NANDA Nursing

Nursing Care Plan Seizure Disorders

Nursing Care Plan Seizure Disorders

CARE SETTING

Community; however, may require brief inpatient care on a medical or subacute unit for stabilization/treatment of status epilepticus.

RELATED CONCERNS
  1. Cerebrovascular accident (CVA)/stroke
  2. Craniocerebral trauma (acute rehabilitative phase)
  3. Psychosocial aspects of care
  4. Substance dependence/abuse rehabilitation
  5. Patient Assessment Database

ACTIVITY/REST

May report:
  1. Fatigue, general weakness
  2. Limitation of activities/occupation imposed by self/significant other (SO)/healthcare provider or others

May exhibit:
  1. Altered muscle tone/strength
  2. Involuntary movement/contractions of muscles or muscle groups (generalized tonic-clonic seizures)
CIRCULATION


May exhibit:
  1. Ictal: Hypertension, increased pulse, cyanosis
  2. Postictal: Vital signs normal or depressed with decreased pulse and respiration

EGO INTEGRITY

May report:
  1. Internal/external stressors related to condition and/or treatment
  2. Irritability; sense of helplessness/hopelessness
  3. Changes in relationships

May exhibit:
Wide range of emotional responses

ELIMINATION

May report:
Episodic incontinence

May exhibit:
Ictal: Increased bladder pressure and sphincter tone
Postictal : Muscles relaxed, resulting in incontinence (urinary/fecal)

FOOD/FLUID

May report:
Food sensitivity nausea/vomiting correlating with seizure activity

May exhibit:
Dental/soft-tissue damage (injury during seizure)
Gingival hyperplasia (side effect of long-term phenytoin [Dilantin] use)

NEUROSENSORY

May report:
  1. History of headaches, recurring seizure activity, fainting, dizziness
  2. History of head trauma, anoxia, cerebral infections
  3. Prodromal phase: Vague changes in emotional reactivity or affective response preceding aura in some cases and lasting minutes to hours
  4. Presence of aura (stimulation of visual, auditory, hallucinogenic areas)
  5. Postictal: Weakness, muscle pain, areas of paresthesia/paralysis

May exhibit:
  1. Seizure characteristics: (ictal, postictal)
  2. Generalized seizures:
  3. Tonic-clonic (grand mal): Rigidity and jerking posturing, vocalization, loss of consciousness, dilated pupils, stertorous respiration, excessive salivation (froth), fecal/urinary incontinence, and biting of the tongue may occur and last 2–5 min.
  4. Postictal phase: Patient sleeps 30 min to several hours, then may be weak, confused, and amnesic concerning the episode, with nausea and stiff, sore muscles
  5. Myoclonic: Short abrupt muscle contractions of arms, legs, torso; may not be symmetrical; lasts seconds
  6. Clonic: Muscle contraction with relaxation resembling myoclonic movements but with slower repetitions; may last several minutes
  7. Tonic: Abrupt increase in muscle tone of torso/face, flexion of arms, extension of legs; lasts seconds
  8. Atonic: Abrupt loss of muscle tone; lasts seconds; patient may fall
  9. Absence (petit mal): Periods of altered awareness or consciousness (staring, fluttering of eyes) lasting 5–30 sec, which may occur as many as 100 times a day; minor motor seizures may be akinetic (loss of movement), myoclonic (repetitive motor contractions), or atonic (loss of muscle tone). Postictal phase: Amnesia for seizure events, no confusion, able to resume activity
  10. Status epilepticus: Defined as 30 or more minutes of continuous generalized seizure activity or two or more sequential seizures without full recovery of consciousness in between, possibly related to abrupt withdrawal of anticonvulsants and other metabolic phenomena. If absence seizures are the pattern, problem may go undetected for a period of time because patient does not lose consciousness
  11. Partial seizures:
  12. Complex (psychomotor/temporal lobe): Patient generally remains conscious, with reactions such as dream state, staring, wandering, irritability, hallucinations, hostility, or fear. May display involuntary motor symptoms (lip smacking) and behaviors that appear purposeful but are inappropriate (automatism) and include impaired judgment and, on occasion, antisocial acts; lasts 1–3 min. Postictal phase: Absence of memory for these events, mild to moderate confusion
  13. Simple (focal-motor/Jacksonian): Often preceded by aura (may report deja vu or fearfulfeeling); no loss of consciousness (unilateral) or loss of consciousness (bilateral); convulsive movements and temporary disturbance in part controlled by the brain region involved (e.g., frontal lobe [motor dysfunction], parietal [numbness, tingling], occipital [bright, flashing lights], posterotemporal [difficulty speaking]). Convulsions may march along limb or side of body in orderly progression. If restrained during seizure, patient may exhibit combative and uncooperative behavior; lasts seconds to minutes

PAIN/DISCOMFORT

May report:
  1. Headache, muscle/back soreness postictally
  2. Paroxysmal abdominal pain during ictal phase (may occur during some partial/focal seizures without loss of consciousness)

May exhibit:
  1. Guarding behavior
  2. Alteration in muscle tone
  3. Distraction behavior/restlessness

RESPIRATION

May exhibit:
  1. Ictal: Clenched teeth, cyanosis, decreased or rapid respirations; increased mucous secretions
  2. Postictal: Apnea

SAFETY

May report:
  1. History of accidental falls/injuries, fractures
  2. Presence of allergies

May exhibit:
  1. Soft-tissue injury/ecchymosis
  2. Decreased general strength/muscle tone

SOCIAL INTERACTION

May report:
  1. Problems with interpersonal relationships within family/socially
  2. Limitation/avoidance of social contacts

TEACHING/LEARNING

May report:
  1. Familial history of epilepsy
  2. Drug (including alcohol) use/misuse
  3. Increased frequency of episodes/failure to improve
  4. Discharge plan
  5. DRG projected mean length of inpatient stay: 4.4 days
  6. May require changes in medications, assistance with some homemaker/maintenance tasks relative to issues of safety, and transportation
  7. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

  1. Electrolytes: Imbalances may affect/predispose to seizure activity.
  2. Glucose: Hypoglycemia may precipitate seizure activity.
  3. Blood urea nitrogen (BUN): Elevation may potentiate seizure activity or may indicate nephrotoxicity related to medication regimen.
  4. Complete blood count (CBC): Aplastic anemia may result from drug therapy.
  5. Serum drug levels: To verify therapeutic range of antiepileptic drugs (AEDs).
  6. Toxicology screen: Determines potentiating factors such as alcohol or other drug use.
  7. Skull x-rays: Identifies presence of space-occupying lesions, fractures.
  8. Electroencephalogram (EEG) may be done serially: Locates area of cerebral dysfunction; measures brain activity.
  9. Brain waves take on characteristic spikes in each type of seizure activity; however, up to 40% of seizure patients have normal EEGs because the paroxysmal abnormalities occur intermittently.
  10. Video-EEG monitoring, 24 hours (video picture obtained at same time as EEG): May identify exact focus of seizure activity (advantage of repeated viewing of event with EEG recording).
  11. Computed tomography (CT) scan: Identifies localized cerebral lesions, infarcts, hematomas, cerebral edema, trauma, abscesses, tumor; can be done with or without contrast medium.
  12. Magnetic resonance imaging (MRI): Localizes focal lesions.
  13. Positron emission tomography (PET): Demonstrates metabolic alterations, e.g., decreased metabolism of glucose at site of lesion.
  14. Single photon emission computed tomography (SPECT): May show local areas of brain dysfunction when CT and MRI are normal.
  15. Magnetoencephalogram: Maps the electrical impulses/potential of brain for abnormal discharge patterns.
  16. Lumbar puncture: Detects abnormal cerebrospinal fluid (CSF) pressure, signs of infections or bleeding (i.e., subarachnoid, subdural hemorrhage) as a cause of seizure activity (rarely done).
  17. Wada’s test: Determines hemispheric dominance (done as a presurgical evaluation before temporal lobectomy).

NURSING PRIORITIES

  1. Prevent/control seizure activity.
  2. Protect patient from injury.
  3. Maintain airway/respiratory function.
  4. Promote positive self-esteem.
  5. Provide information about disease process, prognosis, and treatment needs.

DISCHARGE GOALS

  1. Seizures activity controlled.
  2. Complications/injury prevented.
  3. Capable/competent self-image displayed.
  4. Disease process/prognosis, therapeutic regimen, and limitations understood.
  5. Plan in place to meet needs after discharge.


Source : http://nursingpedia.blogspot.com/2011/07/nursing-care-plan-seizure-disorders.html