Nursing Care Plan for Epilepsy (Seizures)
Nursing Diagnosis for Epilepsy (Seizures) : Ineffective breathing pattern related to neuromuscular damage, increased mucus secretion
Goal : Maintain effective breathing pattern with a patent airway.
Interventions :
1. Encourage clients to vacate the mouth of objects / substances specified / dentures or other devices if the aura phase occurs and to avoid jaw shut if seizures occur without marked symptoms of early.
Rationale : Lowering the risk of aspiration or the entry of foreign objects into the pharynx.
2. Place the client in a position incline, flat surface, tilt the head during a seizure attack.
Rationale : Increase the flow (drainage) secret, preventing the tongue falls to clog the airway.
3. Remove clothing in the area of the neck, chest, and abdomen.
Rationale : To facilitate the effort to breathe.
4. Enter the tongue spatula / artificial airway or soft object rolls as indicated.
Rationale : Prevent being bitten tongue and facilitate during a suction mucus. Artificial airway may be indicated after the easing of seizure activity if the patient is unconscious and can not maintain a safe position of the tongue.
5. Do suction mucus as indicated.
Rationale : Lowering the risk of aspiration or asphyxia.
6. Give supplemental oxygen / ventilation manually as needed on postictal phase.
Rationale : Cerebral hypoxia may decrease as a result of decreased circulation or oxygen secondary to vascular spasm during seizures.
7. Prepare / aids to intubation if indicated.
Rationale : The emergence of prolonged apnea in postictal phase requiring mechanical ventilator support.
