NURSING
DIAGNOSIS
RATIONALE
Risk for injury related
to loss of large or small
muscle coordination
secondary to seizure
Seizures are
disturbances in
normal brain
function resulting
from abnormal
electrical
discharges
in the brain, which
can cause loss of
consciousness,
uncontrolled body
movements,
changes in
behaviors and
sensation, and
changes in the
autonomic system.
During episodes of
seizure, patients
are prone to injuries
since they may
strike different
objects due to
uncontrollable
muscle spasms.
GOALS AND
OBJECTIVES
After 2 hours of nursing
intervention, patient will be able to
attain or sustains no injury during
seizure activity
Will adhere with safety measures
and identifies hazards of noncompliance.
Will verbalize the importance of
lifestyle changes to reduce risk
factors and protect self from
injury.
INTERVENTIONS
RATIONALE
INDEPENDENT
Provide privacy and protect patient from curious
onlookers.
Triage in observation room on bed. Keep padded
side rails up with bed in lowest position.
Proper history taking from EMT.
Document pre seizure activity, presence of aura, or
unusual behaviour, type of seizure activity, such as
location and duration of motor activity, and LOC,
incontinence eye activity, respiratory impairment
and cyanosis, and frequency of recurrence. Note
whether patient fell, expressed vocalization,
drooled, or had automatisms such as lip smacking,
chewing, and picking at clothes.
Apply tag (neon pink) for high risk of fall.
The patient who has an aura(warning of
impending seizure) may have time to seek a
safe, private place.
Minimizes injury should frequent or generalized
seizures occur while client is on bed
Helps localize the cerebral area of involvement
and may be useful in chronic conditions in
helping patient and significant other prepare for
or manage seizure activity.
The most immediate concern when it comes to
epileptic seizures is to prevent traumatic injury
resulting from falls due to uncontrolled violent
movements of the entire body that may lead to
fracture and internal bleeding with damage to
vital organs.
No attempt should be made to restrain the patient
during seizure.
Muscular contractions are strong and restrain
can produce injury.
Maintain strict bed rest if prodromal signs or aura is
experienced. Explain necessity for this actions
Client may feel restless, need to ambulate or
even defecate during aural phase, thereby
inadvertently removing self from safe
environment and easy observation.
Understanding importance of providing for own
safety needs may enhance patient
cooperation.
Stay with the client during and after seizure.
Promotes patient safety and reduces sense of
isolation during the event.
Perform neurological and vital signs check post
seizure: LOC, orientation, ability to comply with
simple commands, ability to speak, memory of
incident, weakness or motor deficits, BP, PR & RR.
Document postictal state & time and
completeness of recovery to normal state. May
identify additional safety concerns to be
addressed.
Reorient patient following seizure acitivity.
Patient may be confused, disoriented, and
possibly amnesic after seizure and need help
to regain control and alleviate anxiety.
COLLABORATIVE
Administered medications as ordered to stop
seizures:
a.)
Diazepam
b.)
Dilantin
Diazepam may be given IV at 5mg/min rate to
control seizure activity by enhancing
neurotransmitter GABA. Cardiovascular and
respiratory depression may occur if diazepam
is used in conjunction with phenobarbital.
Dilantin may be given at 50mg/min rate to
decrease cellular influx of sodium and calcium
and blocking neurotransmitter release. Caution
must be maintained to avoid giving phenytoin
EVALUATION
After 2 hours of nursing intervention,
goals were fully met as evidenced
by:
Patient sustains no injury during
seizure activity
Adheres with safety measures and
identifies hazards of noncompliance.
Verbalize the importance of lifestyle
changes to reduce risk factors and
protect self from injury.
any faster than prescribed rate because of its
pH, and ECG must be monitored for
dysrhythmias while administering this drug.
HEALTH EUCATION:
Explain to the patient the various stimuli that may
precipitate seizure activity.
Discuss seizure warning signs, if appropriate, and
usual seizure pattern. Teach significant other to
recognize warning signs and how to care for patient
during and after seizure.
Alcohol, various drugs, and other stimuli, such
as loss of sleep, flashing lights, and prolonged
TV viewing may increase potential for seizure
activity. Patient may or may not have control
over many precipitating factors, but may
benefit from becoming aware of these risks.
Can enable patient or significant other to
protect individual from injury and to recognize
changes that require notification of physician
and further intervention. Knowing what to do
when seizure occurs can prevent injury or
complications.