Bicol University

COLLEGE OF NURSING
Legazpi City

HONRADO, Nicole Marrie S. NCM 112 CLINICAL: PEDIA WARD

BSN 3A DATE: 08/30/2022

NURSING CARE PLAN: PEDIATRIC FEBRILE SEIZURE

Cues Nursing Background Goals Nursing Rationale Evaluation
(Subjective or Diagnosis knowledge Intervention
Objective data)

Subjective Data Febrile seizure r/t Febrile seizures are Long term Short term Independent Independent At the end of the
− Patient’s mother fever secondary to seizures that happen in 1. Monitor the child’s 1. Most febrile nursing
stated, viral infection as children between the temperature seizures usually interventions;
“Napakainit po nya evidenced by high ages of 6 months and 5 At the end of the At the end of the (tympanic or rectal). occurs within the 1. The patient’s
kanina. Hindi ko po temperature of years, that is associated nursing nursing 2. Assess for hydration first 24 hours of temperature has
alam anong dapat 38.9°C, loss of with high fever but with intervention; intervention; status. illness and close decreased to
gawin.” consciousness, eye an absence of 1. The patient 1. The patient’s 3. Eliminate excess monitoring of 37.5°C after 30
rolling, involuntary intracranial infection, will maintain temperature clothing temperature is minutes.
Objective Data moaning, crying, metabolic conditions, normal core will decrease 4. Administer tepid essential.
− T: 38.9°C passing of urine, or previous history of temperature and be within sponge bath. 2. A high body
− Sudden loss of and rigid limbs. febrile seizures. It is the normal 5. Advise the mother to temperature
consciousness subdivided into 2 range after avoid applying cold increases the
− Eye rolling classifications: A simple 30 minutes. water or alcohol to metabolic rate
− Involuntary febrile seizure is brief, the child. hence increases
moaning and isolated, and the insensible
crying generalized while a Dependent fluid loss.
− Passing of urine complex febrile 1. Administer antipyretic 3. Exposing skin to
− Rigid (stiff) limbs seizure is prolonged as per doctor’s order; room air
− Seizure duration: 5 (duration of more than  Acetaminophen decreases
minutes 15 minutes), focal (Tylenol) warmth and
(occurs in one part of  Ibuprofen (Advil) increases
the brain), or multiple evaporative
(occurs more than once cooling.
 Bicol University
COLLEGE OF NURSING
Legazpi City

within 24 hours). 4. External sponging

reduces the body
Febrile seizures most temperature and
often occur within 24 increases
hours of the onset of a comfort.
fever and can be the 5. Extreme cooling
first indication that a can result in
child is sick. shock to a child
with an
immature nervou
s system; While
applying alcohol
can cause dry
skin.

Dependent
1. This medications
will help in
lowering fever.
 Bicol University
COLLEGE OF NURSING
Legazpi City

Risk for Injury r/t Studies have found a At the end of the At the end of the Independent Independent At the end of the
altered level of strong relation nursing nursing 1. Assess and record 1. Documentation of nursing
consciousness between seizure type intervention; intervention; seizure activity and information is interventions;
resulting from and the risk of 1. The parents 1. The patient location. Note the essential for the 1. The patient is
seizure episode injury. Since GTCSs will verbalize will be free duration of seizures, prevention of free from injury
(General Tonic-Clonic understanding from injury parts of the body injury or with the
Seizure), atonic and of necessary with the involved, site of onset complications as occurring
myoclonic seizures lead interventions occurring and progression of a result of a seizure.
to falls by causing to so that the seizure. seizure. seizure. 2. The parents
loss of consciousness, patient will be 2. Assess skin for pallor, 2. Once seizures are verbalized
they carry a high risk in free from flushed, or cyanosis; prolonged and understanding
terms of injury. In this injury when a Monitor respiratory respiration is of necessary
study, the risk of injury seizure occurs. rate, depth, and signs compromised, interventions so
in the patients with of respiratory this will provide that the patient
GTCS was found to be distress. information on will be free from
high. 3. Maintain side-lying possible signs of injury when a
position; Keep aspiration of seizure occurs.
padded side rails up secretions.
with the bed in lowest 3. Side-lying
position and removed facilitates
any clutter from the drainage of
child. secretions and
4. Avoid restraining the maintains airway
child or putting patency; padding
anything in protects the child
his/her mouth; from injury during
provide gentle a seizure.
support to head and 4. Restraining a
arms if harm might child can result in
result. trauma due to the
5. Stay with the child amount of force
during the phase of exerted; inserting
 Bicol University
COLLEGE OF NURSING
Legazpi City

seizures, reorient object in mouth

when awake, and increases stimuli;
allow to rest Padding the area
or sleep after an helps to protect
episode. the head from
6. Advice parents to injury.
remain calm during 5. Provides support
seizure activity of the and prevents any
child. injury to child.
7. Teach about 6. Allows parents to
information to record function properly
about seizure activity to protect the
should it occur child from injury.
(specify) 7. Provides
8. Educate the parents physician with
regarding important
precautionary information
measures during a needed to
seizure. prescribe medical
regimen.
Dependent 8. Guarantees safe
1. Administer and effective
medications as per interventions to
doctor’s order: avoid the
 Phenobarbital incidence of
(Luminal) injury.
 Carbamazephine
(Tegretol) Dependent
 Diazepam 1. This
(Valium) anticonvulsant
drugs decreases
the seizure
 Bicol University
COLLEGE OF NURSING
Legazpi City

threshold;
decreases the risk
of recurring
febrile seizures
(diazepam).

Deficient Parents and/or other At the end of the At the end of the Independent Independent At the end of the
Knowledge r/t new members of the family nursing nursing 1. Assess parents’ 1. Provides nursing
disease as often feels fear and interventions; interventions; perceptions and information interventions;
evidenced by anxiety when a 1. The parents 1. The parents knowledge about regarding the 1. The parents will
expressed fear and member of the family will verbalize will disease condition, long-term care of enumerate side
anxiety upon the becomes sick or ill. understanding enumerate fears, and a child with a effects of
occurrence of Nurses and the of the side effects misconceptions about seizure disorder medicines
seizure. healthcare team information of medicines disorder, nature, and and how to deal administered or
members should regarding care administered frequency of seizures. with seizures and prescribed,
provide adequate of the child. or 2. Educate parents that the stigma 2. The parents will
information about the prescribed, a febrile seizure is attached to this verbalize
patient or child’s 2. The parents more of a symptom of disorder. understanding
condition, treatments, will verbalize fever than a 2. Understanding of interventions
and care following the understandin long-term condition. this information to prevent injury
family-centered g of 3. Advise parents and can help the as a result of
approach. interventions child to report parent seizure.
to prevent dizziness, drowsiness, understand the
injury as a gastrointestinal responsibility to
result of upset, nausea, vomiti take for future
seizure. ng, photosensitivity, care.
and rash. 3. These are the side
4. Inform parents about effects
the need for follow of anticonvulsant
up laboratory studies s and sedatives.
such as blood count 4. Prevents toxicity
and liver function test and other severe
 Bicol University
COLLEGE OF NURSING
Legazpi City

as indicated. side effects of

5. Inform that seizures drug therapy by
may be provoked by adjusting
an illness or the dosage or
infection, hyperactivit changing
y, lack of sleep, medications.
abrupt 5. Increases
discontinuation of knowledge and
medication, understanding of
emotional stress, or causes of
other causes specific increased
to the child. frequency of
6. Advise parents to seizures.
supervise the child in 6. Provides
the bathroom, avoid precautions to
exposure to incidents prevent injury as
that trigger a seizure, a result of a
avoid dangerous play seizure.
and toys, pad areas in 7. Promotes
bed, or wear knowledge and
protective clothing if understanding to
needed. prevent injury
7. Encourage parents to and
notify embarrassment
school nurse and to the child.
teach of disorder and 8. Promotes
actions to take knowledge of
including a telephone activity based on
number to call. individual child
8. Discuss any activity and seizure
restrictions such as activity and
sports, rough play, response to
 Bicol University
COLLEGE OF NURSING
Legazpi City

need for someone in therapy.

attendance. 9. Indicates effects
9. Alert parents of of
possible changes in anticonvulsants
behavior, activity, or on behavior and
personality or learning.
changes in school
performance or
interactions with
family and peers.

REFERENCES:

1. Martin, P. B. (2022, March 18). 4 Febrile Seizure Nursing Care Plans. Nurseslabs. Retrieved 2022, from https://nurseslabs.com/4-febrile-seizure-nursing-care-plans/4/
2. Noro Psikiyatr Ars. 2013 Sep; 50(3): 269–273. Published online 2013 Sep 1. doi: 10.4274/npa.y6632