24 Questions
What is the nurse's role after a patient has a seizure?
Document the events leading to and occurring during and after the seizure, and prevent complications
What should the nurse do to prevent complications after a seizure?
Place the patient in the sidelying position and facilitate drainage of oral secretions
What should the nurse do if the patient becomes agitated after a seizure?
Stay a distance away, but close enough to prevent injury until the patient is fully aware
What should the nurse do to protect the patient during a seizure?
Ease the patient to the floor and protect the head with a pad to prevent injury
What should the nurse do if the patient is in bed during a seizure?
Remove pillows and raise side rails
What should the nurse do if the patient experiences incontinence of urine or stool during a seizure?
Document the occurrence
What is the purpose of placing the bed in a low position with side rails up and padded after a seizure?
To prevent injury to the patient
What should the nurse do if the patient is drowsy and wishes to sleep after a seizure?
Allow the patient to sleep
What is the nurse's role in preventing injury after a seizure?
Maintain seizure precautions, including having available functioning suction equipment with a suction catheter
What should the nurse do if the patient is confused or wandering after a seizure?
Gently guide the patient to a bed or chair
What is the nurse's role in providing nursing care during a seizure?
Provide privacy and protect the patient from curious onlookers
What should the nurse do if the patient has an aura before a seizure?
Allow the patient time to seek a safe, private place
What is a major responsibility of a nurse during a seizure?
Observing and recording the sequence of signs
What indicates the type of treatment required for a seizure?
The nature of the seizure
What should be documented before and during a seizure?
Circumstances before the seizure
What kind of sensation is an aura?
A premonitory or warning sensation
What information can the first action of a patient during a seizure provide?
The location of the seizure origin in the brain
Why is it important to record the beginning of the seizure?
To state whether the beginning of the seizure was observed
Which of the following is NOT typically documented before a seizure?
Patient's blood pressure
What type of stimuli might be documented as circumstances before a seizure?
All of the above
What does the conjugate gaze position during a seizure indicate?
The location of the seizure origin in the brain
What kind of disturbances are documented before a seizure?
Emotional or psychological disturbances
What is the purpose of assessing the patient before and during a seizure?
To document the sequence of signs for treatment determination
What is an important consideration when recording the onset of a seizure?
Whether the beginning of the seizure was observed
Study Notes
Assessing and Documenting Seizures
- A nurse's primary responsibility is to observe and record the sequence of signs during a seizure, which indicates the type of treatment required.
Pre-Seizure Assessment and Documentation
- The nurse assesses the patient before and during a seizure, documenting the following:
- Circumstances leading up to the seizure, including: • Visual, auditory, or olfactory stimuli • Tactile stimuli • Emotional or psychological disturbances • Sleep • Hyperventilation
- Occurrence of an aura (premonitory or warning sensation), which can be: • Visual • Auditory • Olfactory
Documenting Seizure Onset
- The nurse documents the first thing the patient does during the seizure, including:
- Where the movements or stiffness begin
- Conjugate gaze position
- The position of the head at the beginning of the seizure
- This information provides clues to the location of the seizure origin in the brain.
- It is essential to state whether the beginning of the seizure was observed in the documentation.
Test your knowledge of nursing management during a seizure with this quiz. Learn about the crucial responsibilities of a nurse in observing, recording, and assessing the patient before and during a seizure, as well as the types of treatment required.
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