Nursing Care Plan for Seizure | Risk for Ineffective Airway Clearance |

This care plan is designed for patients suffering from seizure disorder with a nursing diagnosis of risk for ineffective airway clearance related to neuromuscular impairment; tracheobronchial obstruction; and perceptual/cognitive impairment.

Desired Outcome: Maintain effective respiratory pattern with airway patent/aspiration prevented.

Nursing intervention with rationale:
1. Encourage patient to empty mouth of dentures/foreign objects if aura occurs and to avoid chewing gum/sucking lozenges if seizures occur without warning.
Rationale: Reduces risk of aspiration/foreign bodies lodging in pharynx.

2. Place in lying position, flat surface; turn head to side during seizure activity.
Rationale: Promotes drainage of secretions; prevents tongue from obstructing airway.

3. Loosen clothing from neck/chest and abdominal areas.
Rationale: Facilitates breathing/chest expansion.

4. Insert plastic airway or soft roll as indicated and only if jaw is relaxed.
Rationale: If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning/respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue.

5. Suction as needed.
Rationale: Reduces risk of aspiration/asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min.

6. Administer supplemental oxygen/bag ventilation as needed postictally.
Rationale: May reduce cerebral hypoxia resulting from decreased circulation/oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in/out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists (e.g., foreign body/aspiration).

7. Prepare for/assist with intubation, if indicated.
Rationale: Presence of prolonged apnea postictally may require ventilatory support.


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