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Minggu, 19 Januari 2014

Epilepsy - 3 Nursing Diagnosis and Interventions

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Epilepsy - 3 Nursing Diagnosis and Interventions

Epilepsy is a symptom or manifestation of excessive loss of electrical charge in neuronal cells of the central nervous which can cause loss of awareness, involuntary movements, abnormal sensory phenomena, the increase in autonomic activity and a variety of physical disorders (Doenges, 2000).

Signs and symptoms of Epilepsy

1. Generalized seizures
  • Tonic: muscle contraction, leg and elbow lasts approximately 20 seconds, with marked neck and back arched, screams epilepsy for about 60 seconds.
  • Clonic seizures: intermittent flexion spasm, relaxation, hypertension lasted approximately 40 seconds, with a marked mydriasis, tachycardia, hyperhidrosis, hypersalivation.
  • Post-attack: halt muscle activity is characterized by the patient regained consciousness, muscle aches and headaches, sufferers fall asleep 1 to 2 hours.
2. Partial seizures
  • There are simple with no disturbance of consciousness
  • Complex with disorders of consciousness.

Epilepsy - 3 Nursing Diagnosis and Interventions

Nursing Diagnosis I : Risk for Injury 

related to a change of consciousness, weakness, loss of large and small muscle coordination.

1). Assess the originator of the emergence of seizures in patients.
The goal: a controlled seizure.
Rational: alcohol, various medications, and other stimulation (lack of sleep, bright lights, watching television too long), can enhance brain activity which further increases the risk of seizures.

2). Maintain a soft cushion on the bed barrier attached with a low bed position.
Rationale: reducing trauma during seizures.

3). Supervise activities of clients after the seizure occurred.
Rationale: improving patient safety.

4). Record the patient's type of seizure activity such as location, duration, motor, loss of consciousness, incontinence.
Rationale: helps to localize the brain regions affected.


Nursing Diagnosis II : Low Self - Esteem, self-identity is not related to perception of control,
characterized by : fear, and less cooperative medical treatment.

1). Assess the patient's feelings regarding diagnostic, self-perception of the treatment performed on the patient.
Rational : the reaction is between the individual and knowledge is the beginning of the acceptance of the client's medical treatment.

2). Identify and anticipate possible reactions of others to the disease state.
Rationale : provide an opportunity to respond to the problem-solving process and provide control over the situation.

3). Assess the patient's response to the success obtained, or who will be achieved from its strengths.
Rational : focus on the positive aspects can help to eliminate the feelings of failure or awareness of self and patients receiving treatment.

4). Discuss referral to psychotherapy with patients or people nearby.
Rationale : seizures has a profound influence on a person's self esteem and the patient, significant others, probably due to the emergence of stigma from society.


Nursing Diagnosis III : Knowledge Deficit (learning needs), and rules regarding the treatment of conditions related to lack of understanding, misinterpretation of information, lack of recall.

1). Assess the patient's level of knowledge of the type of illness
Rational : to know the extent of the client's ability to understand the type of illness will be more cooperative client understanding the importance of prevention, treatment and so on.

2). Explain again about the pathophysiology or disease prognosis, treatment, and management in the long run according to the procedure.
Rationale : provide an opportunity to clarify misperceptions and the state of the illness.

3). Review the medication, dosage, instructions, and discontinuation of medication as instructed doctors.
Rational : will add to the understanding of the client's health condition suffered.

4). Discuss the benefits of good general health, such as adequate diet, adequate rest, and exercise and moderate exercise regularly, and avoid foods adan beverages containing harmful substances.

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