In this guide are five nursing diagnosis for seizures nursing care plans including their nursing interventions and nursing assessment. Learn about the goals, related factors of nursing diagnosis and rationale for each nursing intervention for seizure.
What are seizures?
Seizures are physical findings or changes in behavior caused by uncontrolled electrical firing or discharges from the nerve cells of the cerebral cortex and are characterized by sudden, brief attacks of altered consciousness, motor activity and sensory phenomena. The term “seizure” is often used interchangeably with “convulsion.”
Seizures can be caused by head injuries, brain tumors, lead poisoning, maldevelopment of the brain, genetic and infectious illnesses, and fevers. Sensory symptoms arise from the parietal lobe; motor symptoms arise from the frontal lobe.
Nursing Care Plans
Nursing care plan goals for patients with seizure includes maintaining a patent airway, maintaining safety during an episode, and imparting knowledge and understanding about the condition. The nurse should monitor the patient for signs of toxicity: nystagmus, ataxia, lethargy, dizziness, slurred speech, nausea, and vomiting. It is also the duty of the nurse to provide support to the family and answering questions and correcting misconceptions that surround it.
Here are five (5) nursing diagnosis for seizure nursing care plans:
- Risk for Trauma or Suffocation
- Risk for Ineffective Airway Clearance
- Situational Low Self-Esteem
- Deficient Knowledge
Risk for Ineffective Airway Clearance
- Risk for Ineffective Airway Clearance: At risk for the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
The following are the common risk factors:
- Neuromuscular impairment
- Tracheobronchial obstruction
- Perceptual or cognitive impairment
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Common goals and expected outcomes:
- Patient will maintain effective respiratory pattern with airway patent or aspiration prevented.
Nursing Interventions and Rationale
Interventions and actions for the nursing diagnosis Risk for Ineffective Airway Clearance in this seizure nursing care plan are as follows:
|Monitor respiratory rate, rhythm, depth, and effort of respirations.||Provides a baseline data for evaluating adequacy of ventilation.|
|Assess client’s ability to cough effectively.||Infections of the respiratory tract can affect the amount and character of mucus. An ineffective cough compromises airway clearance and prevents secretions to expel freely.|
|Ensure patient to the empty mouth of dentures or foreign objects if aura occurs and to avoid chewing gum and sucking lozenges if seizures occur without warning.||Lessens risk of aspiration or foreign bodies lodging in the pharynx.|
|Maintain in lying position, flat surface; turn head to side during seizure activity.||Helps in the drainage of secretions; prevents the tongue from obstructing the airway.|
|Loosen clothing from neck or chest and abdominal areas.||Aids in breathing or chest expansion.|
|Provide and insert plastic airway or soft roll as indicated and only if the jaw is relaxed.||If inserted before the jaw is tightened, these devices may prevent biting of the tongue and facilitate suctioning or respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if the patient is unconscious and unable to maintain a safe position of the tongue.|
|Suction as needed.||Reduces risk of aspiration or asphyxiation.|
|Supervise supplemental oxygen or bag ventilation as needed postictally.||May lessen cerebral hypoxia resulting from decreased circulation or oxygenation secondary to vascular spasm during a seizure.|
|Get ready for or assist with intubation, if indicated.||Presence of prolonged apnea postictally may need ventilatory support.|
Other Possible Nursing Care Plans
Below are possible nursing diagnosis you can add for your seizure nursing care plans:
- Risk for Injury related to weakness, balancing difficulties, cognitive limitations or altered consciousness, loss of large or small muscle coordination.
- Situational Low Self-Esteem related to stigma associated with condition, perception of being out of control, personal vulnerability, negative evaluation of self or capabilities.
- Ineffective Therapeutic Regimen Management related to ineffective management, social support deficits, perceived benefit (versus side effects of medication), perceived susceptibility (possible long periods of remission).
References and Sources
The following are the references and sources for the nursing diagnosis and nursing care plan for seizure disorder:
- Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby. [Link]
- Joyce, B. M., & Jane, H. H. (2008). Medical surgical nursing. Clinical management for positive outcome. Volume 1. Eight Edition. Saunders Elsevier. St. Louis. Missouri. [Link]
- Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins. [Link]
- Crocker, J. (1999). Social stigma and self-esteem: Situational construction of self-worth. Journal of experimental social psychology, 35(1), 89-107. [Link]
- Kavanagh, A., & McLoughlin, D. M. (2009). Electroconvulsive therapy and nursing care. British journal of nursing, 18(22), 1370-1370. [Link]
- Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins. [Link]
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Neurological Care Plans
Nursing care plans for related to nervous system disorders:
- Alzheimer's Disease | 13 Care Plans
- Brain Tumor | 3 Care Plans
- Cerebral Palsy | 7 Care Plans
- Cerebrovascular Accident | 8+ Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Meningitis | 7 Care Plans
- Multiple Sclerosis | 9 Care Plans
- Parkinson's Disease | 9 Care Plans
- Seizure Disorder | 4 Care Plans
- Spinal Cord Injury | 12 Care Plans