Seizure Nursing Care Plan
When you're writing a nursing care plan you don't put related to, if it's a risk. A risk for ineffective airway clearance would be the nursing diagnosis. I put it's related to neurological function loss. It is evidenced by an inability to clear secretions from the airway. When a patient is seizing their airway is a major concern.
The second nursing diagnosis that I put on is a risk for suffocation related to ineffective airway clearance as evidenced by copious amounts of secretions in the airway.
The last nursing diagnosis is fatigue. This one is related to none as evidenced by but I put fatigue related to muscle spasms and tension as evidenced by postictal weakness. This is something you're going to see in most of your seizure patients. They had all these muscle spasms and tension through their body afterwards the postictal stage.
As far as patient goals I wrote a goal for the patient to be able to recognize signs and symptoms of oncoming seizures. These are also called auras. Some people just have a feeling they know it's coming hours before it happens.
It can be with sight, sound any sort of part of your five senses can be off are different. Some people don't know it's coming at all. If you can educate them to look out for signs and symptoms, and they do have signs and symptoms, that'd be the best way for them to be able to prepare for it.
The second goal that is to educate family and friends on how to care for someone who's having a seizure. You want to make sure that the family knows what to do. Such as timing the seizure, making sure that the area is safe, getting them to the floor so they laid down horizontally on their side. Other precautions are loosened up clothing if there's anything that's restricting on them.
The third goal that is to take all prescribed medications as they are prescribed. This is super important for preventing any seizures. But also if the patient has that aura make sure that they're taking their anti-seizure medication, whatever it is that might be prescribed.
For our first intervention of being able to recognize signs and symptoms of oncoming seizures. You as a nurse are going to educate the patient on what auras. to talk to them about what to look out for and what to do if they feel a seizure coming on.
This leads to the second intervention that you're gonna do, which is also educate the patient themselves on what they're going to tell their family and friends. Make sure that the patient knows what the family in front should be doing. Turn patient on their side, keep it in your wake clear airway during and make sure that the time the seizure during the seizure.
The third intervention is to educate the patient on the importance of medicating medication compliance and have them use a dispenser for the days of the weekend. This is the best way to make sure that they have taken their meds instead of they forget doing it.
Implementation is all pretty important. I put yes for all of the rules in order to evaluate the outcomes.
As for the first patient goal, the patient tells you there are signs and symptoms of an impending seizure, what it looks like and what to look for such as smells, taste, vision etc. This is the teach-back method and it is by far the number one method that I use in my current nursing practice.
I definitely make sure that they repeat back to me what I've said and they can tell me everything because it has made a major difference I can tell the patient is remembering and listening. I know it can be difficult to remember what someone just told you at the moment.
The second evaluation one of the things you can do is you can check in with the family and friends to confirm that they know what they're looking for . Have them use the teach-back method on them as well. Ask them what they were taught, what the family member or the patient told them.
And the last one is to make sure the patient has a list of all their medications and can tell you what they take, when they take it, why they take it. Those kinds of questions are super important because it helps them if they are ever in a situation where they had a seizure, or they are not responsive or able to help out. Having this list is important.
It also helps family members know what to do during a time of crisis and what medications that they need to take.
Again, it is your care plan. Probably, the most important thing that we want to look out for is the airway. The second most important thing that we want to do for these patients is to make sure that they're well educated on how to handle having a seizure, how to prevent having a seizure and making sure that their family members are involved in all of this.