Student Name: _____________________________________________
Area of Assignment: __________________________
Identified Problem: Tonic- Clonic Seizure?
Nursing Diagnosis: risk for ineffective airway clearance r/t neuromuscular impairment
CUES OBJECTIVES
N/A
The patient will be able to:
-maintain effective respiratory
pattern with airway patent
-aspiration prevented
Date of Care: _______________
Clinical Instructor: _____________________________
NURSING CARE PLAN
INTERVENTIONS
Ensure patient to empty mouth of dentures or
foreign objects if aura occurs and to avoid
chewing gum and sucking lozenges if
seizures occur without warning.
Maintain in lying position, flat surface; turn
head to side during seizure activity.
Loosen clothing from neck or chest and
abdominal areas.
Provide and insert plastic airway or soft roll
as indicated and only if jaw is relaxed.
Suction as needed.
Supervise supplemental oxygen or bag
ventilation as needed postictally.
Score: ___________
RATIONALE EVALUATION
Lessens risk of aspiration or foreign Short term:
bodies lodging in pharynx.
Helps in drainage of secretions;
prevents tongue from obstructing
airway.
Aids in breathing or chest expansion.
If inserted before jaw is tightened, these
devices may prevent biting of tongue Long term:
and facilitate suctioning or 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.
Reduces risk of aspiration or
asphyxiation. Note: Risk of aspiration is
low unless individual has eaten within
the last 40 min.
May lessen cerebral hypoxia resulting
from decreased circulation or
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
or out of lungs during sustained
contraction of respiratory musculature.
As seizure abates, respiratory function
will return unless a secondary problem
exists (foreign body or aspiration).

Presence of prolonged apnea postictally

Get ready for or assist with intubation, if may need ventilatory support.
indicated.