Facebook Twitter RSS Reset

Epilepsy- Nursing assessment, Nursing diagnosis, goal, interventions, patient education

Nursing Assessment

  • Obtain seizure history, including prodromal signs and symptoms, seizure behavior, postictal state, history of status epilepticus.
  • Document the following about seizure activity
    • Circumstances before attack, such as visual, auditory, olfactory, or tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation
    • Description of movement, including where movement or stiffness started; type of movement and parts involved; progression of movement; whether beginning of seizure was witnessed
    • Position of the eyes and head; size of pupils
    • Presence of automatisms, such as lip smacking or repeated swallowing
    • Incontinence of urine or feces
    • Duration of each phase of the attack
    • Presence of unconsciousness and its duration
    • Behavior after attack, including inability to speak, any weakness or paralysis (Todd’s paralysis), sleep
  • Investigate the psychosocial effect of seizures.
  • Obtain history of drug or alcohol abuse.
  • Assess compliance and medication-taking strategies.

Drug Related History

Nonadherence to medication regimen as well as toxicity of antiepileptic medications can increase seizure frequency. Obtain drug levels before implementing medication changes.

NURSING DIAGNOSES

  • Ineffective breathing pattern related to neuromuscular impairment secondary to prolonged tonic phase of seizure or during postictal period as evidenced by abnormal respiratory rate,rhythm, and or depth
  • Ineffective Tissue Perfusion (cerebral) related to seizure activity.
  • Risk for Injury related to seizure activity
  • Ineffective Coping related to psychosocial and economic consequences of epilepsy

NURSING DIAGNOSES

  • Ineffective breathing pattern related to neuromuscular impairement secondary to prolonged tonic phase of seizure or during postictal period as evidenced by abnormal respiratory rate,rhythm, and/ or depth.

Nursing Goal :  Normal breathing pattern adequate to meet oxygen needs.

Nursing Interventions

Airway management

  • Monitor respiratory and oxygenation status to determine presence and extend of problem and to initiate appropriate interventions.
  • Position patient (side lying) to maximize ventilation potential.
  • Identify patient requiring actual/potential airway insertion to facilitate intubation as necessary.
  • Perform endotracheal or nasotracheal suctioning to maintain airway as needed.

Seizure management

  • Loosen clothing to prevent restricted breathing.
  • Apply oxygen as appropriate to maintain oxygenation and prevent hypoxia.

 Nursing Diagnosis

  • Ineffective Tissue Perfusion (cerebral) related to seizure activity

Nursing goal : Maintaining Cerebral Tissue Perfusion

Nursing Interventions

  • Maintain a patent airway until patient is fully awake after a seizure.
  • Provide oxygen during the seizure if cyanotic changes occurs.
  • Stress the importance of taking medications regularly.
  • Monitor serum levels for therapeutic range of medications.
  • Monitor patient for toxic adverse effects of medications.
  • Monitor platelet and liver functions for toxicity due to medications.

Nursing Diagnosis

  • Risk for Injury related to seizure activity

Nursing Goal : Preventing Injury

Nursing Interventions

  • Provide a safe environment by padding side rails and removing clutter which may be harmful to the patient.
  • Monitor compliance in taking antiseizure medications to determine risk for seizure.
  • Keep suction, Ambu bag,mouth piece at the bedside to maintain airway and oxygenation if needed.
  • Place the bed in a low position.
  • Do not restrain the patient during a seizure.
  • Do not put anything in the patient’s mouth during a seizure.
  • Place the patient on side during a seizure to prevent aspiration.
  • Protect the patient’s head during a seizure. If seizure occurs while ambulating or from chair, cradle head or provide cushion/support for protection against head injury.
  • Stay with the patient who is ambulating or who is in a confused state during seizure.
  • Provide a helmet to the patient who falls during seizure.
  • Manage the patient in status epilepticus.

Nursing Diagnosis

Ineffective Coping related to psychosocial and economic consequences of epilepsy

Nursing Goal: Strengthening Coping

Nursing Interventions

  • Consult with social worker for community resources for vocational rehabilitation, counselors, support groups.
  • Teach stress reduction techniques that will fit into patient’s lifestyle.
  • Initiate appropriate consultation for management of behaviours related to personality disorders, brain damage secondary to chronic epilepsy.
  • Answer questions related to use of computerized video EEG monitoring and surgery for epilepsy management.

PATIENT EDUCATION AND HEALTH MAINTENANCE

  • Counsel patients with uncontrolled seizures about driving or operating dangerous equipment.
  • Assess home environment for safety hazards in case the patient falls, such as crowded furniture arrangement, sharp edges on tables, glass. Soft flooring and furniture and padded surfaces may be necessary.
  • Support patient in discussion about seizures with employer, school, and so forth
  • Encourage the patient to determine existence of trigger factors for seizures (eg, skipped meals, lack of sleep, emotional stress, menstrual cycle).
  • Remind the patient of the importance of following medication regimen. Stress the importance of taking medications regularly.
  • Teach the patient regarding regular blood tests ,to monitor serum levels for therapeutic range of medications which is very essential for the seizure control.
  • Teach the patient regarding symptoms and the need to monitor the toxic adverse effects of medication.
  • Tell the patient to avoid alcohol because it interferes with metabolism of antiepileptic medications.
  • Encourage the patient and family to discuss feelings and attitudes about epilepsy.
  • Encourage patient to carry or wear a MedicAlert card or bracelet.
  • Encourage a moderate lifestyle that includes exercise, mental activity, and nutritional diet
  • Gingival hyperplasia (Side Effect of antiepileptic drugs), teach the patient regarding the need for maintaining oral hygiene.
  • For the surgical candidate, reinforce instructions related to surgical outcome of the specific surgical approach (temporal lobectomy, corpus callosotomy, hemispherectomy, and extratemporal resection).

Part1|Part2|Part3|Part4|Part5