Risk for Trauma/Suffocation | Nursing Care Plan for Seizures Disorder

Risk factors may include

Weakness, balancing difficulties

Cognitive limitations, altered consciousness

Loss of large or small muscle coordination

Emotional difficulties

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Risk Detection

Verbalize understanding of factors that contribute to possibility of trauma or suffocation and take steps to correct situation.

Risk Control

Demonstrate behaviors and lifestyle changes to reduce risk factors and protect self from future seizure events and injury.

Modify environment as indicated to enhance safety.

Maintain treatment regimen to control or eliminate seizure activity.

Significant Other [SO]/Caregiver Will

Knowledge: Personal Safety

Identify actions or measures to take when seizure activity occurs.

Nursing care plan with rationale:

1. Explore with client the various stimuli that may precipitate seizure activity.

Rationale: Alcohol, various drugs, and other stimuli, such as loss of sleep, flashing lights, and prolonged television viewing, may increase the potential for seizure activity. Client may or may not have control over many precipitating factors, but may benefit from becoming aware of risks.

2. Discuss seizure warning signs, if appropriate, and usual seizure pattern. Teach SO to recognize warning signs and how to care for client during and after seizure.

Rationale: Can enable client or SO to protect individual from injury and to recognize changes that require notification of physician and further intervention. Knowing what to do when seizure occurs can prevent injury or complications and decreases SO’s feelings of helplessness.

3. Keep padded side rails up with bed in lowest position, or place bed up against wall, and add floor pad if rails are not available or appropriate.

Rationale: Minimizes injury should frequent or generalized seizures occur while client is in bed.

4. Maintain strict bedrest if prodromal signs or aura is experienced. Explain necessity for these actions.

Rationale: Client may feel restless, need to ambulate or even defecate during aural phase, thereby inadvertently removing self from safe environment and easy observation. Understanding importance of providing for own safety needs may enhance client cooperation.

5. Stay with client during and after seizure.

Rationale: Promotes client safety and reduces sense of isolation during event.

6. Turn head to side and suction airway as indicated. Insert soft bite block per facility protocol, only if jaw relaxed.

Rationale: Helps maintain airway and reduces risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Current practice is mixed regarding the use of airways during seizure activity.

7. Cradle head, place on soft area, or assist to floor if out of bed. Do not attempt to restrain.

Rationale: Gentle guiding of extremities reduces risk of physical injury when client lacks voluntary muscle control. Note: If attempt is made to restrain client during seizure, erratic movements may increase, and client may injure self or others.

8. Perform neurological and vital sign checks after seizure: level of consciousness, orientation, ability to comply with simple commands, ability to speak, memory of incident, weakness or motor deficits, blood pressure (BP), pulse, and respiratory rate.

Rationale: Documents postictal state and time and completeness of recovery to normal state. May identify additional safety concerns to be addressed.

9. Reorient client following seizure activity.

Rationale: Client may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety.

10. Allow postictal “automatic” behavior without interfering while providing environmental protection.

Rationale: May display behavior of motor or psychic origin that seems inappropriate or irrelevant for time and place. Attempts to control or prevent activity may result in client becoming aggressive or combative.