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
- Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
Common related factors for this nursing diagnosis:
- Lack of exposure, unfamiliarity with resources
- Information misinterpretation
- Lack of recall; cognitive limitation
The common assessment cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement.
- Questions, statement of concerns
- Increased frequency or lack of control of seizure activity
- Lack of follow-through of drug regimen
Common goals and expected outcomes:
- Patient will verbalize understanding of the disorder and various stimuli that may increase potentiate seizure activity.
- Patient will participate in the learning process.
- Patient will exhibit increased interest or assume responsibility for own learning by beginning to look for information and ask questions.
- Patient will adhere to the prescribed drug regimen.
- Patient will identify the relationship of signs and symptoms to the disease process and correlate symptoms with causative factors.
- Patient will initiate necessary lifestyle or behavior changes as indicated.
Nursing Interventions and Rationales
Here are the nursing assessment and interventions for this seizure nursing care plan.
|Ascertain level of knowledge, including anticipatory needs.||To assess readiness to learn|
|Determine client’s ability or readiness and barriers to learning.||Individual may not be physically, emotionally, or mentally capable at this time.|
|Review pathology and prognosis of the condition and lifelong need for treatments as indicated. Discuss the patient’s particular trigger factors (flashing lights, hyperventilation, loud noises, video games, TV viewing).||Provides an opportunity to clarify or dispel misconceptions and present condition as something that is manageable within a normal lifestyle.|
|Review the possible effects of hormonal changes.||Alterations in hormonal levels that occur during menstruation and pregnancy may increase the risk of seizures.|
|Discuss the significance of maintaining good general health, (adequate diet, rest, moderate exercise, and avoidance of exhaustion, alcohol, caffeine, and stimulant drugs).||Regularity and moderation in activities may aid in reducing or controlling precipitating factors, enhancing a sense of general well-being, and strengthening coping ability and self-esteem. Note: Too little sleep or too much alcohol can precipitate seizure activity in some people.|
|Know and instill the importance of good oral hygiene and regular dental care.||Lessens risk of oral infections and gingival hyperplasia.|
|Identify necessity and promote acceptance of actual limitations; discuss safety measures regarding driving, using mechanical equipment, climbing ladders, swimming, and hobbies.||Lessens risk of injury to self or others, especially if seizures occur without warning.|
|Review local laws and restrictions pertaining to persons with epilepsy and seizure disorder. Encourage awareness but not necessarily acceptance of these policies.||Although legal and civil rights of persons with epilepsy have improved during the past decade, restrictions still exist in some states pertaining to obtaining a driver’s license, sterilization, workers’ compensation, and required reportability to state agencies.|
|Review medication regimen, the necessity of taking drugs as ordered, and not discontinuing therapy without physician supervision. Include directions for a missed dose.||Lack of cooperation with a medication regimen is a leading cause of seizure breakthrough. The patient needs to know the risks of status epilepticus resulting from the abrupt withdrawal of anticonvulsants. Depending on the drug dose and frequency, the patient may be instructed to take a missed dose if remembered within a predetermined time frame.|
|Recommend taking drugs with meals, if appropriate.||May reduce the incidence of gastric irritation, nausea, and vomiting.|
|Discuss nuisance and adverse side effects of particular drugs (drowsiness, fatigue, lethargy, hyperactivity, sleep disturbances, gingival hypertrophy, visual disturbances, nausea and vomiting, rashes, syncope and ataxia, birth defects, aplastic anemia).||May indicate the need for change in dosage or choice of drug therapy. Promotes involvement and participation in the decision-making process and awareness of potential long-term effects of drug therapy, and provides an opportunity to minimize or prevent complications.|
|Provide information about potential drug interactions and the necessity of notifying other healthcare providers of the drug regimen.||Knowledge of anticonvulsant use reduces the risk of prescribing drugs that may interact, thus altering seizure threshold or therapeutic effect. For example, phenytoin (Dilantin) potentiates the anticoagulant effect of warfarin (Coumadin), whereas isoniazid (INH) and chloramphenicol (Chloromycetin) increase the effect of phenytoin (Dilantin), and some antibiotics (erythromycin) can cause elevation of serum level of carbamazepine (Tegretol), possibly to toxic levels.|
|Familiarize proper use of diazepam rectal gel (Diastat) with the patient, SO and caregiver as appropriate.||Useful in controlling serial or cluster seizures. Can be administered in any setting and is effective usually within 15 min. May reduce dependence on emergency department visits.|
|Encourage patient to wear an identification tag or bracelet stating the presence of a seizure disorder.||Expedites treatment and diagnosis in emergency situations.|
|Stress need for routine follow-up care and laboratory testing as indicated (CBC should be monitored biannually and in presence of sore throat or fever, signs of other infection).||Therapeutic needs may change and or serious drug side effects (agranulocytosis or toxicity) may develop.|
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]
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- 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