Nursing Assessment for Epilepsy - ABCDE

Nursing Assessment for Epilepsy - ABCDE

Airway
In the ictal phase, the client usually found clenched his teeth so that obstruct the airway, the client bite the tongue, mouth foaming, and the postictal phase, usually found injury to the tongue and gums due to the bite.

Breathing
In the ictal phase, the client breathing down / speed, increased mucus secretion, and skin was pale even cyanosis. In phase posiktal, clients have apnea.

Circulation
In the ictal phase pulse and cyanosis increase, the client usually unconscious.

Disability
Clients can be realized or not depends on the type of attacks or characteristics of epilepsy suffered. Usually the patient was confused, and do not remember the incident when the seizures.

Exposure
Client's clothing was opened to thoracic examination, whether there are additional injuries due to seizures.

Nursing Diagnosis for Epilepsy

Nursing Diagnosis and Interventions Risk for Injury - Seizures