Assessment - Nursing Care Plan for Febrile Seizures

Nursing Care Plan for Febrile Seizures

According to Doengoes (1999: 259-261 and 871-872) includes:

History of causative factors:

• Idiopathic no cause is known.
• Post-trauma, head injury, inflammation of the lining of the brain, high fever.

History of seizures

• Since what age?
• How long seizures occur?
• How many times a seizure occurs within 1 hour?
• When was the last seizures experienced?

Physical examination, by inspection, palpation, percussion and auscultation.

a. Activity / rest.
Symptoms:

• Fatigue, general weakness.
• Limitations in activities / work caused by self-/ significant other / nursing care giver or others.

Signs:

• Change of tone / muscle strength.
• Involuntary movements / muscle contraction.

b. Circulation
Symptoms:

• Ictal: hypertension, increased pulse and cyanosis.
• Post-ictal: normal vital signs or depression with decreased pulse and respiration.

Signs:

• Heart sound: disratmia and development can lead to myocardial dysfunction, effects of acidosis / electrolyte imbalance.
• The skin is warm, dry, luminous, pale, moist, and mottled.

c. Ego integrity
Symptoms:

• Stressor external / internal related to the state and or a treatment.
• Receptors: feeling no / not helpless, changes in relationships.

Signs:

• Widening of emotional response.

d. Elimination
Symptoms:

• Episodic urinary incontinence.

Signs:

• Ictal: increased pressure bladder and sphincter tone.
• Post-ictal: muscle relaxation resulting in urinary incontinence.

e. Food / fluid
Symptoms:

• Sensitivity to food, anorexia, nausea, vomiting associated with seizure activity.

Signs:

• Weight loss, decreased subcutaneous fat.
• Decreased urine output concentration, progress towards oligoria and anuria.
• Soft tissue damage / teeth (injury during a seizure).
• Gingival hyperplasia.

f. Neurological
Symptoms:

• Headache, dizziness, fainting, history of head trauma, cerebral anoxia and infection.
• Post-ictal: weakness, muscle pain, paralysis area.

Signs:

• Anxiety, fear, mental chaotic, disorientation, delirium / coma.
• Involuntary movements / muscle contraction.

g. Pain / comfort
Symptoms:

• Headache, muscle pain / back to the post-ictal period abdominal seizures.
• Localization of pain / discomfort urticaria.

Signs:

• Attitude / behavior that careful changes in muscle tone.
• Agitated behavior.

h. Breathing
Symptoms:

• Ictal phase: teeth shut, cyanosis, decreased breathing rapidly, increased secretion mokus.
• Post-ictal phase: apnea.

Signs:

• Temperatures generally rising to 37.5 0C or more.
• Chills.

i. Security
Symptoms:

• History dropped / trauma or invoice.

Signs:

• Trauma to the soft tissue / ecchymosis overall decrease in muscle strength.

j. Interaction
Symptoms:

• Related interpersonal problems in the family or social environment.

k. Education / learning
Symptoms:

• A history of seizures or epilepsy in the family.
• The use of antibiotic drugs recently or long term.