The first febrile seizure is one of life’s most frightening moments for parents. Most parents are afraid that their child will die or have brain damage. Thankfully, simple febrile seizures are harmless. There is no evidence that simple febrile seizures cause death, brain damage, mental retardation, a decrease in IQ, or learning difficulties. (www.nlm.com) However, a very small percentage of children go on to develop other seizure disorders such as epilepsy later in life.
A febrile seizure is a convulsion in a child triggered by a fever. Such convulsions occur without any underlying brain or spinal cord infection or other neurological cause. According to studies, about 3-5% of otherwise healthy children between the ages of 9 months and 5 years will have a seizure caused by a fever. Toddlers are most commonly affected. Most occur well within the first 24 hours of an illness, not necessarily when the fever is highest.
Nursing Care Plans
Here are 5 benign febrile convulsions nursing care plans.
1. Hyperthermia
Benign Febrile Convulsion is a convulsion triggered by a rise in body temperature. Fever is not an illness and is an important part of the body’s defense against infection. Antigens or microorganisms cause inflammation and the release of pyrogens which is a substance that induces fever.
Assessment
Patient may manifest
- Increase in temperature
- Flushed skin
- Convulsions
- Hyperthermia
Outcomes
- Patient’s temperature will decrease from [39°C] to normal range of [36.5°C to 37°C].
- Patient will be free of complications and maintain normal core temperature.
| Nursing Interventions | Rationale |
|---|---|
| Assess underlying condition and body temperature. | To obtain baseline data. |
| Monitor and recorded vital signs. | To note for progress and evaluate effects of hyperthermia. |
| Remove unnecessary clothing that could only aggravate heat | To decrease or totally diminish pain. |
| Promote adequate rest periods. | Reduces metabolic demands or oxygen. |
| Provide TSB | To promote surface cooling. |
| Advice to increase fluid intake. | To help decrease body temperature. |
| Loosen clothing. | To provide proper ventilation and promote release of heat through evaporation. |
| Administer IV fluids at prescribed rate. Monitor regulation rate frequently. | To promote fluid management. |
| Administer antipyretics as ordered. | Antipyretics lower core temperature. |
2. Imbalanced Nutrition
The nutritional requirements of the human body reflect the nutritional intake necessary to maintain optimal body function and to meet the body’s daily energy needs. Malnutrition (literally, “bad nutrition”) is defined as “inadequate nutrition,” and while most people interpret this as undernutrition, falling short of daily nutritional requirements. The etiology of malnutrition includes factors such as poor food availability and preparation, recurrent infections, and lack of nutritional education.
Assessment
Patient may manifest
- Weakness
- Low weight
- Loss of appetite
- Poor muscle tone
- Imbalanced Nutrition: Less than the body requirement related to economical factors.
Outcomes
- Patient’s will identify measures to promote nutrition and follow the treatment regimen.
- Patient weight will be within normal values.
| Nursing Interventions | Rationale |
|---|---|
| Review patient’s records. | To obtain baseline data. |
| Assess underlying condition. | To determine specific interventions. |
| Discuss eating habits and encourage diet for age. | To achieve health needs of the patient with the proper food diet for his disease. |
| Note total daily intake includes patterns and time of eating. | To reveal change that should be made in the client’s dietary intake. |
| Consult physician for further assessment and recommendation regarding food preferences and nutritional support. | For greater understanding and further assessment of specific food. |
3. Ineffective Tissue Perfusion
The circulation to the tissues is not getting enough oxygen or nourishment. Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level.
Assessment
Patient may manifest
- Decreased hgB concentration
- Body temperature changes
- Skin discoloration
- Pallor
Nursing Diagnosis
- Ineffective tissue perfusion related to decreased Hgb concentration in blood as evidenced by low Hgb count in CBC result
Outcomes
- Patient will demonstrate behaviour lifestyle changes to improve circulation.
- Patient’s S.O. will verbalize understanding of the condition.
| Nursing Interventions | Rationale |
|---|---|
| Determine factors related to individual situation. | To gain information regarding the condition. |
| Evaluate for signs of infection especially when immune system is compromised. | To observe for possible risk factors. |
| Discuss individual risk factors. | This information would be necessary for the client’s S.O. |
| Elevate head of bed at night. | To increase gravitational blood flow. |
| Discuss the importance of a healthy diet. | To promote a healthy diet to help increase RBC synthesis and Hgb count for faster recovery. |
4. Risk for Infection
The immune system is the body’s defense against bacteria, viruses, and other foreign organisms or harmful chemicals. It is very complex and it has to work properly to protect us from the harmful bacteria and other organisms in the environment which may infect our body. If the immune system is compromised, it can affect the normal production of WBC from the bone marrow. If there is an increase in number of WBC, therefore it may increase the possibility to increase infection.
Assessment
Patient may manifest
- body weakness
- fatigue
- poor muscle tone
Nursing Diagnosis
- Risk for infection
Outcomes
- Patient will verbalize understanding of ways on how to prevent spread of infection.
- Patient will be free from infections and further complications
| Nursing Interventions | Rationale |
|---|---|
| Establish good working relationship with the client and S.O. | To gain their trust and cooperation |
| Monitor and record vital signs | For comparative baseline data |
| Determine pt’s individual strength | To know when to assist client |
| Provide peaceful environment | To promote optimum level of functioning |
| Provide adequate rest and sleep. | To prevent fatigue and conserve energy |
| Emphasize importance of handwashing | To prevent occurrence of further infections |
| Provide safety measures | To prevent falls and injuries |
| Monitor I & O | To note for imbalances |
| Advice pt to increase oral fluid intake when allowed | To replace fluid electrolyte loss |
5. Risk for Injury
A seizure or convulsion is the visible sign of a problem in the electrical system that controls your brain. A single seizure can have many causes, such as a high fever and lack of oxygen. Hemoglobin is a protein in red blood cells that carries oxygen. Therefore, Low levels of hemoglobin in the human body may result to seizure. During episodes of convulsion, patients are prone to injuries since they may strike different objects due to uncontrollable muscle spasms.
Assessment
Patient may manifest
- Fever
- Convulsions
Nursing Diagnosis
- Risk for injury related to possible convulsion
Outcomes
- The SO will modify environment as indicated to enhance safety.
- The SO will verbalize understanding of individual factors that contribute to possibility of injury.
- The patient will be free from injury.
| Nursing Interventions | Rationale |
|---|---|
| Ascertain knowledge of safety needs/ injury prevention | to prevent injuries in home, community, and work setting |
| Note clients gender, age, developmental stage, decision making ability, level of cognition/competence | affects client’s ability to protect self/others and influence choice of interventions/ teachings |
| Provide health care within a culture of safety | to prevent errors resulting in client injury, promote client safety and model safety behaviors for client/SO |
| Identify interventions/safety devices | to promote safe physical environment and individual safety |
| Discuss importance of self monitoring of conditions/ emotions | it can contribute to occurrence of injury |
See Also
You may also like the following posts and care plans:
- 1,000+ Nursing Care Plans List – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- What is a Nursing Care Plan? 9 Steps on How to Write a Care Plan – learn how to write an excellent care plan. We explain the concepts and walk you through the steps.
- Nursing Diagnosis: The Complete List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
- The Ultimate Guide to Nursing Diagnosis – learn how to formulate nursing diagnoses correctly in this easy-to-follow guide!
Other Care Plans
Miscellaneous nursing care plans that don’t fit other categories:
- Alcohol Withdrawal | 5 Care Plans
- Benign Febrile Convulsions | 5 Care Plans
- Cancer | 13 Care Plans
- End-of-Life Care (Hospice Care) | 4 Care Plans
- Substance Dependence and Abuse | 8 Care Plans
- Surgery (Perioperative Client) | 13 Care Plans
- Systemic Lupus Erythematosus | 4 Care Plans
- Total Parenteral Nutrition | 4 Care Plans
Further Reading
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans
