Risk for Ineffective Airway Clearance/Breathing Pattern | Nursing Care Plan for Seizures Disorder

Risk factors may include

Neuromuscular impairment

Tracheobronchial obstruction

Perceptual or cognitive impairment

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Maintain effective respiratory pattern with airway patent and aspiration prevented.

Nursing care plan with rationale:

1. Encourage client to empty mouth of dentures or foreign objects if aura occurs and to avoid chewing gum or sucking lozenges if seizures can occur without warning.

Rationale: Reduces risk of aspiration or foreign bodies lodging in pharynx.

2. Place in lying position on a flat surface; turn head to side during seizure activity.

Rationale: Promotes drainage of secretions; prevents tongue from obstructing airway.

3. Loosen clothing from neck, chest, and abdominal areas.

Rationale: Facilitates chest expansion, enhancing breathing.

4. Insert soft airway as indicated per facility protocol and only if jaw is relaxed.

Rationale: If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning and respiratory support if required. Airway adjunct may be indicated after

cessation of seizure activity if client is unconscious and unable to maintain safe position of tongue. Note: Current opinion is mixed regarding the use of airways during seizure activity.

5. Suction as needed.

Rationale: Reduces risk of aspiration or asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 minutes.

6. Administer supplemental oxygen or bag ventilation, as needed postictally.

Rationale: May reduce cerebral hypoxia resulting from decreased circulation and oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in and out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory

function will return unless a secondary problem exists, such as foreign body or aspiration.

7. Prepare for and assist with intubation, if indicated.

Rationale: Presence of prolonged apnea postictally may require ventilatory support.