4 Febrile Seizure Nursing Care Plans

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Febrile seizures are seizures that happen in children between the ages of 6 months and 5 years, that is associated with high fever but with an absence of intracranial infection, metabolic conditions, or previous history of febrile seizures. It is subdivided into 2 classifications: A simple febrile seizure is brief, isolated, and generalized while a complex febrile seizure is prolonged (duration of more than 15 minutes), focal (occurs in one part of the brain), or multiple (occurs more than once within 24 hours).

Febrile seizures most often occur within 24 hours of the onset of a fever and can be the first indication that a child is sick. Symptoms may include a high fever (102°F to 104°F [38.9°C to 40°C]), sudden loss of consciousness, eye rolling, involuntary moaning, crying, and passing of urine, rigid (stiff) limbs, apnea or jerky movements on one side of the body (such as arm and leg).

Nursing Care Plans

Nursing goals for a child experiencing febrile seizures include maintain airway/respiratory function, maintain normal core temperature, protection from injury, and provide family information about disease process, prognosis, and treatment needs.

Here are four (4) nursing care plans (NCP) and nursing diagnosis (NDx) for febrile seizure:

  1. Ineffective Airway Clearance
  2. Hyperthermia
  3. Risk for Injury
  4. Deficient Knowledge
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Hyperthermia

Hyperthermia: Body temperature elevated above normal range.

May be related to

  • Antigens or microorganisms that cause inflammation

Possibly evidenced by

  • High body temperature (102°F to 104°F [38.9°C to 40°C])
  • Flushed skin, warm to touch
  • Tachypnea
  • Tachycardia

Desired Outcomes

  • Child will demonstrate temperature within normal range and will not experience complications.
Nursing InterventionsRationale
Monitor the child’s temperature (tympanic or rectal temperature).Most febrile seizures happen when the temperature is greater than 102.2 ºF (39ºC). It usually occurs within the first 24 hours of illness and close monitoring of temperature is essential.
Assess for hydration status.A high body temperature increases the metabolic rate hence increases the insensible fluid loss.
Eliminate excess clothing.Exposing skin to room air decreases warmth and increases evaporative cooling.
Administer tepid sponge bath.External sponging reduces the body temperature and increases comfort.
Advise the mother to avoid applying cold water or alcohol to the child.Extreme cooling can result in shock to a child with an immature nervous system;  While applying alcohol can cause dry skin.
Administer antipyretic as indicated:
  • Acetaminophen (Tylenol)
Lowers fever by directly acting on the hypothalamic heat-regulating centers that promote distribution of body heat through sweating and vasodilation.
Aa nonsteroidal anti-inflammatory drug (NSAID) that inhibits the production of prostaglandins (chemicals that promote inflammation, pain, and fever).
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See Also

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