Febrile Seizures - 4 Nursing Diagnosis And Interventions - NANDA

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Febrile Seizures - 4 Nursing Diagnosis and Interventions

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.

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