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5BenignFebrileConvulsionsNursingCarePlansNurseslabs

5 Benign Febrile Convulsions Nursing


Care Plans
Jan 25, 2012

Thefirstfebrileseizureisoneoflifesmostfrighteningmomentsforparents.Mostparents
areafraidthattheirchildwilldieorhavebraindamage.Thankfully,simplefebrileseizures
areharmless.Thereisnoevidencethatsimplefebrileseizurescausedeath,braindamage,
mentalretardation,adecreaseinIQ,orlearningdifficulties.(www.nlm.com)However,a
verysmallpercentageofchildrengoontodevelopotherseizuredisorderssuchasepilepsy
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laterinlife.

Definition

Afebrileseizureisaconvulsioninachildtriggeredbyafever.Suchconvulsionsoccur
withoutanyunderlyingbrainorspinalcordinfectionorotherneurologicalcause.According
tostudies,about35%ofotherwisehealthychildrenbetweentheagesof9monthsand5
yearswillhaveaseizurecausedbyafever.Toddlersaremostcommonlyaffected.Most
occurwellwithinthefirst24hoursofanillness,notnecessarilywhenthefeverishighest.

Nursing Care Plans

Contents[show]

Hyperthermia
BenignFebrileConvulsionisaconvulsiontriggeredbyariseinbodytemperature.Feveris
notanillnessandisanimportantpartofthebodysdefenseagainstinfection.Antigensor
microorganismscauseinflammationandthereleaseofpyrogenswhichisasubstancethat
inducesfever.

Assessment
Subjective:Objective:

Planning

Nursing
Interventions

Rationale

Expected
Outcome

Short

Short

term:After4

term:The

hoursof

patients

nursing

temperature

interventions,

shallhave

thepatients

decreased

temperature

from39Cto

warmtotouch

willdecrease

normalrange

Convulsion

from39Cto

of36.5Cto

RR=34bpm

normalrange

37C.

thepatientmanifested:
febriletemp=
39C
flushedskinand

of36.5Cto
thepatientmay

37C.

LongTerm:

LongTerm:

Thepatient

manifest:
highfever
weakness

shallhave
After2days

beenableto

ofnursing

befreeof

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interventions,

1.Assess

1.Toobtain

complications

thepatient

underlying

baselinedate.

andmaintain

willbeable

condition

2.Tonotefor

core

tobefreeof

andbody

progressand

temperature

complications

temperature.

evaluate

within

andmaintain

2.Monitor

effectsof

normal

core

andrecorded

hyperthermia.

range.

temperature

vitalsigns.

3.To

withinnormal

3.Remove

decreaseor

range.

unnecessary

totally

clothingthat

diminishpain.

couldonly

4.Reduces

aggravate

metabolic

heat.

demandsor

4.Promote

oxygen.

adequate

5.Topromote

restperiods.

surface

5.Provide

cooling.

TSB

6.Tohelp

6.Adviseto

decreasebody

increasefluid

temperature.

intake.

7.Toprovide

7.Loosen

proper

clothing.

ventilation

8.

andpromote

Administer

releaseof

IVfluidsat

heatthrough

prescribed

evaporation.

rate.Monitor

8.Topromote

regulation

fluid

rate

management.

frequently.

9.

9.

Antipyretics

Administer

lowercore

antipyretics

temperature.

asordered.

Imbalanced Nutrition
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Thenutritionalrequirementsofthehumanbodyreflectthenutritionalintakenecessaryto
maintainoptimalbodyfunctionandtomeetthebodysdailyenergyneeds.Malnutrition
(literally,badnutrition)isdefinedasinadequatenutrition,andwhilemostpeople
interpretthisasundernutrition,fallingshortofdailynutritionalrequirements.Theetiology
ofmalnutritionincludesfactorssuchaspoorfoodavailabilityandpreparation,recurrent
infections,andlackofnutritionaleducation.
NDx:ImbalancedNutrition:Lessthanthebodyrequirementrelatedtoeconomicalfactors.

Assessment
Subjective:Objective:

Planning
Short
term:After4

thepatientmanifested:

hoursof
nursing

bodyweakness

interventions,

weightof7.9kg

thepatients

lossofappetite

willidentify

poormuscletone

measuresto
promote

thepatientmay

nutritionand

manifest:

followthe
treatment

abnormallaboratory

regimen

studies
pallor

LongTerm:
After2days
ofnursing
interventions,
thewill
demonstrate
behavioursor
lifestyle
changesto
regain

Nursing
Interventions

Rationale

1.Review

1.Toobtain

patients

baselinedata.

records.

2.To

2.Assess

determine

underlying

specific

condition.

interventions.

3.Discuss

3.Toachieve

eatinghabits

healthneeds

andencourage

ofthepatient

dietforage.

withthe

4.Notetotal

properfood

dailyintake

dietforhis

includes

disease.

patternsand

4.Toreveal

timeofeating.

changethat

5.Consult

shouldbe

physicianfor

madeinthe

further

clients

assessmentand

dietaryintake.

recommendation

5.Forgreater

regardingfood

understanding

preferencesand

andfurther

nutritional

assessmentof

support.

specificfood.

Expected

Outcome
Short
term:The
patientshal
have
identified

measuresto
promote
nutritionan
followthe
treatment
regimen.

LongTerm
Thepatient
shallhave

demonstrate

behaviourso
lifestyle
changesto
regain
appropriate
weight.

appropriate
weight.

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Ineffective Tissue Perfusion


Thecirculationtothetissuesisnotgettingenoughoxygenornourishment.Decreasein
oxygenresultinginthefailuretonourishthetissuesatthecapillarylevel.
NDx:IneffectivetissueperfusionrelatedtodecreasedHgbconcentrationinbloodas
evidencedbylowHgbcountinCBCresult

Assessment
Subjective:Objective:

Planning
Short
term:After4

Thepatientmanifested:

hoursof
nursing

Bodytemperature
changes.
Skindiscoloration

intervention,
thepatient
will
demonstrate

Thepatientmay

behaviour

manifest:

lifestyle
changesto

Anemia

improve
circulation.

Longterm:
After2days
ofnursing
intervention,
thepatients
S.O.will
verbalize
understanding
ofthe
condition.

Nursing
Interventions
1.Establish
rapport.
2.Monitor
VS.
3.Determine
factors
relatedto
individual
situation.
4.Evaluate
forsignsof
infection
especially
when
immune
systemis
compromised.
5.Discuss

Rationale

Expected
Outcome
Short
term:The
patientshall
have
demonstrated
behaviour
lifestyle
change.
Longterm:
Thepatients
S.O.shall
have
verbalized
understanding
ofthe
condition.

individualrisk
factors.
6.Elevate
headofbed
atnight.
7.Discussthe
importanceof
ahealthy
diet..

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1.Togain
patientand
S.O.strust
and
promote
cooperation.
2.To
monitor
patients
status.
3.Togain
information
regarding
the
condition.
4.To
observefor
possiblerisk
factors.
5.This
information
wouldbe
necessary
forthe
clientsS.O.
6.To
increase
gravitational
bloodflow.
7.To
promotea
healthydiet
tohelp
increase
RBC
synthesis
andHgb
countfor
faster
recovery.
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Risk for Infection


Theimmunesystemisthebodysdefenseagainstbacteria,viruses,andotherforeign
organismsorharmfulchemicals.Itisverycomplexandithastoworkproperlytoprotect
usfromtheharmfulbacteriaandotherorganismsintheenvironmentwhichmayinfectour
body.Iftheimmunesystemiscompromised,itcanaffectthenormalproductionofWBC
fromthebonemarrow.IfthereisanincreaseinnumberofWBC,thereforeitmayincrease
thepossibilitytoincreaseinfection.

Assessment
S=O

Planning

Nursing
Interventions

Rationale

Expected
Outcome

Short

Short

Term:After3

Term:After3

thepatient

hoursof

hoursof

manifested:

nursing

nursing

interventions,

interventions,

thepatientwill

thepatient

verbalize

shallhave

fatigue

understanding

verbalized

poor

ofwaysonhow

understanding

toprevent

ofwaysonhow

spreadof

toprevent

infection.

spreadof

body
weakness

muscletone
Thepatient
maymanifest:

infection.
LongTerm:

elevated

LongTerm:

body

After1weekof

temperature

nursing

After1weekof

Hgb=112

interventions,

nursing

WBC=

thepatientwill

interventions,

befreefrom

thepatient

infectionsand

shallhavebeen

further

freefrom

complications

infectionsand

22.9
RBC=
3.97
HCT=
0.34
Platelet

further
complications.

count=234

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1.Establish

1.Togain

goodworking

theirtrust

relationship

and

withthe

cooperation

clientand

2.For

S.O.

comparative

2.Monitor

baselinedata

andrecord

3.Toknow

vitalsigns

whento

3.Determine

assistclient

pts

4.To

individual

promote

strength

optimum

4.Provide

levelof

peaceful

functioning

environment

5.To

5.Provide

prevent

adequaterest

fatigueand

andsleep.

conserve

6.Emphasize

energy

importanceof

6..to

handwashing

prevent

7.Provide

occurrenceof

safety

further

measures

infections

8.MonitorI

7.To

&O

preventfalls

9.CheckIV

andinjuries

andRegulate

8.Tonote

IVF

for

10.Advicept

imbalances

toincrease

9.Toensure

oralfluid

proper

intakewhen

hydration

allowed

10.To
replacefluid
electrolyte
loss

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Risk for Injury


Aseizureorconvulsionisthevisiblesignofaproblemintheelectricalsystemthatcontrols
yourbrain.Asingleseizurecanhavemanycauses,suchasahighfeverandlackofoxygen.
Hemoglobinisaproteininredbloodcellsthatcarriesoxygen.Therefore,Lowlevelsof
hemoglobininthehumanbodymayresulttoseizure.Duringepisodesofconvulsion,
patientsarepronetoinjuriessincetheymaystrikedifferentobjectsduetouncontrollable
musclespasms.
NDx:Riskforinjuryrelatedtopossibleconvulsion

Assessment

Planning

NursingInterventions

Rationale

Short
term:After4
hoursof

Short

nursing

term:

interventions,

shallh

theSOwill

modifie

modify
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Subjective:Objective:
thepatientmaymanifest
thefollowing:
Fever
Convulsion
Low
LowHgbLevel=
112

environment

1.Establishrapport

1.Togain

environ

asindicated

2.Monitorandrecord

patients

asindi

toenhance

VitalSigns

trust

toenha

safety.

3.Ascertain

2.Toobtain

safety.

knowledgeofsafety

baselinedata

needs/injury

3.toprevent

prevention

injuriesin

After2days

4.Noteclients

home,

TheSO

ofnursing

gender,age,

community,

have

interventions,

developmentalstage,

andwork

verbali

theSOwill

decisionmaking

setting

unders

verbalize

ability,levelof

4.affects

ofindiv

understanding

cognition/competence

clientsability

factors

ofindividual

5.Providehealthcare

toprotect

contrib

factorsthat

withinacultureof

self/others

possibi

contributeto

safety

andinfluence

injury.

possibilityof

6.Identify

choiceof

injury.

interventions/safety

interventions/

devices

teachings

7.Discuss

5.toprevent

importanceofself

errors

monitoringof

resultingin

conditions/emotions

clientinjury,

Longterm:

Longt

promote
clientsafety
andmodel
safety
behaviorsfor
client/SO
6.topromote
safephysical
environment
and
individual
safety
7.itcan
contributeto
occurrenceof
injury

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