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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Risk for Injury

Risk for Injury: Vulnerable to injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to

  • Internal factors of biochemical regulatory
  • Altered level of consciousness resulting from seizure episode

Possibly evidenced by

  • [Not applicable]

Desired Outcomes

  • Child will be free from injury when a seizure occurs.
Nursing InterventionsRationale
Assess and record seizure activity and location. Note the duration of seizures, parts of the body involved, site of onset and progression of seizure.Documentation of information is essential for the prevention of injury or complications as a result of a seizure.
Assess skin for pallor, flushed, or cyanosis; Monitor respiratory rate, depth, and signs of respiratory distress.Once seizures are prolonged and respiration is compromised, this will provide information on possible signs of aspiration of secretions.
Maintain side-lying position; Keep padded side rails up with the bed in lowest position and removed any clutter from the child.Side-lying facilitates drainage of secretions and maintains airway patency; padding protects the child from injury during a seizure.
Avoid restraining the child or putting anything in his/her mouth; provide gentle support to head and arms if harm might result.Restraining a child can result in trauma due to the amount of force exerted; inserting object in mouth increases stimuli; Padding the area helps to protect the head from injury.
Stay with the child during the phase of seizures, reorient when awake, and allow to rest or sleep after an episode.Provides support and prevents any injury to child.
Advice parents to remain calm during seizure activity of the child.Allows parents to function properly to protect the child from injury.
Teach about information to record about seizure activity should it occur (specify).Provides physician with important information needed to prescribe medical regimen.
Educate the parents regarding precautionary measures during a seizure.Guarantees safe and effective interventions to avoid the incidence of injury.
Administer medications as indicated:
  • Phenobarbital (Luminal)
This is a central nervous system depressant that acts as an anticonvulsant by decreasing the seizure threshold.
  • Carbamazepine (Tegretol)
This is an anticonvulsant that works by decreasing nerve impulses that cause seizures and pain.
  • Diazepam (Valium)
This is an anticonvulsant drug that can reduce the risk of recurring febrile seizures.
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See Also

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