Nursing Care Plan for Febrile Seizures
I. Increased body temperature related to the presence of pyrogens that disrupt the thermostat, the average increase in metabolism and disease dehydration.
Goal: Normal body temperature.
Outcomes: temperature 36.5 ° C - 37.5 ° C and the clients are free from fever.
Interventions and Rational:
1. Observation of vital signs every four hours.
R /: Vital signs are increased, is a manifestation of the occurrence of seizures and complications.
2. Provide a description of the family regarding the provision compress.
R /: Cold compresses can reduce body temperature.
3. Give light clothing that can absorb sweat.
R /: Facilitate the release of heat into the air.
4. Encourage clients to drink.
R /: Prevent dehydration.
5. Engage in collaboration with the medical team for giving antipyretics and antibiotics.
R /: Antipyretics to reduce body temperature and antibiotics for the treatment of infections.
II. Risk for ineffective airway clearance related to neuromuscular damage and obstruction trakeobroncial.
Goal: maintain effective breathing pattern with a clean airway and prevented from aspiration.
Outcomes:
Normal respiration: 15-30 x per minute and no muscle retraction.
Interventions and Rational:
1. Place the patient in a comfortable position (semi-Fowler).
R /: Freeing airway to prevent asphyxiation.
2. Loosen clothing, especially on the neck, chest and abdomen.
R /: Make it easy breathing and comfort.
3. Give spatel in mouth
R /: Preventing trauma to the tongue.
4. Section if necessary.
R /: Eliminate secretions and prevent aspiration and cleaning the airway of secretions.
5. Give 02 In accordance with the requirement.
R /: Overcoming hypoxia.
III. Knowledge Deficit: families with respect to misinterpretation and lack of information.
Goal: Verbally client can reveal that stimulation may increase seizures
Outcomes:
Clients can take medication on a regular basis.
Interventions and Rational
1. Assess pathology and prognosis of the condition of the client.
R /: to demonstrate and determine the action to be performed.
2. Assess treatment that has been done.
R /: Preventing conflicts of drug effects.
3. Provide nutritious food.
R /: Restoring general condition and condition as well as preventing a decrease in body weight.
4. Discuss the effects of drugs.
R /: Knowing the signs of allergic reaction and know the development of the client's condition.
5. Explain how to prevent infection.
R /: Improve knowledge of the client and prevent complications.
6. Immediately lower the heat in the event of a seizure.
R /: Heat can cause repeated seizures.
7. Teach the family to give anti-seizure drugs and anti-pyretic in accordance with the rules of the medical team.
R /: Preventing drug misuse.
IV. Risk for injury or trauma related to weakness, changes in consciousness.
Goal: Verbally clients can find out the factors that allow the trauma.
Outcomes:
Clients are free from trauma when a seizure occurs.
Interventions and Rational
1. Explain the factors predisposing to seizures.
R /: Preventing false perceptions and increase client cooperative attitude.
2. Keep clients from trauma by providing a safety on the side of the bed.
R /: Safety handy while preventing trauma (fall) when the seizure occurred.
3. Keep the client in the event of an aura.
R /: Knowing early impending seizures and prevent trauma.
4. Stay with the client during the phase of seizures.
R /: To prevent complications as early as possible.
V. Impaired self-concept (low self esteem) related to epilepsy and wrong perceptions and uncontrolled.
Goal: Verbally clients do not experience a mis interpretation and low self-esteem does not happen
Outcomes:
Clients and families can know correctly about prognosis, treatment regimen and treatment of seizures.
Interventions and Rational
1. Provide a description of the disease, treatment and prevention method.
R /: Improving cooperation and prevent misinterpretation.
2. Explain how to avoid the risk factors.
R /: Knowing the risk factors for the client to avoid the cause of the seizures.
3. Answers questions and accommodate all clients and families.
R /: Meet the lack of information about febrile seizures.
