Nursing Care Plan (NCP) for Seizures
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Lesson Objective for Nursing Care Plan (NCP) for Seizures
What is a Seizure?
A seizure is like an electrical storm in the brain. Normally, brain cells communicate through controlled electrical signals, but during a seizure, these signals become abnormal and excessive, leading to sudden, temporary changes in behavior, movement, feeling, or consciousness.
Types of Seizures:
Generalized Seizures: Affect the whole brain. For example, tonic-clonic seizures, where the body stiffens and jerks.
Focal Seizures: Start in just one part of the brain. They might cause twitching or a change in sensation or emotions.
What Causes Seizures?
They can be caused by various things, like epilepsy, head injuries, certain illnesses, or even high fevers (especially in children).
Symptoms:
- Can vary widely, from blank staring, muscle stiffness, and jerking movements, to loss of consciousness or awareness.
- After a seizure, a person might feel confused or tired.
Upon completion of this care plan, nursing students will be able to:
- Understand the pathophysiology of Seizures, including the mechanisms that lead to abnormal electrical activity in the brain.
- Conduct a thorough nursing assessment, identifying seizure triggers, aura, and associated signs and symptoms.
- Formulate and prioritize nursing diagnoses, addressing both the immediate management of seizures and the long-term care of individuals with epilepsy.
- Develop evidence-based nursing interventions, focusing on seizure prevention, safety measures, and patient education.
- Educate patients and caregivers on seizure management, including medication adherence, lifestyle modifications, and appropriate emergency responses.
Pathophysiology of Seizures
Seizures happen when there’s too much electrical activity in the brain. Imagine your brain as a busy city with lots of streets and cars. Normally, everything runs smoothly, but sometimes the traffic lights go haywire.
- Nerve Excitement:
- Blocked Roads: Some roads (or pathways) in the brain get blocked, making it hard for signals to move smoothly.
- Confused Signals: Signals between nerve cells can get mixed up because the traffic lights (or chemicals in the brain) aren’t working as they should.
- Everyone Starts Moving Together:
- Neighborhood Chaos: When one area of the brain gets too excited, it’s like all the neighbors start doing the same thing at the same time.
- Spread of Excitement: This excitement can spread quickly to other areas, causing a seizure where the brain’s signals go a bit wild.
- Problems with the Brain’s “Blueprint”:
- Brain Construction Issues: Sometimes, the brain’s construction has some problems, like bumps in the roads or areas that aren’t developed properly.
- Genetic Factors: Some people are born with a higher chance of having seizures because it runs in their families or their brain’s construction is a bit different.
- Other Factors:
- Low Energy or Imbalances: If the brain doesn’t get enough energy or if certain chemicals are imbalanced, it can cause trouble with the traffic lights and lead to seizures.
- Substance Issues:
- Withdrawal Trouble: Suddenly stopping certain medications or substances, like alcohol or certain drugs, can also cause the brain to act up.
Etiology of Seizures
Understanding why seizures occur is crucial for nursing students working with patients experiencing these events. Think of the brain as a complex system, and seizures as disruptions in its normal functioning. Here’s a simplified breakdown of the potential causes:
- Genetic Factors:
- Familial Predisposition: Individuals with a family history of seizures may have a genetic predisposition.
- Genetic Coding: Certain genetic codes may influence the likelihood of experiencing seizures.
- Structural Brain Variances:
- Congenital Variances: Structural differences in the brain present at birth may contribute.
- Neural Pathways: Variations in neural pathways could lead to abnormal signal propagation.
- Disturbances in Neural Traffic:
- Signal Interruptions: Disruptions in the normal flow of signals between neurons may occur.
- Hyperexcitability: Some areas of the brain may become overly excited, leading to cascading effects.
- Metabolic and Chemical Imbalances:
- Energy Deprivation: Insufficient energy supply to the brain can result in glitches.
- Neurotransmitter Imbalances: Disturbances in the balance of neurotransmitters may affect signal transmission.
- Substance-Related Factors:
- Abrupt Cessation: Suddenly stopping certain medications or substances can induce seizures.
Desired Outcome for Nursing Care Plan (NCP) for Seizures
- Seizure Control:
- Short-Term Goal: Achieve immediate control and termination of the seizure episode.
- Interventions: Administer prescribed antiepileptic medications promptly. Ensure a safe environment to prevent injury during the seizure.
- Reduced Frequency of Seizures:
- Intermediate-Term Goal: Decrease the frequency and intensity of seizures over time.
- Interventions: Optimize medication adherence. Collaborate with the healthcare team to adjust medications as needed.
- Improved Quality of Life:
- Long-Term Goal: Enhance overall quality of life by minimizing the impact of seizures on daily activities.
- Interventions: Provide ongoing education on lifestyle modifications, stress management, and coping strategies.
- Medication Adherence:
- Intermediate-Term Goal: Ensure consistent adherence to prescribed antiepileptic medications.
- Interventions: Conduct regular medication reviews, address concerns or side effects, and utilize strategies to support adherence.
- Seizure-Free Periods:
- Long-Term Goal: Achieve extended periods without seizures.
- Interventions: Continuously assess and adjust the care plan. Collaborate with neurologists to explore alternative or adjunct therapies.
- Optimized Neurological Function:
- Long-Term Goal: Preserve and optimize neurological function.
- Interventions: Regularly monitor cognitive function. Collaborate with neurology specialists for comprehensive neurological assessments.
Seizures Nursing Care Plan
Subjective Data:
- Loss of awareness
- Confusion
- Pt may report aura before the seizure
- A postictal state (drowsiness, nausea, vomiting, headache)
Objective Data:
- Rhythmic twitching
- Stiff contraction
- Loss of consciousness
- Staring off blankly
- Repetitive behavior (lip smacking, laughing)
Nursing Assessment for Seizures
- Seizure History:
- Frequency and Duration: Determine how often seizures occur and how long they typically last.
- Aura or Warning Signs: Explore if there are any warning signs or auras before a seizure.
- Current Seizure Episode:
- Observations: Document the sequence of events during the current seizure, including any unusual movements, changes in consciousness, or postictal phases.
- Triggers: Identify potential triggers such as stress, lack of sleep, or specific stimuli.
- Medical History:
- Underlying Conditions: Assess for any underlying medical conditions, neurological disorders, or structural brain abnormalities.
- Medication History: Review current and past medications, including antiepileptic drugs, and assess adherence.
- Neurological Examination:
- Cognitive Function: Evaluate the patient’s cognitive function, memory, and attention.
- Motor Function: Assess for any motor deficits, weakness, or abnormalities.
- Medication Adherence:
- Current Medications: Review the patient’s current antiepileptic medications, dosages, and frequency.
- Barriers to Adherence: Identify any barriers to medication adherence, such as side effects or forgetfulness.
- Seizure Triggers and Patterns:
- Identify Triggers: Explore potential triggers, including stressors, lack of sleep, or specific environmental factors.
- Pattern Recognition: Note any patterns in the occurrence of seizures, such as time of day or specific situations.
- Psychosocial Assessment:
- Emotional Well-being: Explore the patient’s emotional well-being, addressing any anxiety, depression, or stigma related to seizures.
- Social Support: Assess the availability of social support, including family and community resources.
Nursing Interventions and Rationales
- Initiate seizure precautions for patients at risk for seizures.
- Suction set up and working
- Ambu-bag in room
- Padding side rails
- All side rails up
Seizures frequently happen without warning, therefore we must ensure safety in case it occurs. Once one begins, it’s too late to try to implement the safety precautions
- Maintain airway
During a seizure, the patient may not be able to maintain their airway, or they may not be able to handle their oral secretions and aspirate.
- Maintain safety during any seizure activity
- Turn pt to the side
- NOTHING in mouth
- Do NOT restrain
- Patients may vomit during a seizure, therefore turning them to their side can help to prevent aspiration (in addition to having suction available).
- Putting things in the mouth can cause the patient injury as they tend to clench their teeth during seizures
- Restraining the patient may cause injury because of the unpredictable muscle movements
- Assess, monitor, and document seizure activity
It is essential to know the precipitating factors, what happened during the seizure (rhythmic twitching and specific location), and the specific timing (30 seconds vs. 2 minutes vs. 6 minutes) – you must be as specific as possible to enable the medical team to make appropriate clinical decisions.
- Administer antiepileptics (PRN and scheduled) medications per orders
Many patients with seizures, or who are at risk will have scheduled antiepileptic medications. They must receive these promptly, as ordered. Also, be aware of your PRN antiepileptics and when to administer them (typically for seizures lasting longer than 2 minutes)
- Reevaluate any medications that may lower the seizure threshold (some antibiotics, antidepressants, narcotics, and many more may do this)
We want to do all we can to prevent seizures from occurring, therefore the healthcare team must evaluate meds that may increase the seizure risk and closely look at them to decide if the benefit is worth the risk, or if an alternative is available that does not lower the seizure threshold
- Educate patient and family on hospital procedures, and when to notify staff
Some patients with a history of seizures can tell when one is coming on, which is helpful to communicate to the nurse. Also, it’s helpful to let them know what you as the nurse will do when/if a seizure occurs so that they are prepared mentally and emotionally, as it can be somewhat scary for families to witness and patients to experience.
- Provide emotional support
Seizures are serious and upsetting to witness. The more empathy and support you can provide patients and loved ones, the better.
- Help the patient develop a seizure action plan for after discharge
The patient and family need to know what to do should a seizure occur at home. Not all seizures are emergencies. They should know what to do to keep the patient safe and when to call 911:
- Cyanosis or not breathing
- Back-to-back seizures
- Seizure lasting > 5 minutes
Evaluation for Nursing Care Plan (NCP) for Seizures
- Seizure Control:
- Expected Outcome: Immediate control and termination of the seizure episode.
- Evaluation Criteria: Compare the patient’s response to interventions during seizures with baseline episodes. Assess the effectiveness of antiepileptic medications.
- Frequency of Seizures:
- Expected Outcome: Decreased frequency and intensity of seizures.
- Evaluation Criteria: Compare the number and severity of seizures over time. Analyze patterns and note any improvement or exacerbation.
- Medication Adherence:
- Expected Outcome: Consistent adherence to prescribed antiepileptic medications.
- Evaluation Criteria: Monitor medication adherence through patient self-report and medication records. Address any identified barriers to adherence.
- Seizure-Free Periods:
- Expected Outcome: Extended periods without seizures.
- Evaluation Criteria: Monitor for seizure-free intervals. Adjust the care plan based on the frequency and duration of seizure-free periods.
- Neurological Function:
- Expected Outcome: Preserved and optimized neurological function.
- Evaluation Criteria: Regularly assess cognitive function, motor skills, and neurological status. Collaborate with neurology specialists for comprehensive evaluations.
References
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Transcript
Today, we’re going to talk about seizures for our nursing care Plan. First, we have to collect the information, so we are going to gather that data. Remember, we have subjective and objective data. Our subjective data is what the client’s reporting. Maybe they are saying that they feel more confused than normal, if they’re aware of that. Maybe they have an aura that occurs before a seizure occurs, that one is coming, or maybe they have experienced that postictal state where they’re super drowsy and tired. They have had some nausea and vomiting with that, or a headache.
Our objective data are things that we’ve observed. So let’s say we actually see the seizure. You see either twitching happening, you see those convulsions, so, you know it’s a seizure. Remember all kinds of different seizures can happen. You could have that blank stare occur on your patient, or they have a loss of consciousness. Just any of those,you know, tightness, those contractions that they have, the stiffness, or maybe even an EEG is done showing brain waves that show that a seizure is occurring. Those are going to be our objective data.
So next, we’re going to look at the information. We are going to diagnose and prioritize by analyzing the information. So what’s the problem? Well, the patient is seizing and that is a safety risk, right? Huge safety risk. What needs to be improved? What can we do? So, we could do medications to help this seizure stop, whatever it may be, as soon as possible. Really, we want to minimize any damage, anything we can do to minimize damage, which would be things like our seizure precautions that we can put patients on. So, like padded side rails, those kinds of things, having suction available, or an ambu bag, and that will help improve our outcomes. Then what’s our priority? So for me with seizures, the biggest thing if they’re seizing is going to be patient safety is our priority, as well as getting it to stop, right? We want to stop that seizure from happening.
Alright, so now we’re going to plan, implement and evaluate. This is our asking, how, how do we know it was a problem? Well, this is where you kind of are linking your data together. All those symptoms that objective data and subjective data that we gathered, you’re linking it to this. That’s how we knew it was a problem. The patient sees an aura, whatever it may be, that’s how we knew, and how are we going to address it? Well, hopefully they have an anti-epileptic drug ordered. Those anti-seizure medications that we can give to stop the seizure from happening. We can put the patient on those seizure precautions and this will help to keep the patient safe during a seizure. Then, how would I know it gets better? Well, they remain safe during a seizure, or depending on what’s happening with this patient, the seizure stops, then we would know that it got better.
Alright, so onto the translation. So these are our high-level nursing concepts where you’re really concise. So for me, our concepts would be safety, I would go with coping and comfort because more so for the family, which they are patient to when this situation occurs, it can be super scary. So, just allowing for coping and comfort and helping that family through this, and then patient education, of course, always a good one. Alright, so now we have to go in and we transcribe, this is where you’re going to put those problems, those priorities. You’re going to link your data together that told you what the problem was. We are going to intervene. This is the why, why are we intervening, and then, what do we expect to see happen?
So, here our priorities are safety, comfort, coping and patient education. Next is objective data, subjective data. The patient said they had an aura coming on. So we know this patient’s about to cease, so we can intervene. We would intervene by padding the side rails, turning the patient because remember, the patients can vomit a lot. They have nausea and vomiting. They can vomit during the seizure. We don’t want them to aspirate, so turning them on the side, having suction available and an ambu bag to keep our good airway, and oxygenate the patient. These are interventions that we can do, all of our seizure precautions.
Now our rationale. So why, well, this is going to, we’re going to do this, and it is going to provide safety for that client, and then our expected outcome. So our expected outcome is that the patient will remain safe during the seizure. Okay, our comfort and coping. Our data we have, the patient maybe has a lack of understanding of what’s happening, or maybe they’re scared. We want interventions to be empathetic, right? It’s scary. Just listening to the patient, helping them feel supported about it, and then helping them devise a seizure action plan could be an intervention, because when a patient feels prepared for something, or the family feels prepared, it helps give them that confidence.
Onto our rationale. So, why are we doing this? Well, it’s going to help them feel supported, and then having a plan will help them feel comforted. The expected outcome is for them to have that plan and feel supported. Next, our patient education. Perhaps it’s on epileptic medications, they need education on that. They need education on the aura, like who to call for help when a seizure is coming, what to do when they get that aura. Our intervention here is going to be, we’re going to educate on the medications and when to take, and of course, if there’s any drug interaction that could happen with those medications. We also want them to notify if they have that aura, so that they can go ahead and take medication, or know when to take it. Usually, if the seizures last more than like two minutes, we would give medication to the family. To know that, will be important. Then also, if they or somebody that has epilepsy, then they might be given medication to be taken daily, so they need to know about that. They need to know when to take that med.
Our rationale, so we’ll understand when to take the meds, like we said, and how these meds are going to interact with other drugs, foods, anything that could cause an interaction and then the aura so that they are aware, this is going to give them the reason. Why we want them to know is, we want them to be aware of seizures coming, so that they know when to medicate themselves. Our expected outcomes. So, with our education, usually we can let them verbalize or demonstrate that the education has been successful, that they have an understanding.
Alright guys, let’s look at our key points. So, we have to collect information. This is going to be our assessment data, that subjective and objective data. We want to analyze that information, which is going to allow for diagnosing and prioritizing our tasks, ask how and this is how we are going to plan, implement and evaluate. It’s going to help us do all that. Translate, so concise terms, those concepts, and then transcribe, describe whatever form you prefer, whatever works for you, just to lay it all out and link everything together.
Alright guys, thanks for listening to this. Check out all the care plans that we have available for you to look at on NURSING.com. We love you. Now, go out and be your best selves today and as always, happy nursing!
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