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NURSING CARE PLAN FOR A SEIZURE
A febrile seizure is a convulsion in a child triggered by a fever. Such
convulsions occur without any underlying brain or spinal cord infection or
other neurological cause. According to studies, about 3-5% of otherwise
healthy children between the ages of 9 months and 5 years will have a seizure
caused by a fever. Toddlers are most commonly affected. Most occur well
within the first 24 hours of an illness, not necessarily when the fever is
highest.
Nursing Care Plans
Here are 5 benign febrile convulsions nursing care plans.
1. Hyperthermia
Benign Febrile Convulsion is a convulsion triggered by a rise in body
temperature. Fever is not an illness and is an important part of the body’s
defense against infection. Antigens or microorganisms cause inflammation
and the release of pyrogens which is a substance that induces fever.
Assessment
Patient may manifest
• - Increase in temperature
• - Flushed skin
• - Convulsions
Nursing Diagnosis
• - Hyperthermia
Outcomes
• - Patient’s temperature will decrease from [39°C] to normal range of
[36.5°C to 37°C].
• - Patient will be free of complications and maintain normal core
temperature.
Nursing Interventions Rationale Assess underlying condition and body temperature. To obtain baseline data.
Monitor and recorded vital signs. To note for progress and evaluate effects of hyperthermia.
Remove unnecessary clothing that could only aggravate heat To decrease or totally diminish pain.
Promote adequate rest periods. Reduces metabolic demands or oxygen.
Provide TSB To promote surface cooling.
Advice to increase fluid intake. To help decrease body temperature.
Loosen clothing. To provide proper ventilation and promote release of heat through evaporation.
Administer IV fluids at prescribed rate. Monitor regulation rate frequently. To promote fluid management.
Administer antipyretics as ordered. Antipyretics lower core temperature.
2. Imbalanced Nutrition
The nutritional requirements of the human body reflect the nutritional intake
necessary to maintain optimal body function and to meet the body’s daily
energy needs. Malnutrition (literally, “bad nutrition”) is defined as “inadequate
nutrition,” and while most people interpret this as undernutrition, falling short
of daily nutritional requirements. The etiology of malnutrition includes factors
such as poor food availability and preparation, recurrent infections, and lack of
nutritional education.
Assessment
Patient may manifest
• - Weakness
• - Low weight
• - Loss of appetite
• - Poor muscle tone
Nursing Diagnosis
Outcomes
• - Patient will demonstrate behaviour lifestyle changes to improve
circulation.
• - Patient’s S.O. will verbalize understanding of the condition.
Nursing Interventions Rationale Determine factors related to individual situation. To gain information regarding the condition.
Evaluate for signs of infection especially when immune system is compromised. To observe for possible risk factors.
Discuss individual risk factors. This information would be necessary for the client’s S.O.
Elevate head of bed at night. To increase gravitational blood flow.
Discuss the importance of a healthy diet.
To promote a healthy diet to help increase RBC synthesis and Hgb count for faster recovery.
4. Risk for Infection
The immune system is the body’s defense against bacteria, viruses, and other
foreign organisms or harmful chemicals. It is very complex and it has to work
properly to protect us from the harmful bacteria and other organisms in the
environment which may infect our body. If the immune system is
compromised, it can affect the normal production of WBC from the bone
marrow. If there is an increase in number of WBC, therefore it may increase
the possibility to increase infection.
Assessment
Patient may manifest
• - body weakness
• - fatigue
• - poor muscle tone
Nursing Diagnosis
• - Risk for infection
Outcomes
• - Patient will verbalize understanding of ways on how to prevent spread
of infection.
• - Patient will be free from infections and further complications
Nursing Interventions Rationale Establish good working relationship with the client and S.O. To gain their trust and cooperation
Monitor and record vital signs For comparative baseline data
Determine pt’s individual strength To know when to assist client
Provide peaceful environment To promote optimum level of functioning
Provide adequate rest and sleep. To prevent fatigue and conserve energy
Emphasize importance of handwashing To prevent occurrence of further infections
Provide safety measures To prevent falls and injuries
Monitor I & O To note for imbalances
Advice pt to increase oral fluid intake when allowed To replace fluid electrolyte loss
5. Risk for Injury
A seizure or convulsion is the visible sign of a problem in the electrical system
that controls your brain. A single seizure can have many causes, such as a
high fever and lack of oxygen. Hemoglobin is a protein in red blood cells that
carries oxygen. Therefore, Low levels of hemoglobin in the human body may
result to seizure. During episodes of convulsion, patients are prone to injuries
since they may strike different objects due to uncontrollable muscle spasms.
Assessment
Patient may manifest
• - Fever
• - Convulsions
Nursing Diagnosis
• - Risk for injury related to possible convulsion
Outcomes
