4 Febrile Seizure Nursing Care Plans

4 Febrile Seizure Nursing Care Plans


Febrile seizures are seizures that happen in children between the ages of 6 months and 5 years, that is associated with high fever but with an absence of intracranial infection, metabolic conditions, or previous history of febrile seizures. It is subdivided into 2 classifications: A simple febrile seizure is brief, isolated, and generalized while a complex febrile seizure is prolonged (duration of more than 15 minutes), focal (occurs in one part of the brain), or multiple (occurs more than once within 24 hours).
Febrile seizures most often occur within 24 hours of the onset of a fever and can be the first indication that a child is sick. Symptoms may include a high fever (102°F to 104°F [38.9°C to 40°C]), sudden loss of consciousness, eye rolling, involuntary moaning, crying, and passing of urine, rigid (stiff) limbs, apnea or jerky movements on one side of the body (such as arm and leg).

Nursing Care Plans

Nursing goals for a child experiencing febrile seizures include maintain airway/respiratory function, maintain normal core temperature, protection from injury, and provide family information about disease process, prognosis, and treatment needs.
Here are four (4) nursing care plans (NCP) for febrile seizure:

1. Ineffective Airway Clearance


Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
May be related to
  • - Tracheobronchial obstruction (foreign body aspiration)
  • - Neuromuscular damage
Possibly evidenced by
  • - Excessive secretions
  • - Hypoxemia/cyanosis
  • - Inability to remove airway secretions
Desired Outcomes
  • - Child will maintain a patent airway.
Nursing InterventionsRationale
Assess the child’s airway patency using the look, listen and feel approach.This will ensure that seizure does not affect the supply of oxygenated blood to the brain and prevent the development of hypoxia.
Auscultate lungs for the presence of normal or adventitious breath sounds.Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate airway is obstructed.
Place the child on a flat surface then turn the head on the side during a seizure episode.Turning the child’s head to the side helps in maintaining a patent airway by promoting drainage of secretions and avoid aspirations to the lungs.
Loosen any restrictive clothing, especially on the neck, chest, and abdomen.This will facilitate ease of breathing and maintain an unobstructed airway.
Suction secretions gently as indicated.Suctioning will eliminate secretions and decreases the possibility of aspiration.
Provide supplemental oxygenation as indicated.Oxygen therapy is prescribed to improve oxygen saturation and reduce possible complications.
Prepare for/assist with possible intubation as indicated.Extended apnea episodes after a seizure may require a need for ventilatory support.

2. Hyperthermia


Hyperthermia: Body temperature elevated above normal range.
May be related to
  • - Antigens or microorganisms that cause inflammation
Possibly evidenced by
  • - High body temperature (102°F to 104°F [38.9°C to 40°C])
  • - Flushed skin, warm to touch
  • - Tachypnea
  • - Tachycardia
Desired Outcomes
  • - Child will demonstrate temperature within normal range and will not experience complications.
Nursing InterventionsRationale
Monitor the child’s temperature (tympanic or rectal temperature).Most febrile seizures happen when the temperature is greater than 102.2 ºF (39ºC). It usually occurs within the first 24 hours of illness and close monitoring of temperature is essential.
Assess for hydration status.A high body temperature increases the metabolic rate hence increases the insensible fluid loss.
Eliminate excess clothing.Exposing skin to room air decreases warmth and increases evaporative cooling.
Administer tepid sponge bath.External sponging reduces the body temperature and increases comfort.
Advise the mother to avoid applying cold water or alcohol to the child.Extreme cooling can result in shock to a child with an immature nervous system; While applying alcohol can cause dry skin.
Administer antipyretic as indicated:
  • - Acetaminophen (Tylenol)
Lowers fever by directly acting on the hypothalamic heat-regulating centers that promote distribution of body heat through sweating and vasodilation.
  • - Ibuprofen (Advil)
Aa nonsteroidal anti-inflammatory drug (NSAID) that inhibits the production of prostaglandins (chemicals that promote inflammation, pain, and fever).

3. Risk for Injury


Risk for Injury: Vulnerable to injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
May be related to
  • - Internal factors of biochemical regulatory
  • - Altered level of consciousness resulting from seizure episode
Possibly evidenced by
  • [Not applicable]
Desired Outcomes
  • - Child will be free from injury when a seizure occurs.
Nursing InterventionsRationale
Assess and record seizure activity and location. Note the duration of seizures, parts of the body involved, site of onset and progression of seizure.Documentation of information is essential for the prevention of injury or complications as a result of a seizure.
Assess skin for pallor, flushed, or cyanosis; Monitor respiratory rate, depth, and signs of respiratory distress.Once seizures are prolonged and respiration is compromised, this will provide information on possible signs of aspiration of secretions.
Maintain side-lying position; Keep padded side rails up with the bed in lowest position and removed any clutter from the child.Side-lying facilitates drainage of secretions and maintains airway patency; padding protects the child from injury during a seizure.
Avoid restraining the child or putting anything in his/her mouth; provide gentle support to head and arms if harm might result.Restraining a child can result in trauma due to the amount of force exerted; inserting object in mouth increases stimuli; Padding the area helps to protect the head from injury.
Stay with the child during the phase of seizures, reorient when awake, and allow to rest or sleep after an episode.Provides support and prevents any injury to child.
Advice parents to remain calm during seizure activity of the child.Allows parents to function properly to protect the child from injury.
Teach about information to record about seizure activity should it occur (specify).Provides physician with important information needed to prescribe medical regimen.
Educate the parents regarding precautionary measures during a seizure.Guarantees safe and effective interventions to avoid the incidence of injury.
Administer medications as indicated:
  • - Phenobarbital (Luminal)
This is a central nervous system depressant that acts as an anticonvulsant by decreasing the seizure threshold.
  • - Carbamazepine (Tegretol)
This is an anticonvulsant that works by decreasing nerve impulses that cause seizures and pain.
  • - Diazepam (Valium)
This is an anticonvulsant drug that can reduce the risk of recurring febrile seizures.

4. Deficient Knowledge


Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
  • - New disease
  • - Lack of exposure to information about ongoing care
Possibly evidenced by
  • - Expressed request for information about medication treatment
  • - Cause of seizures and when to report to physician
Desired Outcomes
  • - Parents will obtain information regarding care of the child.
Nursing InterventionsRationale
Assess parents’ perceptions and knowledge about disease condition, fears, and misconceptions about disorder, nature, and frequency of seizures.Provides information regarding the long-term care of a child with a seizure disorder and how to deal with seizures and the stigma attached to this disorder.
Educate parents that a febrile seizure is more of a symptom of fever than a long-term condition.Understanding this information can help the parent understand the responsibility to take for future care.
Advise parents and child to report dizziness, drowsiness, gastrointestinal upset, nausea, vomiting, photosensitivity, and rash.These are the side effects of anticonvulsants and sedatives.
Inform parents about the need for follow up laboratory studies such as blood count and liver function test as indicated.Prevents toxicity and other severe side effects of drug therapy by adjusting the dosage or changing medications.
Inform that seizures may be provoked by an illness or infection, hyperactivity, lack of sleep, abrupt discontinuation of medication, emotional stress, or other causes specific to the child.Increases knowledge and understanding of causes of increased frequency of seizures.
Advise parents to supervise the child in the bathroom, avoid exposure to incidents that trigger a seizure, avoid dangerous play and toys, pad areas in bed, or wear protective clothing if needed.Provides precautions to prevent injury as a result of a seizure.
Encourage parents to notify school nurse and teach of disorder and actions to take including a telephone number to call.Promotes knowledge and understanding to prevent injury and embarrassment to the child.
Discuss any activity restrictions such as sports, rough play, need for someone in attendance.Promotes knowledge of activity based on individual child and seizure activity and response to therapy.
Alert parents of possible changes in behavior, activity, or personality or changes in school performance or interactions with family and peers.Indicates effects of anticonvulsants on behavior and learning.
References and Sources : nurseslabs.com

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