Nursing Diagnosis and Interventions Risk for Injury - Seizures

Nursing Diagnosis and Interventions Risk for Injury - Seizures

Nursing Care Plan for Epilepsy

Nursing Diagnosis : Risk for Injury

Risk for Injury related to uncontrolled seizure activity (balance disorder).

Goal:

• Clients can identify the precipitation of an attack and to minimize / avoid it, creating a state that is safe for the client, avoid any physical injury, avoid falling.

Expected outcomes:

• no physical injury to the client, 
• client is in a safe condition, 
• no bruises, 
• no fall.

Nursing Diagnosis and Interventions Risk for Injury - Seizures

Observation:

1. Identification of environmental factors that allow the risk of injury.
Rational:
The stuff around the patient may be harmful during the seizure.

2. Monitor neurological status every 8 hours
Rational:
Identify deviations of development or expected results

Independent :

3. Keep objects that could cause injury to the patient during a seizure.
Rational:
Reduce the occurrence of injury as a result of uncontrolled seizure activity.

4. Install the barrier the patient's bed.
Rational:
Safeguards for security, to prevent injury or fall

5. Place the patient in a low and flat.
Rational:
Areas of low and flat to prevent injury to the patient.

6. Together with the patient in some time after the seizure.
Rational:
Providing safeguards for patient safety for the possibility of back spasms.

7. Prepare a soft cloth to prevent biting the tongue occurs during seizures.
Rational:
Potentially bitten tongue during seizures because of sticking out.

8. Ask the patient if there are unusual feelings experienced just before a seizure.
Rational:
To identify early manifestation before the occurrence of seizures in patients.

Collaboration:

9. Provide anti-convulsive fit your doctor's advice.
Rational:
Reduce prolonged seizure activity, which could reduce the supply of oxygen to the brain

Education:

10. Instruct patient to tell if there is something that does not feel comfortable, or experience something unusual for a start having seizures.
Rational:
For information on the nurses to take immediate action before the seizures continued.

11. Provide information to the family about what to do during the patient's seizures.
Rational:
Involving families to reduce the risk of injury.

Nursing Diagnosis for Epilepsy

Nursing Diagnosis for Epilepsy

Nursing Care Plan for Epilepsy

Epilepsy is a condition which affects the communication between the nerve cells of the nervous system when there is a sudden overactive electrical discharge in the brain. Epilepsy is a serious condition that affects millions of people across the globe.

There are many epilepsy symptoms to look out for. The largest one is the occurrence of epileptic seizures, which can come in a number of forms. Epileptic seizures can feel like a moment of confusion, a sudden blackout, a sudden change in smells or tastes, involuntary jerking of the legs and arms, and a long, blank staring spell. Epileptic seizures are essentially long moments of abnormal brain activity caused by electric signals that you generate in brain. This disease can usually be treated with the proper implementation and prescription of treatment drugs and possibly even surgery.

A seizure is a symptom of epilepsy, but not all seizures are caused by epilepsy.

A seizure not related to epilepsy can be caused by a reaction to:

• A drug
• A high fever
• A severe head injury
• Other disorders such diabetes, some heart conditions, and narcolepsy, among others.

Sometimes people have a single seizure for which no cause can ever be found.

Several conditions or behaviors mimic epilepsy but are not epilepsy.

• Epilepsy is not a fainting disorder.
• Epilepsy cannot be caused by holding the breath. Some children act out by holding their breath until they faint. This is not epilepsy.
• Epilepsy is not momentary confusion, forgetfulness, or a lack of concentration.
• Epilepsy is not catatonia, a specific type of schizophrenia characterized by stupor and bizarre movements.

Although epilepsy can start at any point during a person's life, most epilepsy is diagnosed in childhood, and most of all in the first year of life - around 140 out of every 100,000 babies under the age of one are diagnosed with epilepsy per year. This drops to 40 adults per 100,000. However, recent reports have shown that epilepsy is increasing in older people, who account for a quarter of all new diagnoses, according to a survey by the National Society for Epilepsy. The condition is twice as common in older people as it is in the population as a whole.


8 Nursing Diagnosis for Epilepsy


1. Risk for Injury
related to:
uncontrolled seizure activity (balance disorder).

2. Ineffective airway clearance
related to:
blockage of the tongue, endotracheal,
increased secretion of saliva

3. Social isolation
related to:
low-self against the disease state, and the bad stigma against epilepsy in the community.

4. Ineffective breathing pattern
related to:
dyspnoea and apneu

5. Activity intolerance
related to:
decreased cardiac output, tachycardia

6. Impaired sensory perception
related to:
disturbances in nerve sensory organs of perception

7. Anxiety
related to:
lack of knowledge about the disease

8. Risk for Ineffective cerebral Tissue Perfusion
related to:
decreased oxygen supply to the brain.