Seizures Nursing Care Plans Diagnosis and Interventions
Seizures NCLEX Review and Nursing Care Plans
Seizure is the general term associated to any sudden and uncontrolled disturbance in the brain’s functioning. The effects of seizures could either be changes on the person’s behavior, body movements, and level of consciousness.
Seizure episodes of two or more within 24 hours that have no identifiable cause could be considered epilepsy.
There are different types of seizure disorders, each varying on severity, accompanying manifestations, location in the brain and extent of affected area. Seizures commonly last 30 seconds to two minutes.
However, seizures lasting more than five minutes are a medical emergency and would need prompt intervention.
Signs and Symptoms of Seizures
The clinical manifestations of seizures are the following:
- Temporary confusion
- Staring spells
- Uncoordinated, uncontrollable jerking of any part of the body, usually the arms and legs
- Loss of consciousness
- Cognitive symptoms such as fear or anxiety
Types of Seizures
Seizure disorders are subdivided into two groups, focal and generalized seizures:
- Focal seizures. These are seizures that affect the electrical activity of one area of the brain. It can be subclassified as either of the following:
- Focal seizure with impaired awareness – oftentimes, this seizure type is characterized as having dream-like state of consciousness. The patient may seem awake but is actually in a trance-like state while performing repetitive movements. The patient is not aware or cannot remember the seizure in this subtype.
- Focal seizure without impaired awareness – in this subtype, the patient will have altered senses or change in perception. For example, the patient may feel suddenly angry, but would have accompanying difficulty in speaking and experience flashing lights.
- Generalized seizures. Generalized seizures involve all areas of the patient’s brain. These seizures are further subdivided into other subtypes:
- Absence seizure – seizures that are characterized by staring blankly into space with subtle jerking or movement of the body (e.g. smacking of lips). Episodes lasts for 5 to 10 seconds but can occur multiple times in a day and in clusters. It is oftentimes seen in children. This is previously known as petit mal seizures.
- Tonic seizure – another seizure subtype wherein it causes for the muscles of the back, arms, and legs to stiffen, and consequently will make the patient lose balance.
- Atonic seizure – a seizure subtype wherein the patient suddenly loses muscle control of his body and may cause him/her to collapse to the ground. Another term for this is drop seizure.
- Clonic seizure – these seizures that causes for the rhythmic and repeated jerky movement of the patients’ muscles of the extremities.
- Myoclonic seizure – a seizure subtype wherein there are sudden and brief jerky movements on the patients arms and legs.
- Tonic-clonic seizure – a seizure subtype characterized by sudden loss of consciousness, body stiffness, jerky movements, and sometimes loss of bladder control with biting of the tongue. This is previously known as Grand Mal seizures.
Causes and Risk Factors of Seizures
The neurons in the brain create, transmit, and receive electrical impulses all throughout the brain. Any disruptions from this would cause seizures to the patient. Recent studies are looking at whether genetic mutations may also result to seizures.
The most common cause of seizures is epilepsy. However, other causes or trigger factors may cause seizures. They are:
- High fever
- Sleep deprivation
- Visual stimulants (moving objects, flashing lights)
- Medications (Antidepressants, pain relievers)
- Head trauma
- Structural abnormalities in the blood vessels of the brain
- Autoimmune disorders
- Brain tumor
- Use of illegal substance
- Alcohol abuse
Complications of Seizures
- Falls. Seizure episodes can make the balance of the patient unstable and thereby causing them to fall and causing injuries
- Drowning. Patients with seizure disorders are prone to accidental drowning
- Car accidents. If there is any loss of consciousness during a seizure activity, the patient will be prone to accidents while driving vehicles or operating machineries.
- Pregnancy complications. Seizure disorders compromise both the mother and infant. This is especially true for patients on anti-epilepsy medications for these can cause birth defects.
- Emotional health issues – People with seizure disorders oftentimes have depression and anxiety, either caused by difficulties in dealing with the condition or as side effects of medications taken.
Diagnosis of Seizures
- Neurological exam – to assess for baseline health of the patient pertaining to mood and cognitive functions of the brain.
- Blood tests – to look for signs of infection, genetic conditions that may cause seizures.
- Lumbar puncture – to test the cerebrospinal fluid by doing lumbar punctures; this will help in assessing for signs of infection in the brain.
- Electroencephalogram (EEG) – to assess the electrical activity of the brain in order to look for dysfunction that may cause seizures.
- MRI – to assess the brain’s internal structure to look for abnormalities (e.g. tumors, etc.).
- CT scan – another imaging test used to visualize the brains structures. Single-photon emission computerized tomography (SPECT) uses low dose radioactive material to make 3D map of the brain during seizures.
- PET scan – this is an imaging test involving using small dose radioactive material that will help visualize active and inactive areas in the brain.
Treatment for Seizures
Medications. The use of medications such as benzodiazepines, anticonvulsants, anti-epileptics, and other anti-seizure drugs are utilized to control, if not stop the occurrence of seizure.
Diet therapy. Some studies suggest that having a ketogenic diet or high fat, low carbohydrate diet can improve seizure control. This should be consulted with the dietitian and physician if appropriate to the patient.
Surgery. If medications are insufficient, surgery maybe done to control seizures. Surgical procedures for seizure include:
- Lobectomy – the surgical removal of the part of the brain causing seizures.
- Multiple subpial transection – a type of brain surgery wherein portions of the brain are removed when it is difficult to remove entirely the seizure-causing area.
- Corpus callosotomy – a brain surgery involving cutting off the connections of the brain’s left and right hemisphere.
- Hemispherectomy – an extreme surgery wherein half of the brain’s outer layer is removed.
- Thermal ablation – involves the application of targeted heat to the affected area of the brain to stop seizures.
- Vagus nerve stimulation – involves the implantation of a device underneath the skin of the chest that will send signals to the brain to stop it from having seizures.
- Responsive neurostimulation – a device is implanted near the surface of the brain that will deliver an electrical stimulation once it detects beginning seizure activity.
- Deep brain stimulation – involves the implantation of electrodes in the brain to produce electrical impulses to counteract beginning seizures in the brain.
Nursing Diagnosis for Seizures
Seizure Nursing Care Plan 1
Nursing Diagnosis: Risk for Injury related to loss of sensory coordination and muscular control secondary to seizures
Desired Outcome: The patient will be able to prevent trauma or injury by means of maintaining his/her treatment regimen in order to control or eliminate seizure activity.
|Nursing Interventions for Seizures||Rationales|
|Explore the usual seizure pattern of the patient and enable to patient and caregiver to identify the warning signs of an impending seizure.||To empower the patient and his/her caregiver to recognize a seizure activity, and help protect the patient from any injury or trauma. To reduce the feeling of helplessness on both the patient and the caregiver.|
|Place the bed in the lowest position. Put pads on the bed rails and the floor.||To prevent or minimize injury in a patient during a seizure.|
|Advise the carer to stay with the patient during and after the seizure.||To promote safety measures and support to the patient. To ensure that the patient is safe if the seizure recurs.|
|Administer prescribed medications such as benzodiazepines, anticonvulsants, anti-epileptics, and other anti-seizure drugs.||To prevent or control the occurrence of seizures.|
|During seizure, turn the patient’s head to the side, and suction the airway if needed. Use a plastic bite block only when the jaw is relaxed.||To maintain a patent airway. Avoid inserting the plastic bite block when the teeth are clenched to prevent any dental damage. Do not use wooden tongue depressors as they can break or splinter, causing oral damage.|
Seizure Nursing Care Plan 2
Nursing Diagnosis: Deficient Knowledge related to seizures as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of seizure and its management.
|Nursing Interventions for Seizures||Rationales|
|Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. decreased cognitive ability).||To address the patient’s cognition and mental status towards the new diagnosis of seizure and to help the patient overcome blocks to learning.|
|Explain what seizure is, its types, and related signs and symptoms. Avoid using medical jargons and explain in layman’s terms.||To provide information on seizure and its pathophysiology in the simplest way possible.|
|Educate the patient about safety measures related to epilepsy and seizure activity. Create a plan for Activities of Daily Living (ADLs) with the patient and the carer, especially including important activities such as driving, operating machinery, swimming, and bathing.||To help the patient avoid alcohol intake that may lead to preventing further damage to the pancreas. To encourage the patient to live his/her daily life optimally, while ensuring that he/she is safe from injury if a seizure occurs.|
|Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to manage seizure. Ask the patient to repeat or demonstrate the self-administration details to you.||To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.|
|Encourage the patient to wear his/her medical bracelet at all times, which indicates that he/she has a seizure disorder.||To enable the patient to receive an expedited care during an emergency situation.|
Seizure Nursing Care Plan 3
Risk for Ineffective Airway Clearance
Nursing Diagnosis: Risk for Ineffective Airway Clearance related to neuromuscular and cognitive impairment secondary to seizures.
- The patient will maintain an effective breathing pattern and will be able to demonstrate a patent airway and prevent aspiration.
- The patient will be able to demonstrate ways to maintain a clear and open airway.
|Nursing Interventions for Seizures||Rationale|
|Assess the patient’s airway patency.||Maintaining a clear and open airway is essential to retain airway clearance.|
|Keep track of the patient’s breathing rate, rhythm, depth, and exertion.||Provides a baseline for measuring ventilation adequacy.|
|Evaluate the patient’s coughing ability and expectoration of secretions.||Mucus production and character might be affected by respiratory tract infections. A cough that is inefficient obstructs airway clearance and inhibits secretions from readily expelling.|
|If an aura appears, remind the patient to remove any dentures or foreign objects from their mouth and to avoid chewing gum or sucking lozenges if seizures occur suddenly.||Reduces the chances of aspiration or foreign bodies becoming lodged in the throat.|
|Position the patient properly. Maintain a flat surface in a laying position and move the patient’s head to the side during seizure activity.||Helps with secretion outflow and keeps the tongue from blocking the airway.|
|Remove the patient’s clothing from the neck, chest, and abdomen.||Aids in chest expansion or breathing.|
|Provide a postictal use of supplementary oxygen or bag ventilation as indicated.||Reduces cerebral hypoxia caused by reduced circulation or oxygenation as a result of vascular spasm during a seizure.|
|Prepare or assist the patient with intubation if necessary.||Postictally, prolonged apnea may necessitate ventilatory support.|
|Ensure the patency of the patient’s airway by turning head to the side as directed. This should also help if the patient cannot cough out secretions. Only use a plastic bite block if the jaw is relaxed.||Proper head positioning aids in airway maintenance and minimizes the risk of oral trauma, but it should not be “pushed” or inserted when teeth are clinched since dental and soft-tissue damage can occur. Note that it is not advisable to use wooden tongue blades because they may splinter and shatter in the patient’s mouth.|
|Auscultate the patient’s chest and determine the presence of abnormal breath sounds.||Ineffective airway clearance is indicated by abnormal breath sounds such as crackles, wheezes, and stridor. Baseline information will aid in the development of care plan and evaluation of the treatment goal.|
|Educate the patient on the techniques to maintain a clear airway including proper hydration, proper use of medications, and avoidance of cigarette smoking.||The patient needs to understand different ways to maintain a clear airway and prevent a mucus build up in the lungs and airway.|
|Educate the patient on proper positioning, frequent position changes, use of abdominal muscles to cough effectively, and the use of incentive spirometry||These techniques will help the patient in proper secretion and drainage of mucus to prevent blocking the airway.|
|Monitor the patient’s oxygen saturation with the use of a pulse oximeter.||To determine if the patient has adequate oxygenation.|
|Perform a neurological or vital sign check on the patient after the seizure including the degree of awareness, orientation, capacity to obey basic directions, ability to talk, recall of the episode, weakness or motor impairments, blood pressure, pulse, and respiratory rate.||It is crucial to document the postictal state as well as the length of time it took to return to normal as it facilitates additional safety methods that need to be utilized and concerns that should be addressed.|
Seizure Nursing Care Plan 4
Risk for Trauma
Nursing Diagnosis: Risk for Trauma related to body weakness, difficulty in balancing, reduced muscle, hand-and-eye coordination, and altered consciousness secondary to seizures.
- The patient will verbalize understanding of the elements that lead to the risk of trauma or suffocation, and take actions to correct the problem.
- The patient will be able to determine what actions or procedures are appropriate to take when seizure activity begins.
- The patient will be able to identify and correct relevant environmental risk factors.
- The patient will exhibit actions and lifestyle adjustments that will help in lowering risk factors and prevent injury.
- The patient will identify ways on improving environmental safety and avoid accidents by identifying the need for assistance.
- The patient will stick to the treatment plan in order to manage the seizure activity.
|Nursing Interventions for Seizures||Rationale|
|Determine the risk factors related to the patient’s seizure activity and current circumstances.||Influences the extent and intensity of interventions to deal with the safety threat.|
|Take note of the patient’s age, gender, developmental stage, decision-making ability, and cognitive or competency level.||Influences the patient’s ability to defend himself and others, as well as the interventions and instructional methods used.|
|Determine the patient’s understanding of several stimuli that can cause seizure activity.||Alcohol, other medicines, and other stimuli (lack of sleep, flashing lights, continuous television viewing) can all increase brain activity, which can lead to seizures.|
|Assess the result for impairments and imbalances in the patient’s diagnostic examinations or laboratory tests.||Confusion, tetany, pathological fractures, and other diseases may develop or be exacerbated as a result of this.|
|Educate and explain to the patient the seizure warning indicators as well as the typical seizure pattern. Teach the significant others how to recognize warning signals, as well as how to care for the patient during and after a seizure.||Allows the patient to protect himself from harm and notice changes that necessitate medical notification and subsequent assistance. Knowing what to do in the event of a seizure can help the significant others feel less helpless and prevent further problems.|
|Position the patient with the bed in the lowest position, use and pad side rails, or place the bed against the wall and pad floor if rails are not available or acceptable.||When seizures occur when the patient is in bed, this device helps to prevent or reduce harm. Note that most patients seize in place and are unlikely to tumble out of bed if the seizure happens in the middle of the night.|
|Encourage the patient to only smoke while supervised.||If the cigarette is dropped during aura or seizure activity, it may cause burns.|
|Determine if the patient requires a protective headgear or not.||Patients who suffer from recurring or severe seizures may benefit from wearing a helmet.|
|Take the patient’s temperature with a tympanic thermometer, if necessary, avoid using breakable thermometers.||Reduces the chance of a patient biting and breaking the glass thermometer, or of damage if a seizure occurs suddenly.|
|Maintain a strict bedrest for the patient if prodromal indications or aura are present. Explain to the patient why these activities are necessary.||During the aural phase, the patient may become restless, need to ambulate, or even defecate, unwittingly removing himself from a safe area and simple surveillance. Understanding the necessity of meeting one’s own safety needs can help patients cooperate more effectively.|
|Stay with the patient during and after a seizure, do not leave the patient.||Encourages safety precautions.|
|Support the patient’s head, rest it on a soft surface, or help the patient to the floor if out of the bed. Do not restrain the patient.||When a patient lacks voluntary muscle control, supporting the extremities reduces the chance of physical damage. Note that if the patient is restrained during a seizure, the patient’s unpredictable movements may worsen, and the patient may damage himself or others.|
|Turn the patient’s head to the side and suction the airway as necessary. Only use a plastic bite block if the jaw is relaxed.||Helps maintain airway patency and lowers the risk of oral trauma, but should not be pressed or placed when teeth are clinched because this can cause dental and soft-tissue injury. Note that it is not advisable to use wooden tongue blades because they may splinter and shatter in the patient’s mouth.|
|Re-orient the patient after a seizure||After the seizure, the patient may be confused, disoriented, and perhaps amnesic, and will want assistance to restore control and reduce anxiety.|
|Allow the patient to have automatic postictal activity without interfering with environmental protection.||May engage in physical or psychic action that appears improper or irrelevant for the time and place. The patient may become angry or confrontational as a result of attempts to regulate or prohibit activities.|
|Examine the patient for any reports of pain.||It could be the result of repetitive muscle contractions or a symptom of an injury that needs to be evaluated or treated.|
Seizure Nursing Care Plan 5
Nursing Diagnosis: Hyperthermia related to inflammation caused by microorganisms secondary to seizures, as evidenced by a high body temperature of 102°F, flushing of the skin, warm to touch, loss of appetite, tachycardia, and tachypnea.
- The patient will demonstrate normal temperature and will not experience further complications.
- The patient will be able to maintain the blood pressure and heart rate within normal limits.
|Nursing Interventions for Seizures||Rationale|
|Assess the patient for hyperthermia symptoms.||Flushed face, weakness, rash, respiratory trouble, tachycardia, malaise, headache, and irritability are all signs and symptoms of hyperthermia. Keep an eye out for complaints of excessive perspiration, hot and dry skin, or being too hot|
|Determine track of the patient’s temperature (tympanic or rectal temperature).||The majority of febrile seizures occur when the temperature exceeds 102.2°F (39°C). It usually happens within the first 24 hours of illness, and temperature monitoring is very important.|
|Assess the patient’s hydration level and examine for indications of dehydration caused by heat.||Because a high body temperature raises the metabolic rate, insensible fluid loss increases. Thirst, a wrinkled tongue, dry lips, dry oral membranes, poor skin turgor, decreased urine output, elevated urine concentration, and a weak, quick pulse are all indications of dehydration.|
|Remove any unnecessary clothing or linen that is covering the patient’s body.||When skin is exposed to room air, it loses warmth and gains evaporative cooling.|
|Apply a tepid sponge bath to the patient as necessary.||A non-pharmacological measure to allow evaporative cooling is a tepid sponge bath. External sponging lowers body warmth while also increasing comfort.|
|Advise the patient’s significant others to keep the patient (especially children) away from cold water and alcohol.||Applying extreme chilling to a young patient with an underdeveloped nervous system might produce shock, whereas applying alcohol can create dry skin.|
|Advise the patient to take the antipyretic medication as advised by the healthcare provider and continue taking the antiseizure medication.||Reduces fever by working directly on the hypothalamic heat-regulating centers, which enhance body heat dispersion through perspiration and vasodilation.|
|Monitor and record the patient’s fluid intake and output. To monitor fluid status if the patient is unconscious, central venous or pulmonary artery pressure should be assessed.||To rectify dehydration, fluid resuscitation may be required. The severely dehydrated patient can no longer sweat, which is required for evaporative cooling.|
|Provide the patient with hypothermia or cooling blankets when required.||When the body temperature needs to be lowered quickly, use cooling blankets that circulate water. To prevent shivering, set the temperature regulator to 1°C below the client’s current temperature.|
|Monitor the patient’s skin during the cooling process.||The skin can be damaged by prolonged exposure to ice. To avoid skin damage, wrap ice packs in a towel and change the application site on a frequent basis.|
|Provide the patient with a comfortable environment, and adjust and monitor environmental elements such as room temperature and bed linens.||To manage the patient’s temperature, the room temperature can be adjusted to a near-normal body temperature, and blankets and linens can be altered as needed.|
|Adjust the cooling measures provided to the patient based on the physical response, and monitor the patient for shivering.||Shivering can be caused by excessive cooling or cooling too quickly, which increases metabolic rate and temperature. Shivering should be avoided because it impedes the cooling process.|
|Provide adequate nutritional support to the patient.||Food is required to fulfill the higher energy demands and high metabolic rate that hyperthermia causes. Because fever causes a loss of appetite, the food must be enticing to the patient.|
|Always keep the patient’s clothes and bed linens dry.||Because diaphoresis occurs during defervescence, it provides comfort and helps to prevent cooling.|
|Encourage the patient to increase oral fluid intake.||Provide cool beverages to assist reduce the body temperature if the client is alert enough to swallow. Fluid loss may also contribute to fever if the patient is dehydrated or diaphoretic.|
More Seizure Nursing Diagnosis
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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