Learn about nursing diagnosis and care plans for febrile seizures in children with our comprehensive guide. Discover assessment and diagnostic criteria, as well as effective treatment and management strategies for this condition. With our guide, nurses can develop comprehensive care plans to improve patient outcomes and promote better health and well-being.
What are Febrile Seizures?
Febrile seizures are seizures that happen in children between the ages of 6 months and 5 years, they are 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 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 maintaining airway/respiratory function, maintaining normal core temperature, protecting from injury, and providing family information about the disease process, prognosis, and treatment needs.
Here are four (4) nursing care plans (NCP) and nursing diagnosis (NDx) for febrile seizure:
Ineffective Airway Clearance
During a febrile seizure, neuromuscular damage can cause the child’s airway muscles to become weak, leading to ineffective airway clearance. In addition, tracheobronchial obstruction can occur due to inflammation or edema of the airways, further impeding airway clearance. Both neuromuscular damage and tracheobronchial obstruction can contribute to ineffective airway clearance and can be potentially life-threatening if not addressed promptly.
- Ineffective Airway Clearance
May be related to
- Tracheobronchial obstruction (foreign body aspiration)
- Neuromuscular damage
Possibly evidenced by
- Excessive secretions
- Inability to remove airway secretions
- The child will maintain a patent airway.
Nursing Assessment and Rationales
1. Assess the child’s airway patency using the look, listen, and feel approach.
This will ensure that seizure does not affect the supply of oxygenated blood to the brain and prevent the development of hypoxia.
2. Auscultate lungs for the presence of normal or adventitious breath sounds.
Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate airway is obstructed.
Nursing Interventions and Rationales
1. Place the child on a flat surface then turn the head to the side during a seizure episode.
Turning the child’s head to the side helps in maintaining a patent airway by promoting drainage of secretions and avoiding aspiration to the lungs.
2. Loosen any restrictive clothing, especially on the neck, chest, and abdomen.
This will facilitate ease of breathing and maintain an unobstructed airway.
3. Suction secretions gently as indicated.
Suctioning will eliminate secretions and decreases the possibility of aspiration.
4. Provide supplemental oxygenation as indicated.
Oxygen therapy is prescribed to improve oxygen saturation and reduce possible complications.
5. Prepare for/assist with possible intubation as indicated.
Extended apnea episodes after a seizure may require a need for ventilatory support.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
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