5 Benign Febrile Convulsions Nursing Care Plans

January 25, 2012

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.

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

Nursing Diagnosis

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.

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

Nursing Diagnosis

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.

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.

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

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