Medical Surgical Nursing

o No evidence of inflammation or infection at surgical site

o Absence of seizures

o No evidence of DVT or GI bleeding

Nursing Process

The Patient with Epilepsy

Assessment
The nurse elicits information about the patient's seizure history. The patient is asked
about the factors or events that may precipitate the seizures. Alcohol intake is
documented. The nurse determines whether the patient has an aura before an epileptic
seizure, which may indicate the origin of the seizure (eg, seeing a flashing light may
indicate that the seizure originated in the occipital lobe). Observation and assessment
during and after a seizure assist in identifying the type of seizure and its management.
The effects of epilepsy on the patient's lifestyle are assessed (Stafstrom & Rho, 2004).
What limitations are imposed by the seizure disorder? Does the patient have a
recreational program? Social contacts? Is the patient working, and is it a positive or
stressful experience? What coping mechanisms are used?

Diagnosis
Nursing Diagnoses
Based on the assessment data, the patient's major nursing diagnoses may include the
following:

 Risk for injury related to seizure activity

 Fear related to the possibility of seizures

 Ineffective individual coping related to stresses imposed by epilepsy

 Deficient knowledge related to epilepsy and its control

Collaborative Problems/Potential Complications
The major potential complications for patients with epilepsy are status epilepticus and
medication side effects (toxicity).
Planning and Goals
The major goals for the patient may include prevention of injury, control of seizures,
achievement of a satisfactory psychosocial adjustment, acquisition of knowledge and
understanding about the condition, and absence of complications.

Nursing Interventions
Preventing Injury
Injury prevention for the patient with seizures is a priority. If the type of seizure the
patient is having places him or her at risk for injury, the patient should be lowered
gently to the floor (if not in bed), and any potentially harmful items nearby (eg,
furniture) should be removed. The patient should never be restrained or forced into a
position, nor should anyone attempt to insert anything into the patient's mouth once a
seizure has begun. Patients for whom seizure precautions are instituted should have
pads applied to the side rails while in bed.