Seizure

Seizure

Clinical Findings

Neuro: Loss of consciousness (blank stare if petit mal seizure). Resp: Inability to breathe adequately, apnea. Skin: Cyanosis, cool and moist, or warm and flushed. MS: Repetitive jerking movements of upper and lower extremities, blinking, deviation of eyes and/or tongue. GI/GU: Urinary or fecal incontinence.

Progression of a Seizure

■ Aura (before the seizure starts): An auditory or sensory warning or recognition by Pt that seizure is imminent. ■ Ictal Phase (active seizing):Tonic posturing or clonic jerking. ■ Postictal Phase (after the seizure has subsided): ALOC, extreme confusion, fatigue, fear, and disorientation.

Nursing Interventions

■ Protect Pt from injury by clearing immediate area of potential hazards (e.g., tables, chairs) and call for help. ■ If Pt is in bed, raise side rails and protect from injury by placing pillows between Pt and rails and call for help. ■ If Pt is out of bed, assist Pt to floor and call for help. ■ If Pt is found on the floor, anticipate possible head and spinal injury, and take cervical spine precautions, but do not attempt to restrain Pt forcefully during seizure. ■ Assess Pt’s airway and effectiveness of respiratory effort. ■ Position Pt (if able) in lateral recumbent position to help minimize risk of aspiration, and suction oropharynx to clear secretions if Pt’s airway becomes compromised. ■ Administer supplemental oxygen (if able) and be prepared to ventilate Pt manually using BVM if needed. ■ Stay with Pt, and do not insert any objects into Pt’s mouth. ■ Administer STAT anticonvulsant medication as ordered. ■ Assess ABCs and LOC once seizure has subsided. ■ Obtain STAT bedside blood glucose level. ■ If seizures are likely to recur, install seizure pads on all side rails to minimize risk of injury. ■ Reorient Pt, provide reassurance, and allow Pt to sleep. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including labs (serum blood levels of anticonvulsant medication, blood glucose level, and electrolytes), pharmacologic therapy (anticonvulsants), or transfer to ICU. ■ Document assessments, type of seizure and duration, any interventions implemented, and outcome.