VELEZ COLLEGE

COLLEGE OF NURSING
F. Ramos St. Cebu City

NURSING CARE MANAGEMENT 109:

CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)
Related Learning Experience

PEDIATRIC EMERGENCY NURSING CASE STUDY

Submitted by:
Delos Reyes, Jermaine
Duran, Celine Eluza
Falcone, Jasmine Mae
Federizo, Enlil Joshua
Labajo, Adreanne Dorothy
Luna, Cristoff Earl
BSN 2A

Submitted to:
Ms. Patricia Mae Gabaca, RN
Clinical Instructor
I. Introduction

Epilepsy
Definition

Epilepsy is a neurological or a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior,
sensations, and sometimes loss of awareness. It is a chronic disorder that causes unprovoked, recurrent seizures. A seizure is a sudden rush of electrical activity
in the brain. Epilepsy is the fourth most common neurological disorder and affects people of all ages.

Types

1. Generalized Epilepsy – Seizures produced by widespread abnormal electrical impulses present throughout the entire brain.
a. Generalized tonic-clonic (Grand Mal). Symptoms: The patient loses consciousness and usually collapses. The loss of consciousness is followed by
generalized body stiffening called the “tonic” phase of the seizure, then by violent jerking called the “clonic” phase of the seizure, after which the
patient goes into a deep sleep called the “postictal” or “after-seizure” phase. During grand-mal seizures, injuries and accidents may occur, such as
tongue biting and urinary incontinence.
b. Absence. Symptoms: Brief loss of consciousness for a few seconds with few or no symptoms. The patient typically interrupts an activity and stares
blankly. These seizures begin and end abruptly and might occur several times a day. Patients are usually not aware that they are having a seizure but
may have a feeling of “losing time.”
c. Myoclonic. Symptoms: Sporadic and brief jerking movements, usually on both sides of the body. Patients sometimes describe the jerks as brief
electrical shocks. When violent, these seizures might result in dropping or involuntarily throwing objects.
d. Clonic. Symptoms: Repetitive, rhythmic jerking movements that involve both sides of the body at the same time.
e. Tonic. Symptoms: Muscle stiffness and rigidity.
f. Atonic. Symptoms: Consist of a sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.
2. Focal/Partial Epilepsy – Seizures produced by electrical impulses that generate from a relatively small or “localized” part of the brain referred to as the
focus.
a. Simple partial (awareness maintained). Simple partial seizures are further divided into four groups according to the nature of their symptoms:
• Motor. Symptoms include movements such as jerking, stiffening, muscle rigidity, spasms, and head-turning.
• Sensory. Symptoms involve unusual sensations affecting any of the five senses (vision, hearing, smell, taste, or touch). The term “aura” is
used to describe sensory symptoms that are present only (and not motor symptoms).
• Autonomic. Symptoms most often involve an unusual sensation in the stomach termed “gastric uprising”.
• Psychological. Symptoms are characterized by various experiences involving memory (the sensation of déjà vu), emotions (such as fear or
pleasure), or other complex psychological phenomena.
 b. Complex partial (awareness impaired). Symptoms: Impairment of awareness. Patients seem to be "out of touch," "out of it," or "staring into space"
during these seizures. Symptoms may also involve some complex symptoms called automatisms. Automatisms consist of involuntary but
coordinated movements that tend to be purposeless and repetitive. Common automatisms include lip smacking, chewing, fidgeting, and walking
around.
c. Partial seizure with secondary generalization. Symptoms: Partial seizure that evolves into a generalized seizure (typically a generalized tonic-clonic
seizure). Approximately 70% of patients with partial seizures can be controlled with medication. Partial seizures that cannot be controlled with
medication can often be treated surgically.

Clinical Manifestations

The clinical diagnosis of seizures is based on the history obtained from the patient and, most importantly, the observers.

a. An aura (unusual sensations) precedes seizures in about 20% of people who have a seizure disorder.
b. Short duration. Almost all seizures are relatively brief, lasting from a few seconds to a few minutes; most seizures last 1 to 2 minutes.
c. Postictal state. When a seizure stops, people may have a headache, sore muscles, unusual sensations, confusion, and profound fatigue; these after-
effects are called the postictal state.
d. Todd paralysis. In some people, one side of the body is weak, and the weakness lasts longer than the seizure (a disorder called Todd paralysis).
e. Visual hallucinations. Visual hallucinations (seeing unformed images) occur if the occipital lobe is affected.
f. Convulsions. A convulsion (jerking and spasms of muscles throughout the body) occurs if large areas on both sides of the brain are affected.

Risk Factors

Certain factors may increase risk of epilepsy:

• Age. The onset of epilepsy is most common in children and older adults, but the condition can occur at any age.
• Family history. If you have a family history of epilepsy, you may be at an increased risk of developing a seizure disorder.
• Head injuries. Head injuries are responsible for some cases of epilepsy. You can reduce your risk by wearing a seat belt while riding in a car and by
wearing a helmet while bicycling, skiing, riding a motorcycle or engaging in other activities with a high risk of head injury.
• Stroke and other vascular diseases. Stroke and other blood vessel (vascular) diseases can lead to brain damage that may trigger epilepsy. You can take a
number of steps to reduce your risk of these diseases, including limiting your intake of alcohol and avoiding cigarettes, eating a healthy diet, and
exercising regularly.
• Dementia. Dementia can increase the risk of epilepsy in older adults.
• Brain infections. Infections such as meningitis, which causes inflammation in your brain or spinal cord, can increase your risk.
 • Seizures in childhood. High fevers in childhood can sometimes be associated with seizures. Children who have seizures due to high fevers generally
won’t develop epilepsy. The risk of epilepsy increases if a child has a long seizure, another nervous system condition or a family history of epilepsy.

Nursing Managements

Nursing assessment includes:

a. History. The diagnosis of epileptic seizures is made by analyzing the patient’s detailed clinical history and by performing ancillary tests for confirmation;
someone who has observed the patient’s repeated events is usually the best person to provide an accurate history; however, the patient also provides
invaluable details about auras, preservation of consciousness, and postictal states.
b. Physical exam. A physical examination helps in the diagnosis of specific epileptic syndromes that cause abnormal findings, such as dermatologic
abnormalities (e.g., neurocutaneous syndromes such as Sturge-Weber, tuberous sclerosis, and others); also, patients who for years have had intractable
generalized tonic-clonic seizures are likely to have suffered injuries requiring stitches

Nursing interventions for a child with seizure disorder include the following:

a. Trauma/injury. Teach SO to determine and familiarize warning signs and how to care for patient during and after seizure attack; avoid using
thermometers that can cause breakage; use tympanic thermometer when necessary to take temperature; uphold strict bedrest if prodromal signs or
aura experienced; turn head to side and suction airway as indicated; support head, place on soft area, or assist to floor if out of bed; do not attempt to
restrain; monitor and document AED drug levels, corresponding side effects, and frequency of seizure activity.
b. Promote airway clearance. Maintain in lying position, flat surface; turn head to side during seizure activity; loosen clothing from neck or chest and
abdominal areas; suction as needed; supervise supplemental oxygen or bag ventilation as needed postictally.
c. Improve self-esteem. Determine individual situation related to low self-esteem in the present circumstances; refrain from over protecting the patient;
encourage activities, providing supervision and monitoring when indicated; know the attitudes or capabilities of SO; help an individual realize that his or
her feelings are normal; however, guilt and blame are not helpful.
d. Enforce education about the disease. Review pathology and prognosis of condition and lifelong need for treatments as indicated; discuss patient’s
particular trigger factors (flashing lights, hyperventilation, loud noises, video games, TV viewing); know and instill the importance of good oral hygiene
and regular dental care; review medication regimen, necessity of taking drugs as ordered, and not discontinuing therapy without physician supervision;
include directions for missed dose.
Medical and Surgical Managements

i. Monotherapy. Monotherapy is desirable because it decreases the likelihood of adverse effects and avoids drug interactions; also, monotherapy may be
less expensive than polytherapy, as many of the older anticonvulsant agents have hepatic enzyme-inducing properties that decrease the serum level of
the concomitant drug, thereby increasing the required dose of the concomitant drug.
ii. Anticonvulsant therapy. The mainstay of seizure treatment is anticonvulsant medication; the drug of choice depends on an accurate diagnosis of the
epileptic syndrome, as a response to specific anticonvulsants varies among different syndromes.
iii. Discontinuing anticonvulsant agents. After a person has been seizure free for typically 2-5 years, the physician may consider discontinuing that patient’s
medication; many patients outgrow many epileptic syndromes in childhood and do not need to take anticonvulsants.
iv. Vagal nerve stimulation. VNS is a palliative technique that involves surgical implantation of a stimulating device; VNS is FDA approved to treat medically
refractory focal-onset epilepsy in patients older than 12 years; some studies demonstrate its efficacy in focal-onset seizures and a small number of
patients with primary generalized epilepsy.
v. Implantable neurostimulator. The NeuroPace RNS System, a device that is implanted into the cranium, senses, and records electrocorticographic
patterns and delivers short trains of current pulses to interrupt ictal discharges in the brain.
vi. Lobectomy. In a randomized, controlled trial of surgery in 80 patients with temporal lobe epilepsy, 58% of patients in the group randomized to anterior
temporal lobe resective surgery were free from seizures impairing awareness at 1 year, as compared with 8% in the group that received anticonvulsant
treatment.
vii. Activity modification and restrictions. The major problem for patients with seizures is the unpredictability of the next seizure; clinicians should discuss
the following types of seizure precautions with patients who have epileptic seizures or other spells of sudden-onset seizures: driving, ascending heights,
working with fire or cooking, using power tools and other dangerous equipment, taking unsupervised baths, and swimming.
viii. Long-term monitoring. In 2018, the FDA cleared for marketing the first smartwatch for seizure tracking and epilepsy management; the Embrace smart
watch identifies convulsive seizures and sends an alert via text and phone message to caregivers; the watch also records sleep, rest, and physical activity
data; the device was tested in a study of 135 epileptic patients and found the watch’s algorithm detected 100% of patient seizures.
 age family history seizures in childhood
EPILEPSY
“seizure disorder”
brain infections head injuries stroke and other vascular diseases
II. Pathophysiology
seizures are not directly caused by another medical
condition, a severe infection or an acute brain injury
Legend:

chronic seizures of any type over a long period primary characteristics

signs and symptoms

unusual sensations affecting
behavior epileptic spasms sustained rhythmical automatisms or repeated
any of the five senses factors
arrest (body flexes and jerking movements (clonic) automatic movements
may be accompanied
(person may extends repeatedly) goosebumps, heart racing,

non-motor symptoms
by eyelid fluttering, mechanism/action
just stare muscles becoming weak or etc. brief muscle twitching
rapid eye blinking, or
and not jerking (clonic) limp (atonic) (myoclonus)
lip smacking

motor symptoms
non-motor symptoms
make any waves of heat or cold organ affected

motor symptoms
other tense or rigid muscles becoming tense or
movements) gastrointestinal sensations jerking (clonic)
muscles (tonic) rigid (tonic)
typical or atypical
absence seizures muscles becoming limp
unknown onset brief muscle twitching lack of movement
(staring spells) or weak (atonic)
(myoclonic) (behavior arrest)

beginning is not known; can be epileptic spasms (body changes in emotions,

tense or rigid muscles
later diagnosed as a focal or flexes and extends thinking or cognition
generalized onset (tonic)
generalized repeatedly)

loss of consciousness simple partial complex partial

(remains conscious and aware) (impaired consciousness and awareness)
affects both sides of the brain or groups of cells
on both sides of the brain at the same time
focal onset
electrical
starts in one area or group of signals are
cells in one side of the brain
Ca2+ comes in sent from brain
seizures neuron to
neuron
fast or long-
lasting activation too little interruption
one or more parts of the brain has a burst of abnormal brain send of NMDA inhibition Clusters of of the
electrical impulses interrupting normal signals paroxysmal neurons in normal neurons
electrical the brain connections synchronously
dysfunctional too much
charges become between active
GABA excitatio
repeatedly temporarily nerve cells
receptors
impaired in the brain affected by either:
congenital genetics or congenital defects
Cl- comes in
affected by either: tumors, brain
acquired injury, infections, stroke, or drugs
 III. Drug Study

Classification Action Indications Contraindications Adverse Effects Nursing Implications

BASELINE ASSESSMENT
Acute narrow-angle • Assess B/P, pulse, respirations immediately before
glaucoma, severe administration.
Short-term relief of • Anxiety: Assess autonomic response (cold, clammy
respiratory IV route may produce
anxiety symptoms, hands, diaphoresis), motor response (agitation,
depression, severe, pain, swelling,
relief of acute alcohol trembling, tension).
uncontrolled pain, thrombophlebitis,
Depresses all withdrawal. Adjunct • Musculoskeletal spasm: Record onset, type,
severe hepatic carpal tunnel
levels of CNS by for relief of acute location, duration of pain. Check for immobility,
insufficiency, sleep syndrome. Abrupt or
enhancing action musculoskeletal stiffness, swelling.
apnea syndrome, too-rapid withdrawal
of gamma- conditions, treatment
myasthenia gravis. may result in • Seizures: Review history of seizure disorder (length,
Diazepam (Valium) aminobutyric of seizures (IV route
Children less than 6 pronounced intensity, frequency, duration, LOC). Observe
acid, a major used for termination
months of age. restlessness, frequently for recurrence of seizure activity. Initiate
Pharmacotherapeutic: inhibitory of status epilepticus).
irritability, insomnia, seizure precautions.
Benzodiazepine neurotransmitter Gel: Control of
Cautions: Those hand tremor,
(Schedule IV). in the brain. increased seizure
receiving other CNS abdominal/ muscle INTERVENTION/EVALUATION
activity in refractory
depressants or cramps, diaphoresis, • Monitor heart rate, respiratory rate, B/P, mental
Clinical: Antianxiety, Therapeutic epilepsy in those on
psychoactive vomiting, seizures. status.
skeletal muscle Effect: stable regimens.
agents, depression, Abrupt withdrawal in • Assess children, elderly for paradoxical reaction,
relaxant, Produces
history of drug and pts with epilepsy may particularly during early therapy.
anticonvulsant anxiolytic effect, OFF-LABEL:
alcohol abuse, produce increase in • Evaluate for therapeutic response (decrease in
elevates seizure Treatment of panic
renal/hepatic frequency/severity of intensity/frequency of seizures; calm, facial
threshold, disorder. Short-term
impairment, seizures. Overdose expression, decreased restlessness; decreased
produces treatment of
hypoalbuminemia, results in drowsiness, intensity of skeletal muscle pain).
skeletal muscle spasticity in children
respiratory disease, confusion, diminished • Therapeutic serum level: 0.5–2 mcg/ml; toxic serum
relaxation. with cerebral palsy.
impaired gag reflexes, CNS level: greater than 3 mcg/ml.
Sedation for
reflex, concurrent depression, coma.
mechanically vented
use of strong Antidote: Flumazenil PATIENT/FAMILY TEACHING
pts in ICU.
CYP3A4 inhibitors • Avoid alcohol.
or inducers. • Limit caffeine.
• May cause drowsiness.
 • Avoid tasks that require alertness, motor skills until
response to drug is established.
• May be habit forming.
• Avoid abrupt discontinuation after prolonged use.

Abrupt withdrawal BASELINE ASSESSMENT

after prolonged • Assess B/P, pulse, respirations immediately before
therapy may produce administration.
Management of Hypersensitivity to • Hypnotic: Raise bed rails, provide environment
increased dreaming,
generalized tonic- other barbiturates, conducive to sleep (back rub, quiet environment,
nightmares, insomnia,
clonic (grand mal) porphyria, low lighting).
tremor, diaphoresis,
seizures, partial preexisting CNS • Seizures: Review history of seizure disorder (length,
vomiting,
seizures, control of depression, severe
hallucinations, presence of auras, LOC). Observe frequently for
Enhances activity acute seizure uncontrolled pain,
Phenobarbital delirium, seizures, recurrence of seizure activity. Initiate seizure
of gamma- episodes (status severe respiratory
status epilepticus. Skin precautions.
aminobutyric epilepticus, disease with
Pharmacotherapeutic: eruptions appear as
acid (GABA) by eclampsia, febrile dyspnea or
Barbiturate hypersensitivity INTERVENTION/EVALUATION
binding to GABA seizures). Used as obstruction, use in
(Schedule IV). reaction. Blood • Monitor CNS status, seizure activity, hepatic/ renal
receptor sedative, hypnotic. nephritic pts.
dyscrasias, hepatic function, respiratory rate, heart rate, B/P.
complex.
Clinical: disease, hypocalcemia • Monitor for therapeutic serum level.
Therapeutic OFF-LABEL: Cautions:
Anticonvulsant, occurs rarely. • Therapeutic serum level: 10–40 mcg/ml; toxic serum
Effect: Depresses Prevention/treatment Renal/hepatic
hypnotic Overdose produces level: greater than 40 mcg/ml.
CNS activity. of neonatal impairment,
cold/ clammy skin,
hyperbilirubinemia acute/chronic pain,
hypothermia, severe PATIENT/FAMILY TEACHING
and lowering of depression, suicidal
CNS depression, • Avoid alcohol, limit caffeine.
bilirubin in chronic tendencies, history
cyanosis, tachycardia, • May be habit forming.
cholestasis; neonatal of drug abuse.
Cheyne- Stokes's • Do not discontinue abruptly.
seizures.
respirations. Toxicity • May cause dizziness/drowsiness; impair ability to
may result in severe perform tasks requiring mental alertness,
renal impairment. coordination.
 IV. Nursing Care Plan

Diagnosis Interventions Evaluation

1. Impaired gas exchange related to ventilation-perfusion Independent Interventions: After Student-nurse client
imbalance as manifested by hypoxia interaction, the client/SO will be
1. Note respiratory rate, depth, use of accessory muscles, pursed-lip able to:
Scientific Basis: breathing, and areas of pallor/cyanosis, such as peripheral (nailbeds)
Two factors make seizures a possible complication of versus central (circumoral) or general duskiness • Client maintains optimal
respiratory insufficiency. Rationale: This provides insight into the work of breathing and adequacy of gas exchange as evidenced
alveolar ventilation. by usual mental status,
References: unlabored respirations at
Schachter, A. (n.d.). Respiratory insufficiency. Retrieved 2. Auscultate breath sounds, note areas of decreased/adventitious breath 12-20 per minute, oximetry
March 08, 2021, from sounds as well as fremitus. results within normal
https://www.epilepsy.com/living- Rationale: In this nursing diagnosis, ventilatory effort is insufficient to deliver range, blood gases within
epilepsy/epilepsy-and/professional-health-care- enough oxygen or to get rid of sufficient amounts of carbon dioxide. Abnormal normal range, and baseline
providers/co-existing-disorders/pulmonary-4 breath sounds are indicative of numerous problems. HR for patient.
• Client participates in
Wayne, G. (2017, September 23). Impaired gas Exchange 3. Assess level of consciousness and mentation changes. procedures to optimize
– Nursing diagnosis & care plan. Retrieved March Rationale: A decreased level of consciousness can be an indirect oxygenation and in
08, 2021, from https://nurseslabs.com/impaired- management regimen
gas-exchange/#nursing_interventions 4. Evaluate pulse oximetry and capnography within level of
Rationale: To determine oxygenation and levels of carbon dioxide retention; capability/condition.
evaluate lung volumes and forced vital capacity to assess lung mechanics, • Client experiences
capacities, and function. absences of respiratory
distress
5. Provide airway adjuncts and suction as indicated
Rationale: To clear or maintain open airway, when client is unable to clear
secretions, or to improve gas diffusion when client is showing desaturation of
oxygen by oximetry or ABGs.

6. Position patient with head of bed elevated, in a semi-Fowler’s position

(head of bed at 45 degrees when supine) as tolerated.
Rationale: Upright position or semi-Fowler’s position allows increased thoracic
capacity, full descent of diaphragm, and increased lung expansion preventing the
abdominal contents from crowding.
 7. Regularly check the patient’s position so that he or she does not slump
down in bed.
Rationale: Slumped positioning causes the abdomen to compress the diaphragm
and limits full lung expansion.

8. Administer humidified oxygen through appropriate device

Rationale: A patient with chronic lung disease may need a hypoxic drive to breathe
and may hypoventilate during oxygen therapy.

9. Reinforce the need for adequate rest while encouraging activity and
exercise.
Rationale: To decrease dyspnea and improve quality of life.

10. Emphasize to the SOs the importance of nutrition.

Rationale: In improving stamina and reducing the work of breathing.

Collaborative Interventions:

1. Identify and refer to specific suppliers for supplemental oxygen/necessary

respiratory devices, as well as other individually appropriate resources,
such as home care agencies, meals on wheels, and so on.
Rationale: To facilitate independence with the client’s SO
2. Hyperthermia as manifested by increasing body Independent Interventions: Desired Outcome:
temperature above the normal range Client will maintain core
1. Monitor vital signs temperature, heart rate and
Scientific Basis: Rationale: Note progress and changes of conditions. respiratory rate within normal
Hyperthermia refers to a group of heat-related range.
conditions characterized by an abnormally high body 2. Adjust and monitor environmental factors like room temperature and bed
temperature, increased heart rate, increased respiratory linens as indicated. Actual Outcome:
rate, malaise or weakness and seizures. Rationale: Room temperature may be accustomed to near normal body Client’s parents or caregiver can
temperature and blankets and linens may be adjusted as indicated to regulate identify underlying cause or
References: temperature of the patient. contributing factors and
importance of treatment, as well
Hyperthermia. (n.d.). Retrieved March 08, 2021, from 3. Encourage ample fluid intake by mouth. as signs/symptoms requiring
https://www.physio-pedia.com/Hyperthermia Rationale: If the patient is dehydrated or diaphoretic, fluid loss contributes to further evaluation or
fever. intervention.
Wayne, G. (2017, September 23). Hyperthermia –
Nursing diagnosis & care plan. Retrieved March 4. Monitor core temperature by appropriate route. Note presence of
08, 2021, from temperature elevation or fever.
https://nurseslabs.com/hyperthermia/ Rationale: Rectal and tympanic temperatures most closely approximate core
temperature; however abdominal temperature monitoring may be dined in the
premature neonate.

5. Give antipyretic medications as prescribed.

Rationale: Antipyretic medications lower body temperature by blocking the
synthesis of prostaglandins that act in the hypothalamus.

6. Educate patient and family members about the signs and symptoms of
hyperthermia and help in identifying factors related to occurrence of
fever.
Rationale: Providing health teachings to the patient and family aids in coping with
disease condition and could help prevent further complications of hyperthermia.

7. Review signs and symptoms of hyperthermia.

Rationale: This indicates a need for prompt intervention.
 8. Monitor respirations
Rationale: Hyperventilation may initially be present, but ventilatory effort may
eventually be impaired by seizures or hypermetabolic state

9. Note the presence or absence of sweating as the body attempts to

increase heat loss by evaporation, conduction, and diffusion.
Rationale: Evaporation is decreased by environmental factors of high humidity
and high ambient temperature, as well as body factors producing loss of ability to
sweat or sweat gland dysfunction.

10. Monitor laboratory studies, such as arterial blood gas levels, electrolytes,
and cardiac and liver enzymes, glucose; urinalysis and coagulation profile.
Rationale: May reveal tissue degeneration, myoglobinuria, proteinuria, and
hemoglobinuria cam occur as products of tissue necrosis. Noting any presence of
disseminated intravascular coagulation.

Collaborative Interventions:

1. Provide supplemental oxygen.

Rationale: To offset increased oxygen demands and consumption.

Independent Interventions: Desired Outcome:

3. Risk for Trauma related to genetic disorder cues: Client will demonstrate
diagnosed with Epilepsy 1. Monitor vital signs. behaviors, lifestyle changes to
Rationale: Serves as a baseline information and any changes may indicate reduce risk factors and will
Scientific Basis: worsening of infant’s condition. receive appropriate care plan by
Epilepsy is a disorder of the brain characterized by the caregiver/parents.
recurrent seizures, which are brief episodes of 2. Note client’s age, gender, developmental age, decision-making ability,
involuntary movement that may involve a part of the level of cognition or competence. Actual Outcome:
body (partial) or the entire body (generalized) and are Rationale: Affects the client’s ability to protect self and others, and influences the Client’s parents or caregiver can
sometimes accompanied by loss of consciousness and choice of interventions and teaching. develop home therapy were
control of bowel or bladder function. indicated and demonstrate
appropriate procedures.
References: 3. Review diagnostic studies or laboratory tests for impairments and
Epilepsy. (n.d.). Retrieved March 08, 2021, from imbalances.
https://www.aans.org/en/Patients/Neurosurgical- Rationale: Such may result in or exacerbate conditions, such as confusion, tetany,
Conditions-and-Treatments/Epilepsy pathological fractures, etc.

Epilepsy. (n.d.). Retrieved March 08, 2021, from 4. Uphold strict bedrest if prodromal signs or aura experienced. Explain the
https://www.who.int/news-room/fact- necessity for these actions.
sheets/detail/epilepsy Rationale: Patient may feel restless or need to ambulate or even defecate during
aural phase, thereby inadvertently removing self from a safe environment and
easy observation. Understanding the importance of providing for own safety needs
may enhance patient cooperation.

5. Explore and expound seizure warning signs (if appropriate) and usual
seizure pattern. Teach SO to determine and familiarize warning signs and
how to care for the patient during and after seizure attack.
Rationale: Enables patient to protect self from injury and recognize changes that
require notification of physician and further intervention. Knowing what to do
when a seizure occurs can prevent injury or complications and decreases SO’s
feelings of helplessness.

6. Do not leave the patient during and after a seizure.

Rationale: Promotes safety measures.

7. Turn head to side and suction airway as indicated. Insert plastic bite block
only if jaw relaxed.
Rationale: Helps maintain airway patency and reduces the risk of oral trauma but
should not be “forced” or inserted when teeth are clenched because dental and
soft-tissue damage may result. Note: Wooden tongue blades should not be used
because they may splinter and break in the patient’s mouth.

8. Support head, place on soft area or assist to the floor if out of bed. Do
not attempt to restrain.
Rationale: Supporting the extremities lessens the risk of physical injury when the
patient lacks voluntary muscle control. Note: If the attempt is made to restrain the
patient during a seizure, erratic movements may increase, and the patient may
injure self or others.

9. Provide neurological or vital sign check 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 or completeness of recovery to a
normal state. May identify additional safety concerns to be addressed.

10. Carry out medications as indicated.

Rationale: Specific drug therapy depends on seizure type, with some patients
requiring polytherapy or frequent medication adjustments.

Collaborative Interventions:

1. Refer to physical or occupational therapist as appropriate.

Rationale: To identify high-risk tasks, conduct site visits, select, create, or modify
equipment; and provide education about body mechanics and musculoskeletal
injuries, as well as provide needed therapies.

2. Assist treatments for underlying medical, surgical, or psychiatric

conditions.
Rationale: To improve cognition and thinking processes, musculoskeletal function,
awareness of own safety needs, and general well-being.
 V. Discharge Teachings

Medications

• Instruct client to take prescribed medications with right dose, at the right frequency, through the right route
• Instruct client to take antiseizure medicine as directed and never stop taking them abruptly.

Environment

• Encourage SO to create a safe home environment for the client.

• Advice the SO to use plastic containers, plates, and drinking cups whenever possible.

Treatments

• Advice the SO to monitor the client’s health condition.

• Advice patient to have ketogenic diet
• Advice patient to learn relaxation techniques.
• Encourage client to drink enough fluids.

Health Teaching

• Advice patient to not play computer or electronic games for long periods of time.
• Encourage the client to get enough sleep everyday.
• Encourage client to practice relaxation techniques.
• If seizure occurs, instruct SO to help the patient lie down on her side.

Observable Signs and Symptoms

• Encourage SO to call emergency medical services if the client experience seizure, shortness of breath, confusion, and trouble staying awake or alert.

Diet

• Advice client to have a balanced diet.

• Instruct client to avoid drinking grapefruit juice and pomegranate juice.
• Instruct client to avoid caffeine.