Nurse Care Plan

Seizures
* episodes of abnormal sensory and autonomic activity that results on excessive discharges of electrical impulses from cerebral neurons.
* it affects level of consciousness
* occurs in any disturbance of CNS
CAUSES
* idiopathic (50%)
* birth injury-most common in forcep delivery
* brain tumor
* CVA
* CNS infection
* High fever
*HPN
* head trauma
* hypoglycemia
TYPES
A. Generalized
* whole brain is affected
1. Tonic-Clonic
* "grand mal"
* up to 5 minutes
MANIFESTATION
* Aura- before the attack
- signs of impending attack
* numbness
* crying loud
* spots before the eyes
* smell of different odor
* episodes of apnea
* chewing of the tongue
* incontinence
* loss of consciousness
* loss of motor function
* tonic (rigidity)
* clonic-alternating muscle contraction and relaxation
* headache
* fatigue
* drowsiness
2. ABSCENCE
* "petit mal"
* (-) LOC
MANIFESTATION
* blank stare
* twitching tongue
* smacking lips
* rolling of eyeballs
B. PARTIAL/FOCAL
* only one hemisphere is affected
TYPES
a. SIMPLE PARTIAL
*(-) LOC
MANIFESTATION
* aura
* shaking of fingers and hands
* unusual sensation
b. COMPLEX
* (+) LOC
* up to 3 minutes
MANIFESTATION
* automaticism- behavior done by a person but unaware
* episodes of amnesia
c. JACKSONIAN
* start from one side of the body and radiate and proceed to tonic-clonic
MANAGEMENT
a. PHARMACOLOGIC
1. anticonvulsants
* phenytoin
* carbamazepine (Tegretol)
2. muscle relaxant
* diazepam (Valium)
b. NURSING
1. asses for clients behavior and surroundings prior to seizure.
2. losen up tight clothings.
3. maintain a patent airway.
4. note for loss of consciousness.
5. provides clients safety.
6. time and document the attack.
7. return the client to side.
AFTER SEIZURE ATTACK
1. reorient the patient.
2. keep the patient in side lying position.
3. allow the patient to relax.
DONT'S
1. do not leave the patient.
2. do not restraint the patient.
3. do not put anything on the mouth one's the seizure began.