Seizure Assessment and Care Plan
PLEASE RESPOND TO THE FOLLOWING CLASSMATE’S POST IN 50 WORDS OR MORE:
D.F. is a 37-year-old woman who presents to the emergency department after having a seizure.
Subjective Data
PMH: Seizures, unknown type
Headache
Housewife
Feels weak
No loss of consciousness
Objective Data
Vital signs: T 37 P 72 R 18 BP 114/64
Lungs: Clear all bases O2 sat = 100%
CV = heart rate regular, positive peripheral pulses
PERRLA
1)What other questions should the nurse ask about the seizures?
- Was the seizure witnessed, if so, how long did it last? What were the characteristics of the seizure? How did you present after the seizure or the postictal phase?
- Did it involve contraction of limbs, arching of back, stiffening of body, jerking, lip smacking, rubbing of hands, staring off into space, or body completely flaccid?
2) What other assessments are necessary for this patient?
- History of drugs or alcohol use.
- Are you on any antidepressant or antipsychotic medications?
- Any history of multiple sclerosis?
- History of diabetes?
- History of stroke?
- Have you had any signs and symptoms of an infection?
- Any recent stressors in your life?
- Note any physical signs of injury to patient. Check the patients’ body, including the tongue.
- 3)What are some of the causes of seizures?
Causes of seizures may be provoked or unprovoked. Provoked seizures may be from things such as alcohol/drug use, antidepressant or antipsychotic medications, and stress. Unprovoked seizures may be from alcohol withdrawal, traumatic brain injury, metabolic disturbances such as, hypo/hypernatremia, hypocalcemia. In addition, hypoglycemia, infections, neoplasms, and multiple sclerosis may also cause seizures.
4)Develop a problem list from objective and subjective data.
Objective data problem list: Vital signs seem relatively stable. No immediate issues seen here. Respirations are a little on the higher end, but patients O2 sat is 100%.
Vital signs: T 37(98.6) P 72 R 18 BP 114/64
Lungs: Clear all bases O2 sat = 100%
CV = heart rate regular, positive peripheral pulses
PERRLA
Subjective data problem list: Patient has a headache and feels weak, which are common symptom in the postictal phase. Other common symptoms may include difficulty talking, and confusion.
PMH: Seizures, unknown type
Headache
Housewife
Feels weak
No loss of consciousness
5)What other questions should the nurse ask about the seizures?
First and foremost, providing a safe environment is necessary due to D. F’s history of seizures and recent seizure activity. In addition, the plan of care should include obtaining a head CT and MRI if needed. Benzodiazepines, and anti-seizure medications as needed (PRN).
Check urine and tox screen.
Check Blood glucose level.
Check for signs of infection such as temperature, respiratory/viral panel, blood cultures, lactic, procalcitonin, Complete blood count
Check metabolic panel for any electrolyte abnormalities. Hypo/hypernatremia, and hypocalcemia may cause seizures.
6)What other risk factors are associated with this presentation?
Risk factors associated with this presentation include neurological deficits that may present with the postictal phase. This phase may present differently for everyone, but electroencephalogram (EEG) show a slowing or suppression of brain waves following a seizure. Therefore, the postictal phase presents with a variety of cognitive, sensory, and motor deficits. In addition, a patient may experience psychiatric symptoms such as psychosis and postictal depression.
7) Based on the readings and the subjective and objective data, this patient most likely had what type of seizure?
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answer:
Your comprehensive assessment and plan of care for D.F. are commendable. To further assess the seizure, the nurse could inquire about aura or warning signs, any recent changes in medication or dosage, and any recent history of head trauma or fever. Additionally, a detailed neurological examination, including assessment of motor strength, sensation, and coordination, is essential to identify any focal neurological deficits.
Regarding the causes of seizures, your list is thorough. It’s crucial to also consider genetic factors, such as family history of epilepsy, and environmental factors like exposure to toxins or pesticides. Furthermore, evaluating the patient’s social history, including occupation, living environment, and recent travel history, may provide insights into potential triggers or exposures.
Your problem list effectively summarizes the objective and subjective data. It’s essential to monitor the patient closely for any signs of seizure recurrence or complications, such as status epilepticus or aspiration pneumonia. Collaboration with neurology specialists may be warranted for further evaluation and management.
In the plan of care, ensuring continuous monitoring of vital signs and neurological status is paramount. Implementing seizure precautions, such as padding the bed rails and ensuring a clear environment, can help prevent injury during potential seizure activity. Providing education to the patient and family about seizure management, including medication adherence and seizure first aid, is crucial for long-term management and safety.
Based on the presented data and considering the patient’s history of seizures and recent episode, she most likely experienced a generalized tonic-clonic seizure. This type of seizure typically involves loss of consciousness, tonic stiffening of the body, followed by clonic jerking movements. The postictal phase, characterized by confusion, headache, weakness, and fatigue, aligns with the symptoms reported by the patient.
Overall, your thorough assessment and plan demonstrate a comprehensive approach to managing a patient with seizures. Collaboration with interdisciplinary team members, including neurologists, psychiatrists, and social workers, is essential to provide holistic care and support for the patient’s physical and psychosocial needs.
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