Nursing care plan for a patient with Epilepsy.

 Nursing care plan for a patient with Epilepsy:

Nursing care plan includes these steps:

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

Nursing Assessment

Nursing assessment includes:

• History. The diagnosis of epileptic seizures is made by analyzing the patient’s detailed clinical history and by performing ancillary tests for confirmation; someone who has observed the patient’s repeated events is usually the best person to provide an accurate history; however, the patient also provides invaluable details about auras, preservation of consciousness, and postictal states.
• Physical exam. A physical examination helps in the diagnosis of specific epileptic syndromes that cause abnormal findings, such as dermatologic abnormalities (e.g., neurocutaneous syndromes such as Sturge-Weber, tuberous sclerosis, and others); also, patients who for years have had intractable generalized tonic-clonic seizures are likely to have suffered injuries requiring stitches.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

• Risk for trauma or suffocation related to loss of large or small muscle coordination.
• Risk for ineffective airway clearance related to neuromuscular impairment.
• Situational low self-esteem related to stigma associated with the condition.
• Deficient knowledge related to information misinterpretation.
• Risk for injury related to weakness, balancing difficulties, cognitive limitations or altered consciousness.

Nursing Care Planning and Goals

The major nursing goals for a child with seizure disorder are:

• The patient or caregiver will verbalize understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to correct the situation.
• The patient or caregiver will identify actions or measures to take when seizure activity occurs.
• The patient or caregiver will identify and correct potential risk factors in the environment.
• The patient or caregiver will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
• The patient or caregiver will modify the environment as indicated to enhance safety.
• The patient or caregiver will maintain treatment regimen to control or eliminate seizure activity
• The patient or caregiver will recognize the need for assistance to prevent accidents or injuries.
• The patient will maintain effective respiratory pattern with airway patent or aspiration prevented.
• The patient or caregiver will demonstrate behaviors to restore positive self-esteem.
• The patient or caregiver will participate in treatment regimen or activities to correct factors that precipitated a crisis.
• The patient or caregiver will verbalize understanding of the disorder and various stimuli that may increase potentiate seizure activity.

Nursing Interventions

Nursing interventions for a child with seizure disorder include the following:

• Prevent trauma/injury. Teach SO to determine and familiarize warning signs and how to care for patient during and after seizure attack; avoid using thermometers that can cause breakage; use tympanic thermometer when necessary to take temperature; uphold strict bedrest if prodromal signs or aura experienced; turn head to side and suction airway as indicated; support head, place on soft area, or assist to floor if out of bed; do not attempt to restrain; monitor and document AED drug levels, corresponding side effects, and frequency of seizure activity.
• Promote airway clearance. Maintain in lying position, flat surface; turn head to side during seizure activity; loosen clothing from neck or chest and abdominal areas; suction as needed; supervise supplemental oxygen or bag ventilation as needed postictally.
• Improve self-esteem. Determine individual situation related to low self-esteem in the present circumstances; refrain from over protecting the patient; encourage activities, providing supervision and monitoring when indicated; know the attitudes or capabilities of SO; help an individual realize that his or her feelings are normal; however, guilt and blame are not helpful.
• Enforce education about the disease. Review pathology and prognosis of condition and lifelong need for treatments as indicated; discuss patient’s particular trigger factors (flashing lights, hyperventilation, loud noises,video games, TV viewing); know and instill the importance of good oral hygiene and regular dental care; review medication regimen, necessity of taking drugs as ordered, and not discontinuing therapy without physician supervision; include directions for missed dose.

Evaluation

Goals are met as evidenced by:

• The patient or caregiver verbalized understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to correct the situation.
• The patient or caregiver identified actions or measures to take when seizure activity occurs.
• The patient or caregiver identified and corrected potential risk factors in the environment.
• The patient or caregiver demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury.
• The patient or caregiver modified environment as indicated to enhance safety.
• The patient or caregiver maintained treatment regimen to control or eliminate seizure activity
• The patient or caregiver recognized the need for assistance to prevent accidents or injuries.
• The patient maintained effective respiratory pattern with airway patent or aspiration prevented.
• The patient or caregiver demonstrated behaviors to restore positive self-esteem.
• The patient or caregiver participated in treatment regimen or activities to correct factors that precipitated a crisis.
• The patient or caregiver verbalized understanding of the disorder and various stimuli that may increase potentiate seizure activity.

Documentation Guidelines

Documentation in a child with seizure disorder include:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.