Nursing Diagnosis: Risk for Trauma/Suffocation Risk factors may include Weakness, balancing difficulties Cognitive limitations/altered consciousness

ss Loss of large or small muscle coordination Emotional difficulties Evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Verbalize understanding of factors that contribute to possibility of trauma and/or suffocation and take steps to correct situation. Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury. Modify environment as indicated to enhance safety. Maintain treatment regimen to control/eliminate seizure activity. Identify actions/measures to take when seizure activity occurs. Nursing actions Rationale Alcohol, various drugs, and other stimuli (e.g., loss of sleep,flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity. Enables patient to protect self from injury and recognize changes that require notification of physician/further intervention. Knowing what to do when seizure occurs can prevent injury/complications and decreases SOs feelings of helplessness.

Explore with patient the various stimuli that may precipitate seizure activity.

Discuss seizure warning signs (if appropriate) and usual seizure pattern. Teach SO to recognizewarning signs and how to care for patient during and after seizure. Keep padded side rails up with bed in lowest position, or place bed up against wall and pad floor if rails not available/appropriate.

Minimizes injury should seizures (frequent/generalized) occur while patient is in bed. Note: Most individuals seize in place and if in the middle of the bed, individual is unlikely to fall out of bed.

Encourage patient not to smoke except while supervised.

May cause burns if cigarette is accidentally dropped during aura/seizure activity. Use of helmet may provide added protection for individuals who suffer recurrent/severe seizures Reduces risk of patient biting and breaking glass thermometer or suffering injury if sudden seizure activity should occur. Patient 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 patient cooperation Promotes patient safety. 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: Wooden tongue blades should not be used because they may splinter and break in patients mouth. (Refer to ND: Airway Clearance/Breathing Pattern, ineffective, risk for Gentle guiding of extremities reduces risk of physical injury when patient lacks voluntary muscle control. Note: If attempt is made to restrain patient during seizure, erratic movements may increase, and patient may injure self or others.

Evaluate need for/provide protective headgear

Use tympanic thermometer when necessary to take temperature.

Maintain strict bed rest if prodromal signs/aura experienced. Explain necessity for these actions.

Stay with patient during/after seizure.

Turn head to side/suction airway as indicated. Insert plastic bite block only if jaw relaxed.

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

Document preseizure activity, presence of aura or unusual behavior, type of seizure activity (e.g., location/duration of motor activity, loss of consciousness, incontinence, eye activity, respiratory impairment/cyanosis), and frequency/recurrence. Note whether patient fell, expressed vocalizations, drooled, or had automatisms (e.g., lipsmacking, chewing, picking at clothes). Perform neurological/vital sign check after seizure, e.g., level of consciousness, orientation, ability to comply with simple commands, ability to speak; memory of incident; weakness/motor deficits; blood pressure (BP), pulse/respiratory rate.

Helps localize the cerebral area of involvement

Documents postictal state and time/completeness of recovery to normal state. May identify additional safety concerns to be addressed Patient may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety. May display behavior (of motor or psychic origin) that seems inappropriate/irrelevant for time and place. Attempts to control or prevent activity may result in patient becoming aggressive/combative. May be result of repetitive muscle contractions or symptom of injury incurred, requiring further evaluation/intervention.

Reorient patient following seizure activity.

Allow postictal automatic behavior without interfering while providing environmental protection.

Investigate reports of pain. Observe for status epilepticus, i.e., one tonic-clonic seizure after another in rapid succession. This is a life-threatening emergency that if left untreated could cause metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased intracranial pressure, airway obstruction,

and respiratory arrest. Immediate intervention is required to control seizure activity and prevent permanent injury/death. Note: Although absence seizures may become static, they are not usually life-threatening. Specific drug therapy depends on seizure type, with some patients requiring polytherapy or frequent medication adjustments. AEDs raise the seizure threshold by stabilizing nerve cell membranes, reducing the excitability of the neurons, or through direct action on the limbic system, thalamus, and hypothalamus. Goal is optimal suppression of seizure activity with lowest possible dose of drug and with fewest side effects. Cerebyx reaches therapeutic levels within 24 hr and can be used for nonemergent loading while waiting for other agents to become effective. Note: Some patients require polytherapy or frequent medication adjustments to control seizure activity. This increases the risk of adverse reactions and problems with adheren

Administer medications as indicated: Antiepileptic drugs (AEDs), e.g., phenytoin (Dilantin), primidone (Mysoline), carbamazepine (Tegretol), clonazepam (Klonopin), valproic acid (Depakene), divalproex (Depakote), acetazolamide (Diamox), ethotoin (Peganone), methsuximide (Celotin), fosphenytoin (Cerebyx);

Nursing Diagnosis: Risk for ineffective Airway Clearance/Breathing Pattern

Risk factors may include Neuromuscular impairment Tracheobronchial obstruction Perceptual/cognitive impairment Evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes Respiratory Status: Ventilation Maintain effective respiratory pattern with airway patent/aspiration prevented. Rationale Nursing actions Encourage patient to empty mouth of dentures/foreign objects if aura occurs and to avoid chewing gum/sucking lozenges if seizures occur without warning. Place in lying position, flat surface; turn head to side during seizure activity. Loosen clothing from neck/chest and abdominal areas.

Reduces risk of aspiration/foreign bodies lodging in pharynx. Promotes drainage of secretions; prevents tongue from obstructing airway.

Facilitates breathing/chest expansion. If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning/respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue. Reduces risk of aspiration/asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min. May reduce cerebral hypoxia resulting from decreased circulation/oxygenation secondary to vascular spasm during seizure. Note:Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in/out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem

Insert plastic airway or soft roll as indicated and only if jaw is relaxed.

Suction as needed. Administer supplemental oxygen/bag ventilation as needed postictally.

exists (e.g., foreign body/aspiration). Prepare for/assist with intubation, if indicated. Presence of prolonged apnea postictally may require ventilatory support.