
  • Neurodegenerative diseases, such as Alzheimer’s or Parkinson’s
  • Stroke

Rationale

Clients may not have control over certain risk factors, such as genetics or prior brain injury, making them more susceptible to seizures.

However, they may benefit from lifestyle modifications, such as avoiding triggers like:

  • Flashing lights
  • Loss of sleep
  • Prolonged TV viewing

Causes

  • Drug overdose
  • Hypoxia
  • Infections
  • Metabolic imbalances
  • Alcohol or drug withdrawal

Subjective (client may report)

  • A sense of detachment
  • Abdominal pain
  • Aura
  • Confusion
  • Dizziness
  • Visual disturbances

Objective

  • Altered or loss of consciousness
  • Cyanosis
  • Incontinence
  • Muscle rigidity
  • Sudden, rhythmic jerking movements

Signs and symptoms of a seizure

  • Alteration in mental status
  • Involuntary movements
  • Loss of bladder or bowel control

Nursing diagnosis for seizures

Based on the assessment of the client’s condition and the identification of the potential or actual problems related to the seizure disorder, some possible nursing diagnoses for seizures are:

  • Risk for trauma/suffocation
  • Risk for ineffective airway clearance
  • Risk for situational or chronic low self-esteem
  • Risk for ineffective self-health management

Assessment

The client has three or more of the following clinical criteria:

  • A history of two or more unprovoked seizures at least 24 hours apart
  • One unprovoked seizure with a high risk for recurrent seizures (such as focal onset, nocturnal, and abnormal EEG)

Nursing interventions for seizures

Seizures are a medical emergency requiring immediate action to ensure the client’s safety.

Nurses need to understand how to respond appropriately in these situations. Nursing interventions for seizures aim to prevent injury, administer medication, and provide emotional support.

Assessment

For signs and symptoms of seizures, monitor the client for changes in condition (after assessment).

Cardiac function

  • Decreased cardiac output
  • Dysrhythmias
  • Hypotension

Respiratory function

  • Ineffective breathing pattern
  • Airway obstruction

Neurologic and sensory functions

  • Altered level of consciousness
  • Muscle weakness or paralysis

Visual appearance and labs

  • Pupillary changes
  • Changes in skin color and temperature
  • Elevated lactate levels

Nursing actions and care notes

Nurses play a crucial role in managing seizures and providing care to clients during and after an episode.

The initial treatment for a seizure is to ensure the client’s safety and protect them from injury.

This may involve removing potentially dangerous objects from their surroundings, loosening tight clothing, and providing a cushion or pillow under their head. Gently turn the client onto their side after a seizure. If any fluid or food is in their mouth, immediately roll them onto their side.

Perform

  • A thorough assessment of the client’s condition
  • Oxygen therapy, if necessary, to maintain adequate oxygenation

Provide

  • Emotional support to the client and their family
  • Reassurance and education on seizure management and prevention

Avoid

  • Restraining the client or putting anything in their mouth during a seizure, as this can cause harm
  • Administering medication without consulting with the health care provider (HCP) first

Administer

  • Anti-seizure medication as prescribed by the health care provider (HCP)
  • Medications to control blood pressure or heart rate if needed

Monitor

  • Vital signs including:
  • Blood pressure
  • Heart rate and rhythm
  • Oxygen saturation
  • Respiratory rate
  • Level of consciousness and neurologic function
  • Adverse reactions to medication

Encourage

Encourage client and family members to inform their HCP of any changes in the client’s condition, take all medications as prescribed, and follow up with the HCP as scheduled.

Goals and outcomes

  • Better quality of life for the client
  • Improved medication compliance
  • Increased client and family education on seizure management
  • Reduced incidence of seizures

Seizure NCLEX question:

Which nursing intervention is the priority during a seizure?

  1. A) Promote the client’s self-esteem.
  2. B) Keep the client safe.
  3. C) Hold the client down or try to stop their movements.
  4. D) Provide information to the client about the disease process, prognosis, and treatment needs.

Answer: B. Keep the client safe.

Rationale: The priority nursing intervention during a seizure is to keep the client safe and prevent harm or injury. Restraining the client or putting anything in their mouth can cause harm, so it’s important to ensure a safe environment and avoid potential triggers. The nurse can promote self-esteem and provide information about the disease after ensuring safety.

Source

https://alraziuni.edu.ye/uploads/pdf/Nursing-Care-Plans-Edition-9-Murr-Alice-Doenges-Marilynn-Moorehouse-Mary.pdf

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