Nursing Care Plan for Epilepsy
Epilepsy is a complex symptom of many disorders of brain function characterized by recurrent seizures. Seizures are the result of uncontrolled electrical liberation from cerebral cortex nerve cells are characterized by sudden attacks, mild disturbances of consciousness, motor activity, or sensory phenomena disorders.
The cause of the epileptic seizures largely unknown (idiopathic). Often occurs in:
- Birth trauma, Asphyxia neonatorum.
- Head injury, infections of the nervous system.
- CO poisoning, intoxication drugs / alcohol.
- Fever, metabolic disorders (hypoglycemia, hypocalcemia, hyponatremia).
- Brain Tumor.
- Vascular abnormalities.
Nursing Diagnosis : Ineffective breathing pattern related to neuromuscular damage, increased mucus secretion
Goal: Maintaining an effective breathing pattern with a patent airway
Interventions:
- Encourage clients to vacate the mouth of objects / substances specified / dentures or other instrument if the aura phase occurs and to avoid jaw shut if seizures occur without marked symptoms early.
- Place the client in a tilted position, flat surface, tilt the head during a seizure.
- Take off the clothing at the neck, chest, and abdomen.
- Enter spatel tongue / artificial airway or soft object rolls as indicated.
- Perform suction as indicated.
- Give supplemental oxygen / ventilation manually as needed in postictal state.
- Prepare / aids to intubation if indicated...
Rational:
- Reduce the risk of aspiration or the entry of foreign objects into the pharynx.
- Increasing flow (drainage) secret, preventing the tongue falling so clog the airway.
- To facilitate the effort to breathe.
- Prevent biting tongue and facilitate exploitation while performing lenders. Artificial airway may be indicated after the easing of seizure activity if the patient is unconscious and unable to maintain a secure position of the tongue.
- Reduce the risk of aspiration or asphyxia.
- Can decrease cerebral hypoxia as akobat of declining circulation or oxygen secondary to vascular spasm during seizures.
- The emergence of prolonged apnea in postictal state, requiring mechanical ventilator support.