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NANDA for Status epilepticus, but no seizures

Posted

Hi guys,

I really need help.

So I had pediatric patient, 4y/o female, new onset seizure 7months ago, have had no seizure for the past 6 months, had general tonic-clonic seizure, rushed to the ED and treated in the ED, admitted for status epilepticus, but since admission and during my day of care, the patient had no seizures at all. The patient had no other problems either, until now they still don't know the cause of the seizures. All labs, imaging were fine. Basically the pt was otherwise healthy. Actually the pt ended up being ordered for discharge because she was fine. What NANDAs can I include for my care plans? I have no idea where to even start. Prevent infection?? (Pt has no history of febrile seizure). Parent education on medication adherence? (what nanda would this be?).

I am so lost :(

Thank you in advance for your help

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

I am confused...did you care for the patient seven months ago and are just now doing a care plan? OR Was the patient admitted for testing?

What semester are you? What was your patient assessment? Why was the patient admitted?

Care plans are all about the patient assessment...don't forget to look at how hospitalization affects children and families.

Thank you Esme12. Pt hasnt had seizure for 6 months, suddenly had a seizure episode while sleepig, brought to the ED, had several seizures in the ED, treated, and then admitted to the neuro floor, the next day I cared for the pt, she had no seizures at all, even the night before she had no seizure. Pt assessment-- nothing was abnormal physiologically, so I'm confused with what to do with physiologic nanda.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

are you the OP?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

The biggest issue for this patient would be at risk for seizures and teaching the parents what to watch for and what to do when the child seizures if everything else is normal. Here is what might apply

1. Risk for Injury

related to:

uncontrolled seizure activity (balance disorder).

2. Ineffective airway clearance (during seizure)

related to: blockage of the tongue, endotracheal, increased secretion of saliva

3. Social isolation (parents depending on the age of the child)

related to: low-self against the the diagnosis, and the bad stigma against epilepsy in the community.

4. Ineffective breathing pattern (during seizure)

related to: dyspnea and apnea

5. Activity intolerance (maybe...not likely)

related to: decreased cardiac output, tachycardia

6. Impaired sensory perception (possible with aura however on children difficult to assess) related to: disturbances in nerve sensory organs of perception

7. Anxiety (parents)

related to: lack of knowledge about the disease process

8. Risk for Ineffective cerebral Tissue Perfusion

related to: decreased O2 to the brain.

Risk for impaired Attachment

Caregiver Role Strain

Compromised family Coping

Edited by Esme12
clarification

NurseGirl525, ASN, RN

Specializes in ICU.

I would say your biggest one is going to be risk for injury. You need to educate the parents on safety measures to be put in place in the home. Especially if the pt is having nocturnal seizures. What safety issues could happen if the pt has another nocturnal seizure? Parents need to be educated on how to handle a seizure so that the child is safe if she has another one. Making sure the airway is clear and such.

are you the OP?

Yes. And thank you for the nanda suggestions.

Can I still use these nandas even if the pt didn't have any seizure the whole shift?

Ineffective airway clearance

Ineffective breathing pattern

Risk for Ineffective cerebral Tissue Perfusion

Maybe write it as "Risk for.. Ineffective airway clearance, Ineffective breathing pattern"??

Thank You

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

probably not....and yes it would be an at risk for if they let you do that....some programs do some don't. It would be ineffective airway clearance with seizure activity and the parents need to know what ot do.

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

Yes. And thank you for the nanda suggestions.

Can I still use these nandas even if the pt didn't have any seizure the whole shift?

Ineffective airway clearance

Ineffective breathing pattern

Risk for Ineffective cerebral Tissue Perfusion

Maybe write it as "Risk for.. Ineffective airway clearance, Ineffective breathing pattern"??

Thank You

It doesn't sound like your patient had ineffective airway clearance, ineffective breathing or ineffective cerebral tissue perfusion.

I think you need to brush up on your knowledge of epilepsy. The vast majority of people (70%) never know the cause of their seizures. And seizures are not constant in people with epilepsy so it's not abnormal at all that she wouldn't have seized during your shift. She probably got LOADED with meds when she came in in status.

What meds is she on at home? What were her levels in the ED? Did the parents administer Diastat or another rescue med when she went into status at home? Did they make any changes? Do the parents understand her meds and seizure first aid?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

It doesn't sound like your patient had ineffective airway clearance, ineffective breathing or ineffective cerebral tissue perfusion.

I think you need to brush up on your knowledge of epilepsy. The vast majority of people (70%) never know the cause of their seizures. And seizures are not constant in people with epilepsy so it's not abnormal at all that she wouldn't have seized during your shift. She probably got LOADED with meds when she came in in status.

What meds is she on at home? What were her levels in the ED? Did the parents administer Diastat or another rescue med when she went into status at home? Did they make any changes? Do the parents understand her meds and seizure first aid?

You know I hope they add risk of airway to the new NANDA coming out in Oct.

Surprised1, MSN, RN

Specializes in pediatric neurology and neurosurgery. Has 9 years experience.

If she had new onset seizures, you could possibly use knowledge deficit as a NANDA dx, for the parents, related to disease management, AEDs, rescue meds, and so on. All seizure pts are fall risk and injury risks, but for your care plan I'm sure your instructor wants more than just "risk for" nursing diagnoses.