Employing Seizure Precautions and Seizure Management

Goal: The patient remains free from injury related to seizure disorder.

1. Review the medical record and nursing plan of care for conditions that would place the patient at risk for seizures. Review the medical orders and the nursing plan of care for orders for seizure precautions.

Seizure Precautions:

2. Gather the necessary supplies and bring to the bedside stand or overbed table.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient.

6. Place the bed in the lowest position with two to three side rails elevated. Apply padding to side rails.

7. Attach oxygen apparatus to oxygen access in the wall at the head of the bed. Place nasal cannula or mask equipment in a location where it is easily reached if needed.

8. Attach suction apparatus to vacuum access in the wall at the head of the bed. Place suction catheter, oral airway, and resuscitation bag in a location where they are easily reached if needed.

9. Remove PPE, if used. Perform hand hygiene.

Seizure Management:

10. For patients with known seizures, be alert for the occurrence of an aura, if known. If the patient reports experiencing an aura, have the patient lie down.

11. Once a seizure begins, close curtains around bed and close the door to the room, if possible.

12. If the patient is seated, ease the patient to the floor.

13. Remove patient’s eyeglasses. Loosen any constricting clothing. Place something flat and soft, such as a folded blanket, under the head. Push aside furniture or other objects in area.

14. If the patient is in bed, remove the pillow and raise side rails.

15. Do not restrain patient. Guide movements, if necessary. Do not try to insert anything in the patient’s mouth or open jaws.

16. If possible, place patient on the side with the head flexed forward, head of bed elevated 30 degrees. Begin administration of oxygen, based on facility policy. Clear airway using suction, as appropriate. (Refer to Skill 14-9, Suctioning the nasopharyngeal and oropharyngeal airways, Chapter 14, Oxygenation.)

17. Provide supervision throughout the seizure.

18. Establish/maintain intravenous access, as necessary. Administer medications, as appropriate, based on medical order and facility policy.

19. After the seizure, place the patient in a side-lying position. Clear airway using suction, as appropriate.

20. Monitor vital signs, oxygen saturation, and capillary glucose as appropriate.

21. Allow the patient to sleep after the seizure. On awakening, orient and reassure the patient.

22. Remove PPE, if used. Perform hand hygiene.