Seizure Disorder, Todds Paralysis

January 5 2015
Estacio, Precious Ann S.

I.

Patient Profile

a. Demographics
Name: DML
Hospital Number: 00429430
Applicable
Birthday: November 10, 2009
Age: 5 years old
Attainment: Student

Religion: Roman Catholic

Occupation: Not
Civil Status: Single
Educational

b. Nursing Assessment:
Neurological Assessment: GCS: 15 E4: Spontaneous, M6:
Obeys, V5: Oriented to time place and person.
Cardiovascular/Peripheral Assessment: Full and Symmetric
peripheral pulsations, Apical Heart rate of 115-138 beats per
minute.
Respiratory Assessment: Clear breath sounds. Symmetrical chest
expansion. Respiratory rate of 32-35 cycles per minute. Nail beds
and mucous membranes are pink. Capillary refill test 3 seconds.
EENT Assessment: Normocephalic and symmetric, with frontal,
parietal and occipital prominences. Symmetric facial movements.
Hair evenly distributed. Pink palpebral conjunctiva. Pupils black in
color, equal in size 3mm in diameter. Pupils equally round and
reactive to light and accommodation. Auricles are mobile, firm, and
not tender. Audible in normal voice tone. Pink nasal mucosa with
nasal septum intact and in midline. No lesion or discharge noted.
Moist, smooth and soft Lips and buccal mucosa. Neck Muscles are
Coordinated, Smooth Movements with no discomfort. No noted
tenderness on throat.
Gastrointestinal Assessment: Rounded Abdomen, Normo-Active
bowel Sounds heard in all four quadrants. No pain upon palpation.
Patient was able to tolerate full meals.
Genitourinary Assessment: Light yellow colored urine with no
presence of bleeding.
Integumentary Assessment: Skin color is brown generally
uniformed in all areas of body. No visible signs of skin problems or
trauma. Skin is warm to touch, smooth and shiny in appearance.
Noted Good skin turgor
Musculoskeletal Assessment: Right side body weakness,
occasional mild stiffening of right leg with flaccid right arm, unable
to walk properly.
Psychological Assessment: Normal affect, response appropriate
in certain situations

Coping Stress Tolerance Assessment: Good support system

mainly the family regarding financial and emotional/physical
wellbeing of the patient
Values-Belief Assessment: No religion restrictions with regards to
treatment.
Intravenous Therapy Assessment: D5IMB 500ml x 49 cc/hr
inserted at right metacarpal vein, patent and intact, no redness and
swelling on surrounding site noted. Dressing is dry and intact.

II.

Sample

Signs and Symptoms

Fever 38.4C, Entire body stiffening with jerking
movements and upward rolling of the eyeballs
Allergies
No known Allergies
Medication
Paracetamol, Diazepam, Valproic Acid
Past Medical History Amoebiasis (2014)
Last Meal Taken
Chicken, rice and Banana
Events That Lead to
Prior to admission Dec. 6 2014 patient was first
hospitalized to St. James
Admission
Hospital at Sta. Rosa, where he is diagnosed of
ameobiasis with first time occurrence of seizure episode,
after 4 days of hospitalization and upon discharged on
Dec. 16, 3 episodes of seizure lasting to 15- 20 second
happened at home, 8 episode of occasional leg and hand
stiffening and jerking movement lasting about a minute.
2nd admission on Dec. 19 on same hospital with EEG lab
result done at Calamba Doctors, Dec. 23 follow up with
their neuropedia, his father forgot to bring lab results but
was able to obtain a video of his son on his seizure
episode, Doctor and the father got an argument that he
opted to consult another specialized doctor in Asian
hospital hence admitted his son on Dec. 25 with ongoing
recurrences of seizures.

III.

Introduction

What happens inside your child's brain during a seizure? Here is a simplified
explanation: Your brain is made up of millions of nerve cells called neurons, and
these cells communicate with one another through tiny electrical impulses. A
seizure occurs when a large number of the cells send out an electrical charge at the
same time. This abnormal and intense wave of electricity overwhelms the brain and

results in a seizure, which can cause muscle spasms, a loss of consciousness,

strange behavior, or other symptoms.
Anyone can have a seizure under certain circumstances. For instance, a fever, lack
of oxygen, head trauma, or illness could bring on a seizure. People are diagnosed
with epilepsy when they have seizures that occur more than once without such a
specific cause. In most cases -- about seven out of 10 -- the cause of the seizures
can't be identified. This type of seizure is called "idiopathic" or "cryptogenic,"
meaning that we don't know what causes them. The problem may be with an
uncontrolled firing of neurons in the brain that trigger a seizure.
Seizures are over so quickly that your doctor probably will never see your child
having one. The first thing a doctor needs to do is rule out other conditions, such as
nonepileptic seizures. These may resemble seizures, but are often caused by other
factors such as drops in blood sugar or pressure, changes in heart rhythm, or
emotional stress.

Your description of the seizure is important to help your doctor with the diagnosis.
You should also consider bringing the entire family into the doctor's office. The
siblings of children with epilepsy, even very young kids, may notice things about the
seizures that parents may not. Also, you may want to keep a video camera handy so
that you can tape your child during a seizure. This may sound like an insensitive
suggestion, but a video can help the doctor enormously in making an accurate
diagnosis.
Todd's paralysis is a neurological condition characterized by a brief period of
transient (temporary) paralysis following a seizure. The paralysis which may be
partial or complete generally occurs on one side of the body and usually subsides
completely within 48 hours. Todd's paralysis may also affect speech or vision. The
cause is not known. Examination of an individual who is experiencing or who has
just experienced Todd's paralysis may help physicians identify the origin of the
seizure. It is important to distinguish the condition from a stroke, which requires
different treatment
The researcher chose this study because it is rare and a mystery for everyone, it is
simple yet very informative to study this case.
The researcher would like to thank the father and the patient for the cooperation
and the statements to make this study complete, also the researcher used the
patients chart as the basis of this study which is validated by the family and the
patient. This study focuses on the second day the patient was admitted and
handled by the care of the researcher on 6 th floor
IV.

Anatomy and Physiology

a. Seizure

The word "seizure," when used accurately, describes the excessive, chaotic
discharge of cerebral neurons. The actual seizure is the aberrant neuronal activity

taking place in the brain. The resultant observable events (such as tonic-clonic jerky
movements of the musculoskeletal system; bowel and/or bladder incontinence;
biting of the buccal mucosa and/or tongue; and accompanying "post-ictal" period of
confusion) are somatic, neurological and musculoskeletal manifestations of the
"neuronal seizure" activity.
The brain, spinal cord, and musculature interact via nerve cells called neurons, the
functional units of the central nervous system.

The neuron is made up of a soma or cell body; dendrites that receive information
from other axons or various receptors; and axons that transmit information from the
cell body to the terminal boutons at the distal end of the axons. Neurons interface
with other nerve cells via small gaps called synapses. At the synapse, an axonal
terminal bouton is in close proximity to a dendrite of another axon. At the synapse,
a chemical neurotransmitter is released from the axonal terminal bouton as a result
of an action potential, the electrophysiologic voltage change manifested in the axon
due to a transient variation in the sodium and potassium permeability of the axon.
This neurotransmitter diffuses across the synapse and binds to receptors on the
dendrites of the next axon.
When the permeabilities of the membrane's ionic channels for sodium and
potassium are varied sequentially, a fluctuation in the membrane voltage occurs,
which is termed the action potential.

As the sodium attempts to enter the nerve cell, the potassium permeability
increases as the potassium channels open, and the membrane begins to repolarize
to the "resting" membrane potential. The nerve cell repolarizes and is ready for the
next action potential to come along. These action potentials are also modified by
the flux of chloride ions and the presence or absence of GABA activity in the
membrane of the axon.
The pathways for information exchange between the brain and musculature can be
divided into two general groups. One group of neurons provides afferent (sensory)
input to the spinal cord and brain from the skeletal muscle and various receptors in
the muscle and skeletal tissue, ligaments and tendons. Another group of neurons
provide efferent (motor) output from the brain and spinal cord to the musculature or
muscular motor unit.

A neuron or group of neurons in the brain can become hyperexcitable or irritable

due to hypoxia, ischemia, hypoglycemia, or electrolyte abnormalities that affect the
action potential and cause these nerve cells to discharge action potentials
irregularly without adequate suppression and attenuation of the abnormal activity. If
this occurs, the corresponding muscle fascicles may begin to contract
inappropriately, thus producing seizure-like activity.
Depending on where the focus of this aberrant discharge is in a particular region of
the brain, the corresponding motor or sensory area will be affected, leading to
either motor symptoms such as tonic-clonic contractions or sensory manifestations
of seizure-like activity, such as paresthesias, dj vu, or hallucinations (auditory,
visual, or olfactory).
These foci of aberrant electrical activity (the seizure) may be isolated, or the focus
may spread and involve various areas of the brain, leading to chaotic, uninhibited
discharge of electrical activity of various neurons in the brain. The resultant motor
and/or sensory activity manifested by and experienced by the patient is clinically
described as a seizure.
Control of the seizure can be accomplished by suppressing the action potential via
manipulation of sodium and potassium ion permeabilities, rendering the axon
refractory to the action potential, or blocking transmission of impulses at the
synapse by blocking the neurotransmitter from binding to its receptor site, or
preventing its release and/or synthesis.

V. Pathophysiology

Nervous
System

Predisposing factor

Etiology/Factors
-an electrical disturbance in the nerve
cell in one section of the brain, causing
(hypoxemia, then to emit abnormal,
recurring, uncontrolled injury, electrical
discharges.
Cellular/Metabolic Changes
-when the integrity of the neuronal cell
membrane is altered, the cell begins firing
with increased frequency and amplitude.
When the intensity discharges reaches the
threshold, the neuronal firing spreads to
adjacent neurons, ultimately resulting to
seizure. Inhibitory neurons have slow
neuronal firing in the cortex. Anterior
thalamus, and basal ganglia. Once the
inhibitory processes develop or the
epileptogenic neurons are exhausted, the
seizure stops then later events depress the

-Noong bata sya parati

-idiophatic (genetic, developmental

defects)

syang nagkakalagnat ng
sobrang taas hindi nya
kinakaya, kinukumbulsyon
sya as verbalized by the
father.

-acquired vascular insufficiency, fever

(childhood), head injury, hypertension,
CNS infections, metabolic and toxic
conditions, brain tumor, drug and

-Still recovering from

Physiologic Manifestation

Gross Anatomical Physical

Changes
-involuntary movements
may spread centrally and
involve the entire limb,
including one side of the
face and lower extremities.
The client also may exhibit
Musculoskeletal
changes in posture
or
Assessment: Right
side body weakness,
occasional mild
stiffening of right leg
with flaccid right arm,
unable to walk

-epigastric sensation, pallor, Cardiovascular/Peripheral

sweating, flushing, goose
Assessment: Full and
flesh, (piloerection) pupillary Symmetric peripheral
dilation, tachycardia and
pulsations, Apical Heart rate of
tachypnea.
115-138 beats per minute.
Respiratory Assessment: Clear
breath sounds. Symmetrical
chest expansion. Respiratory
rate of 32-35 cycles per
minute.
kapag namanhid ung kanang
paa nya alam nya na

Signs and Symptoms

Laboratory Findings

Tonic phase:

-MRI may detect lesions in the

brain, focal abnormalities and
cerebral degenerative changes

-fall, loss of consciousness, yell or tonic cry, extension of arms, legs and/or
face, fingers and jaw clenched. AUTONOMIC SYMPTOMS include increase in
blood pressure, heart rate and bladder pressure, flushing, sweating, increased
salivation and bronchial secretion and apnea.

-EEG may allow diagnosis of the

type and include increase in
blood pressure, flushing,
sweating, increased salivation
and bronchial secretion,
occurring seizure.

Clonic phase:-muscle relax completely, then muscle tone returns which causes
rhythmic jerking of head and body.
Post-Ictal phase:-biting of the tongue, cheek or lip, and urinary incontinence are
seizur
e

-SPECT may identify the

epileptogenic zone area in the
brain giving rise to seizure can
surgically

Complications
-Hypoxic Brain damage and mental retardation may follow
repeated seizures
-Depression and anxiety may develop. Long Term social

Todd's paralysis is a neurological

condition characterized by a brief
period of transient (temporary)
paralysis following a seizure.

EEG
This is an abnormal sleep,
drowsy and awake EEG study
due to the presence of
intermittent epileptiform
activities coming from the left
parietal lobe with occasional
spread towards the left
centro-pareital and temporal
areas predisposing the
patient to focal epilepsy with
secondary generalization.

VI. Medical and Nursing Management

Laboratory Exam
Diagnostic Exam
Blood Urea Nitrogen
4.2mmmol/L
Creatinine
31.0 umol/L
ALT/SGPT
20.0 (Low)
Valproic Acid (Depakene)
774.2 umol

Rationale
Monitoring of liver enzymes,
blood
cell
counts
and
Depakene
levels
have
increased the safety and
efficacy of Depakene.

Nursing Intervention
Nursing Responsibilities
Tell the patient that the BUN test is
used to evaluate kidney function.
ALT/SGPT and Depakene to monitor
medications that cause liver-related
side effects
Inform the patient that he need not to
restrict food and fluids, but should
avoid diet high in meat.
Tell the patient that the test requires
a blood sample.

(Therapeutic)
Explain who will perform the
venipuncture and when.
Explain to the patient that he may
experience slight
discomfort from the tourniquet and
needle puncture.
Notify the laboratory and physician of
medications the patient is taking that
may affect test results; they may
need to be restricted.

Laboratory Exam
Diagnostic Exam

Rationale

Nursing Intervention
Nursing Responsibilities

Urinalysis
Routine Physical Exam
Color
yellow
Transparency
clear
Chemical Reaction
Glucose
negative
Bilirubin
Negative
Ketone
trace
Specific Gravity
1.010
Blood
Negative
pH
7.0
Protein
Negative
Urobilinogen
Negative
Nitrite
Negative
Leucocyte
Negative
Microscopic Exam By FCM
RBC
0.9/uL
WBC
0.3/uL
EPITHELIAL Cells

It
is
part
of
baseline,
screening
and
evaluation
based on patients symptoms.

Collect specimens form infants and

young children into a disposable
collection apparatus consisting of a
plastic bag with an adhesive backing
around the opening that can be
fastened to the perineal area or
around the penis to permit voiding
directly to the bag. Depending on
hospital policy, the collected urine
can be transferred to an appropriate
specimen container.
Cover all specimens tightly, label
properly and send immediately to the
laboratory.
If a urine sample is obtained from an
indwelling catheter, it may be
necessary to clamp the catheter for
about 15-30 minutes before obtaining
the sample. Clean the specimen port
with antiseptic before aspirating the
urine sample with a needle and a
syringe.
Observe standard precautions when
handling urine specimens.
If the specimen cannot be delivered
to the laboratory or tested within an
hour, it should be refrigerated or have
an appropriate preservative added.

0.7/uL
Type
Squamous
Cast
0.0
Bacteria
25.4

Laboratory Exam
Diagnostic Exam

Rationale

Nursing Intervention
Nursing Responsibilities

Brain MRI
Normal MRI of the Brain

Imaging tests that allow a

doctor to view the brain and
evaluate
the
cause
and
location of a possible source
of epilepsy within the brain.
The scans can reveal scar
tissue, tumors, or structural
problems in the brain that
may be the cause of seizures
or epilepsy.

Make sure the scanner can

accommodate the patients weight
and abdominal girth.
Patient Preparation
Explain to the patient that skeletal
MRI assesses bone and soft tissue.
Tell him who will perform the test and
where it will take place.
Explain that the test takes 30 to 90
minutes.
Explain to the patient that although
MRI is painless and involves no
exposure to radiation from the
scanner, a contrast medium may be
used, depending on the type of tissue
being studied.
If the patient is claustrophobic or if
extensive time is required for
scanning, explain to him that a mild
sedative may be administered to
reduce anxiety. Open scanners have
been developed for use on the
patient with extreme claustrophobia
or morbid obesity, but tests using
such machine take longer.
An anesthesiologist may need to be
present to monitor a heavily sedated
patient.

Tell the patient that he must lie flat,

and describe the test procedure.
Explain to the patient that hell hear
the scanner clicking, whirring, and
thumping as it moves inside its
housing.
Reassure the patient that hell be
able to communicate with the
technician at all times.
Instruct the patient to remove all
metallic objects, including jewelry,
hairpins, or watches.
Stop I.V. infusion pumps, feeding
tubes with metal tips, pulmonary
artery catheters, and similar devices
before the test.
Ask whether the patient has any
surgically implanted joints, pins, clips,
valves, pumps, or pacemakers
containing metal that could be
attracted to strong MRI magnet. If he
does, he wont be able to have the
test.
Note and report all allergies.
Make sure that the patient or a
responsible family member has
signed an informed consent form, if

required.
Procedure
At the scanner room door, check the
patient one last time for metal
objects.
The patient is placed on a narrow,
padded, nonmetallic table that moves
into the scanner tunnel. Fans
continuously circulate air in the
tunnel, and a call bell or intercom is
used to maintain verbal contact.
Remind the patient to remain still
throughout the procedure.
While the patient lies within the
strong magnetic field, the area to be
studied in stimulated with radiofrequency waves.
If the test is prolonged with the
patient lying flat, monitor him for
orthostatic hypotension.
Provide comfort measures and pain
medication as needed and ordered
because of prolonged positioning in
the scanner.
After the test, tell the patient that he
may resume his usual activity.

Provide emotional support to the

patient with claustrophobia or anxiety
over his diagnosis.

Laboratory Exam
Diagnostic Exam

Rationale

EEG
This is an abnormal sleep, drowsy
and awake EEG study due to the
presence of intermittent
epileptiform activities coming
from the left parietal lobe with
occasional spread towards the left
centro-pareital and temporal
areas predisposing the patient to
focal epilepsy with secondary
generalization.

A computer records your

brain's electrical patterns as
wavy lines. The EEG may
show abnormal spikes or
waves in brain's electrical
activity patterns.

Nursing Intervention
Nursing Responsibilities
Explain the procedure, emphasizing
the importance of cooperation.
Withhold fluids, foods, and
medications (as prescribed) thatmay
stimulate or depress brain
waves.These include
anticonvulsants,tranquilizers,
depressants, and caffeinecontainingfoods (e.g., coffee, tea,
colas, and chocolate).
Medications areusually withheld for
24 to 48 hours before the test.
Help the client wash the hair before
the test.

Drug
Name

Route, Dose
and
Frequency

Indication

Mechanism
of Action

Side Effects

Adverse
Effects

Nursing
Consideratio

Generic Name:
Paracetamol
Brand Name:
Biogesic
Class:
Antipyretic,
Analgesia

Route: Intravenous
Dose: 140mg
Frequency: As
needed

Route, Dose
Drug
and
Frequency
Name

Generic Name:
Valproic Acid
Brand Name:
Depakene
Class: Anti
epileptic

Route: Oral
Dose: 2.5ml
Frequency: once a
day

Mild to moderate pain

caused by headache,
muscle ache, backache,
minor arthritis, common
cold, toothache or
menstrual cramps; fever

Fever Reduction may

result from
vasodilation and
increased peripheral
blood flow in
hypothalamus, which
dissipates heat and
lowers body
temperature.

rash,
itching/swelling
(especially of the
face/tongue/throat),
severe dizziness,
trouble breathing...

Rash, urticarial,
thrombocytopenia
, haemolytic
anemia,
neutropenia,
leukopenia,
pancytopenia,
heptotoxicity

Indication

Mechanism of
Action

Side Effects

Adverse
Effects

antiepileptic activity
may be related to
the metabolism of
the inhibitory
neurotransmitter,
GABA; divalproex
sodium is a
compound
containing equal
proportions of
valproic acid and
sodium valproate.

Black, tarry stools

bleeding gums
bloating or swelling
of the face, arms,
hands, lower legs,
or feet
blood in the urine or
stools

Nausea, vomiting,
indigestion,
diarrhea,
abdominal
cramps,
constipation,
anorexia with
weight loss,
increased
appetite with
weight gain, lifethreatening
pancreatitis,
hepatic failure

Monitor patient alert

especially with mult
drug therapy for seiz
control. Evaluate pla
levels of the adjunct
anticonvulsants
periodically as indica
for possible neurolog
toxicity

Mechanism of
Action

Side Effects

Adverse
Effects

Nursing
Considerations

Sole and adjunctive

therapy in simple (petit
mal) and complex
absence seizures
Adjunctive therapy with
multiple seizure types,
including absence
seizures

Indication
Drug Route, Dose
and
Frequency
Name

Assess patients pain

temperature before
medication

Determine Intervals
least 4 hours after th
medication

Nursing
Consideratio

Generic Name:
Diazepam
Brand Name:
Vallium
Class:
Antianxiety
agents,anticonvu
lsants,sedative/h
yptonics,skeletal
muscle relaxants

VII.

Route:
Intravenous
Dose: 4mg
Frequency: As
Needed

Drug Analysis

Adjunct in status
epilepticus and
severe recurrent
convulsive seizures,
adjunct in convulsive
disorders

Depress the CNS,

probably by
potentiating GABA,
aninhibitory
neurotransmitter.Produces skeletal
musclerelaxation by
inhibitingspinal
polysynaptic afferent
pathways

dizziness
drowsiness lethargy
hangover headache
depression

Respiratory
depression,
blurred vision,
hypotension

Monitor BP, PR,RR p

periodically through
therapy andfrequen
during IV therapy.Assess IV site freque
duringadministration
diazepam may caus
phlebitis and venous
thrombosis
Observe and record
intensity, durationan
location of seizure a
Theinitial dose of
diazepam offers
seizurecontrol for 15
min after administra

VIII.

Assessment

Nursing Care Plan

Diagnosis

Planning

Intervention

Rationale

Evaluation

Objective Cues:
-Body weakness
on right side of
the body
-GCS: 15, 5 years
old, Male. High
Risk Fall humpty
dumpy scale
-Recurrent
seizure episodes
Verbal Cues:
Nanghihina yung
kanang kamay at
paa nya as
verbalized by the
father

Risk for Trauma as

evidenced by
previous episodes of
muscle stiffening

Short Term Goals:

To promote safety
and secured
environment to
avoid injury within
8 hour shift
Long Term Goals:
After 1-2 days the
patients father will
demonstrate
behaviors, or
lifestyle changes to
reduce risk factor
and protect patient
from self injury

Independent
Nursing
Intervention:
Assessed clients
muscle strength,
gross and fine
motor coordination
Maintained
bed/chair in lowest
position with
wheels and side
rails locked
Instructed
client/Significant
other to request
assistance if
needed; make sure
call light is within
reach
Note preseizure
activity, presence
of aura or unusual
behavior, type of
seizure activity
(location or
duration of motor
activity, loss of
consciousness,
incontinence, eye

To Identify risk for

falls

Prevents or
minimizes injury
when seizures
(frequent or
generalized) occur
while patient is in
bed.
Promotes safety
measures.

Helps localize the

cerebral area of
involvement.

Short term goal:

Goal Met, No noted
Injury within 8 hour
Shift

Long term goal:

Goal Met, Patients
father understood
health teaching and
demonstrates
measurements for
the patients safety

activity, respiratory
impairment or
cyanosis), and
frequency or
recurrence. Note
whether patient
fell, expressed
vocalizations,
drooled, or had
automatisms (lipsmacking, chewing,
picking at clothes).
Provide
neurological or vital
sign check after
seizure (level of
consciousness,
orientation, ability
to comply with
simple commands,
ability to speak;
memory of
incident; weakness
or motor deficits;
blood pressure
(BP), pulse and
respiratory rate).
Explore and
expound seizure
warning signs (if
appropriate) and
usual seizure

Documents
postictal state and
time or
completeness of
recovery to normal
state. May identify
additional safety
concerns to be
addressed.

Enables patient to
protect self from
injury and
recognize changes
that require
notification of
physician and
further
intervention.
Knowing what to do
when seizure
occurs can prevent
injury or
complications and
decreases SOs

pattern. Teach SO
to determine and
familiarize warning
signs and how to
care for patient
during and after
seizure attack.

feelings of
helplessness.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Objective Cues:
-Seizure episodes
-respiratory rate of
35-28 cycles per
minute

Ineffective Airway
Clearance as
evidenced by
previous episodes
of seizure

Short term goal:

To maintain patent
airway within 8
hour shift
Long term goal:
After a day, the
patients father will
verbalize
understanding the
need of
supplemental
oxygen and airway
clearance if needed

Independent
Nursing
Intervention:
Ensure patient to
empty mouth of
dentures or foreign
objects if aura
occurs and to avoid
chewing gum and
sucking lozenges if
seizures occur
without warning.
Maintain in lying
position, flat
surface; turn head
to side during
seizure activity.
Loosen clothing
from neck or chest
and abdominal
areas.
Provide and insert
plastic airway or
soft roll as
indicated and only
if jaw is relaxed.

Helps in drainage
of secretions;
prevents tongue
from obstructing
airway.

Helps in drainage
of secretions;
prevents tongue
from obstructing
airway.
Aids in breathing or
chest expansion.
If inserted before
jaw is tightened,
these devices may
prevent biting of
tongue and
facilitate suctioning
or respiratory
support if required.
Airway adjunct may
be indicated after
cessation of seizure

Short term goal:

Goal met, after 8
hour of shift the
patient maintained
patent airway
Long term goal:
Goal Met, significant
other understood
health teaching

activity if patient is
unconscious and
unable to maintain
safe position of
tongue.
Suction as needed.

Supervise
supplemental
oxygen or bag
ventilation as
needed postictally

Reduces risk of
aspiration or
asphyxiation. Note:
Risk of aspiration is
low unless
individual has
eaten within the
last 40 min.
May lessen cerebral
hypoxia resulting
from decreased
circulation or
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 or out of
lungs during

Get ready for or

assist with
intubation, if
indicated.

sustained
contraction of
respiratory
musculature. As
seizure abates,
respiratory function
will return unless a
secondary problem
exists (foreign body
or aspiration).
Presence of
prolonged apnea
postictally may
need ventilatory
support.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Objective Cues:
-Flushed and warm
to touch

Hyperthermia as
evidenced by
temperature of
38.3C

Short term goal:

After 4 hours of
nursing
interventions, the
patients
temperature will
decrease from
38.3C to normal
range of 36.5C to
37C.
Long term goal:
After 2 days of
nursing
interventions, the
patient will be able
to be free of
complications and
maintain core
temperature within
normal range.

Independent
Nursing
Intervention:
Assess underlying
condition and body
temperature.

To obtain baseline
data

To note for progress

and evaluate
effects of
hyperthermia

To note for progress

and evaluate
effects of
hyperthermia

Remove
unnecessary
clothing that could
only aggravate
heat

To provide proper
ventilation and
promote release of
heat through
evaporation

Promote adequate
rest periods
Provide TSB
Advise to increase
fluid intake
Administer IV fluids
at prescribed rate.
Monitor regulation
rate frequently.
Administer
antipyretics as

Reduces metabolic
demands or oxygen
To promote surface
cooling
To help decrease
body temperature
To promote fluid
management

Antipyretics lower
core temperature

Short term goal:

Goal met, patients
temperature is 37.0C
Long term goal:
The patient shall
have been able to be
free of complications
and maintain core
temperature within
normal range

ordered