5 Seizure Disorder Nursing Care Plans

Risk for Trauma or Suffocation

Clients with seizure disorders are at risk for trauma or suffocation due to the loss of muscle control during seizures, which can lead to falls, head injuries, and difficulty breathing. Additionally, seizures can occur during sleep, putting the client at risk of suffocation from airway obstruction or aspiration. The increased risk for injury may be caused not only by seizures, but also by comorbid conditions affecting cognition, vigilance, or balance, which are frequent in people with seizures or might be an effect of interaction between seizures and comorbidities (Mahler et al., 2018).

Nursing Diagnosis

• Risk for Trauma

Risk Factors

• Weakness, balancing difficulties; reduced muscle, hand or eye coordination
• Poor vision
• Reduced sensation
• Cognitive limitations or altered consciousness
• Loss of large or small muscle coordination
• Emotional difficulties

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.

Desired Outcomes

• The client will verbalize understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to correct the situation.
• The client will identify actions or measures to take when seizure activity occurs.
• The client will identify and correct potential risk factors in the environment.
• The client will demonstrate behaviors, and lifestyle changes to reduce risk factors and protect themself from injury.
• The client will modify the environment as indicated to enhance safety.
• The client will maintain a treatment regimen to control or eliminate seizure activity.
• The client will recognize the need for assistance to prevent accidents or injuries.

Nursing Assessment and Rationales

1. Determine factors related to the individual situation, as listed in Risk Factors, and the extent of risk.
This influences the scope and intensity of interventions to manage the threat to safety. Information on selected conditions associated with seizures and propensity for injuries and accidents should include stroke, brain tumor, dementia, diabetes mellitus, psychiatric disease, including mental retardation, disorders of psychological development, behavioral and emotional disorders with onset usually occurring in childhood and adolescence, and congenital malformations (Mahler et al., 2018).

2. Note the client’s age, gender, developmental age, decision-making ability, and level of cognition or competence.
It affects the client’s ability to protect themself and others and influences the choice of interventions and teaching. The risk due to seizures does not differ by seizure type and are similar in men and women, although women in general had a slightly lower risk than men. No increased risk can be seen in clients exposed to seizures prior to age 15, while all other age categories showed a risk increase among epilepsy cases (Mahler et al., 2018).

3. Ascertain knowledge of various stimuli that may precipitate seizure activity.
Alcohol, various drugs, and other stimuli (loss of sleep, flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity. For clients with a known seizure disorder, the most likely cause is subtherapeutic levels of antiepileptic medications, which usually occur due to medical nonadherence, or systemic derangement that may disrupt the absorption, distribution, and metabolism of medications (Zonnoor & Chang, 2022).

4. Review diagnostic studies or laboratory tests for impairments and imbalances.
Such may result in or exacerbate conditions, such as confusion, tetany, pathological fractures, etc. An American College of Emergency Physicians Clinical Policy recommends the following in adults with new-onset seizures: serum glucose level, serum sodium level, and pregnancy test in women of childbearing age (Zonnoor & Chang, 2022).

5. Explore and expound seizure warning signs (if appropriate) and the usual seizure patterns. Teach significant others (SO) to determine and familiarize warning signs and how to care for the client during and after a seizure attack.
This enables the client to protect themself from injury and recognize changes that require notification of the provider and further intervention. Knowing what to do when a seizure occurs can prevent injury or complications and decreases SO’s feelings of helplessness. There may be a noise or cry at the onset of the seizure. Some clients will describe a prodrome or aura before the event (Munakomi, 2023).

6. Note pre-seizure activity, presence of aura or unusual behavior, type of seizure activity (location or duration of motor activity, and frequency or recurrence. Note whether the client fell, expressed vocalizations, drooled, or had automatisms (lip-smacking, chewing, picking at clothes).
This helps localize the cerebral area of involvement. Many clients with complex focal seizures have an aura warning them of their seizure; the aura itself is a simple focal seizure. Hyperventilation or photic stimulation frequently precipitates absence seizures, which typically begin during childhood or adolescence and may persist into adulthood (AlEissa & Benbadis, 2022).

7. Provide neurological or vital sign check after seizure (level of consciousness, orientation, ability to comply with simple commands, ability to speak; the memory of incident; weakness or motor deficits; blood pressure (BP), pulse, and respiratory rate).
This documents the postictal state and time or completeness of recovery to a normal state. It may identify additional safety concerns to be addressed. Following a generalized tonic-clonic seizure, clients will have some transient alteration consciousness referred to as the postictal state. Accurate vital signs may be difficult to obtain in a generalized tonic-clonic seizure (Zonnoor & Chang, 2022).

8. Investigate reports of pain.
This may be a result of repetitive muscle contractions or symptoms of injury incurred, requiring further evaluation or intervention. Pain is a recognized but rare manifestation of epileptic seizures. Pain associated with seizures can be severe and disabling. Ictal pain is usually associated with paresthesia, thermal sensations, or somatognostic disturbance. If localized, paroxysmal pain is the sole manifestation, seizure may be often overlooked as a cause for pain (Sheetal & Kumar, 2020).

9. Detect status epilepticus (one tonic-clonic seizure after another in rapid succession).
This is a life-threatening emergency that if left untreated could cause metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased intracranial pressure, airway obstruction, and respiratory arrest. Immediate intervention is required to control seizure activity and prevent permanent injury or death. Note: Although absence seizures may become static, they are not usually life-threatening.

10. Monitor and document AED drug levels, corresponding side effects, and frequency of seizure activity.
A standard therapeutic level may not be optimal for an individual client if untoward side effects develop or seizures are not controlled. Although medication nonadherence and subtherapeutic medication levels are among the most common causes of seizure presentations to the ED, clients should also be screened for underlying infectious or metabolic causes of seizure when indicated (Zonnoor & Chang, 2022).

11. Monitor CBC, electrolytes, and glucose levels.
These identify factors that aggravate or decrease the seizure threshold. Studies have shown a low yield for extensive laboratory tests in the evaluation of a client presenting with a first-time single seizure. In one study, laboratory tests such as blood counts, blood glucose levels, and electrolyte panels were abnormal in as many as 15% of individuals (Zonnoor & Chang, 2022).

Nursing Interventions and Rationales

1. Use and pad side rails with the bed in the lowest position, or place the bed up against the wall and pad floor if rails are not available or appropriate.
This prevents or minimizes injury when seizures (frequent or generalized) occur while the client is in bed. Note: Most individuals seize in place and if, in the middle of the bed, the individual is unlikely to fall out of bed. During a seizure, the client may experience convulsive movements that can cause them to hit their limbs or body against the side rails or the floor. Padding acts as a protective barrier, reducing the impact and lessening the chances of bruises, cuts, or fractures.

2. Educate the client not to smoke except while supervised.
This may cause burns if the cigarette is accidentally dropped during aura or seizure activity. Additionally, cigarette smoking may also be an important factor influencing the risk of seizures or epilepsy. It has been reported that cigarette smoking is common in adults with epilepsy. The global prevalence of cigarette smoking was 32.1% among 429 people with epilepsy, significantly higher than the 19% smoking rate reported in the general population (Zhong et al., 2022).

3. Evaluate the need for or provide protective headgear.
The use of a helmet may provide added protection for individuals who suffer recurrent or severe seizures. Wearing a protective helmet is sometimes recommended to minimize the risk of head injury in seizures. The design of helmets for people with seizures usually comprises a dense foam hat encased in leather and worn with a chin strap. The foam can be built up dependent on whether the person usually falls forward or backward (Jory et al., 2019).

4. Avoid using thermometers that can cause breakage. Use a tympanic thermometer when necessary to take the temperature.
This reduces the risk of the client biting and breaking the glass thermometer or suffering injury if sudden seizure activity should occur. Tympanic thermometers are designed to measure body temperature by detecting infrared radiation emitted by the eardrum. They provide a quick and non-invasive method of measuring temperature, which can be crucial in a situation where a client is experiencing seizures.

5. Uphold strict bedrest if prodromal signs or aura are experienced. Explain the necessity for these actions.
Clients may feel restless or need to ambulate or even defecate during an aural phase, thereby inadvertently removing themselves from a safe environment and easy observation. Understanding the importance of providing for own safety needs may enhance client cooperation.

6. Do not leave the client during and after a seizure.
Seizures can be unpredictable, and a client may experience various movements and behaviors during an episode. By staying with the client, the nurse may help ensure their safety and protect them from potential hazards in the environment. In addition, by being present during a seizure the nurse can closely observe the duration, intensity, and characteristics of the seizure. 

7. Turn the head to the side and suction the airway as indicated. Insert plastic bite block only if jaw relaxed.
This helps maintain airway patency and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Wooden tongue blades should not be used because they may splinter and break in the client’s mouth. Mouth guards are the most commonly used intraoral device. Stock mouthguards are durable, easy to use, and inexpensive, but loose and limited in their potential for modification. As such, custom-made mouth protectors such as acrylic splints are considered more effective owing to their customizability, stability, and retention (Avashia et al., 2018).

8. Support the head, place it on a soft area, or assist to the floor if out of bed. Do not attempt to restrain.
Supporting the extremities lessens the risk of physical injury when the client lacks voluntary muscle control. Note: If the attempt is made to restrain the client during a seizure, erratic movements may increase, and the client may injure themself or others. Restraints must be avoided but ensure that the client is in a bed with padded side rails or flat on the floor (Al Sawaf et al., 2023).

9. Reorient the client following seizure activity.
The client may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety. Provide verbal reassurance as the client is regaining consciousness. Being calm and helping reorient the client is of utmost importance (Al Sawaf et al., 2023).

10. Allow postictal “automatic” behavior without interfering while providing environmental protection.
The client may display behavior (of a motor or psychic origin) that seems inappropriate or irrelevant to time and place. Attempts to control or prevent activity may result in the client becoming aggressive or combative. Most clients may experience fatigue, confusion, muscle pain, and/or a headache. Thus, the nurse must also permit the client to sleep (Al Sawaf et al., 2023).

11. Carry out medications as indicated:
Specific drug therapy depends on seizure type, with some clients requiring polytherapy or frequent medication adjustments.

• 11.1. Antiepileptic drugs (AEDs): phenytoin, primidone, carbamazepine, clonazepam, valproic acid, divalproex, acetazolamide, ethotoin, methsuximide, fosphenytoin
  AEDs raise the seizure threshold by stabilizing nerve cell membranes, reducing the excitability of the neurons, or through direct action on the limbic system, thalamus, and hypothalamus. The goal is optimal suppression of seizure activity with the lowest possible dose of a drug and with the fewest side effects. Fosphenytoin reaches therapeutic levels within 24 hours and can be used for nonemergent loading while waiting for other agents to become effective. Note: Some clients require polytherapy or frequent medication adjustments to control seizure activity. This increases the risk of adverse reactions and problems with adherence.
• 11.2. Topiramate, ethosuximide, lamotrigine, gabapentin
  Adjunctive therapy for partial seizures or an alternative for clients when seizures are not adequately controlled by other drugs. Lamotrigine is quickly absorbed if given orally, and 55% is bound to plasma proteins. Topiramate is approved for generalized, primary generalized, tonic-clonic, and partial-onset seizures (AlEissa & Benbadis, 2022).
• 11.3. Phenobarbital
  This potentiates and enhances the effects of AEDs and allows for the lower dosage to reduce side effects. If the client has received a benzodiazepine, the potential for respiratory supression significantly increases. This agent is the best-studied barbiturate for the treatment of status epilepticus (AlEissa & Benbadis, 2022).
• 11.4. Lorazepam
  This is used to abort status seizure activity because it is shorter acting than Valium and less likely to prolong post-seizure sedation. Lorazepam, when available, is thought to be the most effective of the benzodiazepines and has a longer seizure half-life than diazepam. It is the favored agent when intravenous access is preferred (Zonnoor & Chang, 2022).
• 11.5. Diazepam
  This may be used alone (or in combination with phenobarbital) to suppress status seizure activity. Diastat, a gel, may be administered rectally, even in the home setting, to reduce the frequency of seizures and need for additional medical care. The client can also carry rectal diazepam for treatment of breakthrough seizures. Many seizures are preceded by an aura, and clients can be educated to recognize their aura to prepare for a seizure (Zonnoor & Chang, 2022).
• 11.6. Glucose, thiamine
  This may be given to restore metabolic balance if a seizure is induced by hypoglycemia or alcohol. A 50 mL bolus of 50% dextrose IV and 100 mg thiamine can be administered, especially in status epilepticus cases, in some settings where drug intoxication might be likley, consider also adding naloxone to the dextrose bag (Roth & Berman, 2021).

12. Prepare for surgery or electrode implantation as indicated.
A vagal nerve stimulator, magnetic beam therapy, or other surgical intervention (temporal lobectomy) may be done for intractable seizures or well-localized epileptogenic lesions when the client is disabled and at high risk for serious injury. Success has been reported with gamma-ray radiosurgery for the treatment of multiple seizure activities that have otherwise been difficult to control. Efficacy of the stimulating device at 18 months is 40 to 50%. Many clients report improvement in seizure intensity and general mood when using vagal nerve stimulators (AlEissa & Benbadis, 2022).

13. Provide information about the benefits of non-invasive, wearable seizure monitoring.
Non-invasive, wearable biosensors have the greatest immediate potential to meet the needs of the majority of people with seizures. Currently, there are two wearable sensors approved by the FDA and EU for detecting convulsive seizures: a wrist-worn smartwatch (Empatica Embrace), which is linked to the wearer’s smartphone, and a device attached by an adhesive patch affixed to the wearer’s bicep and identifies changes in electromyography to detect convulsions (BrainSentinel SPEAC). This device akso has a cloud-based data platform and can send caregiver alerts (Schindler & Rahimi, 2021).

14. Reinforce limitations about driving.
Driving restrictions differ for each client because of the individual features of their seizures, their degree of seizure control, and in the US, state laws. To resume commercial driving across state lines, a client must have a 5-year seizure-free period (AlEissa & Benbadis, 2022).

15. Advise the client to be vigilant when participating in water activities such as swimming or boating.
Common sense dictates that clients with seizures should not swim alone, and they should be particularly aware of the importance of the presence of an adult lifeguard who can pull them out of the water if needed. Wearing of a life jacket in a boat is important. Additionally, a client who has a seizure while waiting for bath water to warm up may suffer hot-water burns (AlEissa & Benbadis, 2022).

16. Educate the client to avoid activities that may precipitate an injury, such as using power tools.
Injuries can occur with the use of power tools and other dangerous equipment, as well as burn injuries related to cooking. Clients with seizures may also experience an episode in situations such as being up on a roof or engaging in some activity at considerable height from the floor. Caution or supervision is advised when power tools are used, and the use of safety devices , such as an automatic sutoff switch, is recommended (AlEissa & Benbadis, 2022).