Posturing

Seizure Status Epilepticus

Clinical Findings (Progression of Seizure)

Aura (before the seizure starts) A warning or recognition by the Pt that a seizure is imminent.

Ictal Phase (active seizing)

Neuro: Loss of consciousness (blank stare if petit mal seizure).

Resp: Cyanosis, inability to breath adequately, apnea.

MS: Repetitive jerking movements of upper and lower extremities.

GI/GU: Urinary or fecal incontinence.

Postictal Phase (after the seizure has subsided)

ALOC, extremely confused, frightened, and disoriented.

Emergency Management (may need MD order)

■ Establish and manage ABCs and intubate if indicated.

■ Protect the airway by placing Pt into a lateral-lying position and suctioning the airway as needed. Insert an OPA, or, if Pt has a gag reflex and there is no evidence of facial trauma, use an NPA.

■ Administer 100% oxygen via NRB mask or use BVM if indicated.

■ Obtain stat blood glucose level and manage as indicated.

■ Obtain IV access and titrate to hemodynamic status.

■ Order stat labs (electrolytes, ABG, and serum blood levels of anticonvulsant medications).

■ If seizure activity does not terminate within 4–5 minutes of first onset, administer anticonvulsant drugs (lorazepam, diazepam, and phenobarbital) given respectively after 3–5 minutes of each respective dose if the previous drug fails.

■ Document seizure description; aura, onset, type and duration of seizure, interventions, and outcome.

Patient Safety

■ Protect Pt from injury by clearing immediate area of potentially harmful objects including tables, chairs, and medical equipment.

■ Do not attempt to restrain Pt during seizure.

■ Position Pt in a lateral recumbent position (if able) to help minimize the risk of aspiration.

■ Do not insert any objects into Pt’s mouth.

■ Stay with Pt and call for assistance.

■ If Pt is in bed, raise side rails and protect from injury by placing pillows between Pt and rails. If seizures are likely to reoccur, install seizure pads on all side rails to minimize risk of injury.

■ Reorient Pt, provide reassurance, and allow Pt to sleep.

Transfusion Reaction

Clinical Findings

Neuro: Anxiety, restlessness

Resp: Shortness of breath, dyspnea, tachypnea, bronchospasm

CV: CP, tachycardia, hypotension

Skin: Urticaria, pruritus, erythema, burning at infusion site

GI/GU: Nausea and vomiting, diarrhea, hematuria, oliguria,

anuria

MS: Flank, back, or joint pain

Miscellaneous: Fever, chills, oozing at infusion site

Emergency Management (may need MD order)

■ Stop transfusion and run NS through the IV to maintain IV access. Do not use lactated Ringer’s (LR). It contains Ca and will clot blood in the tubing.

■ Establish and manage ABCs as indicated.

■ Obtain baseline VS noting temperature and LOC.

■ Notify physician and blood bank of reaction stat.

■ Recheck Pt ID and blood labels for possible errors.

■ Return unused portion of blood product to blood bank for analysis.

■ Administer prescribed medications (see specific reaction below).

■ Continue to monitor VS, temp, respiratory status, and LOC.

■ Insert urinary catheter and monitor UO.

■ Continue IV fluids to maintain minimum UO 30 mL/hr.

■ Monitor for early detection of any hemodynamic instability, which may include dysrhythmias, abnormal lab values, CHF, etc.

■ Document assessment, interventions, and outcome.

Reaction-Specific Management (may need MD order)

Anaphylactic Reaction

■ Support airway, breathing, and circulation as indicated.

■ Administer epinephrine, diphenhydramine, and corticosteroids.

■ Maintain intravascular volume.

Hemolytic Reaction

■ Implement aggressive fluid resuscitation to maximize renal cortical perfusion.

■ Furosemide may be administered to increase renal blood flow.

■ Low-dose dopamine is considered to improve renal blood flow.

■ Maintain urine output at 30–100 mL/h.

Febrile, Nonhemolytic Reaction

■ Treat fever with acetaminophen.

■ If Pt develops chills, cover with blanket unless temp is  >102 F.