Nursing Management During a Seizure PDF

10/24/23, 3:36 PM Realizeit for Student Nursing Management During a Seizure A major responsibility of the nurse is to observe and record the sequence of signs. The nature of the seizure usually indicates the type of treatment required (AANN, 2016a). Before and during a seizure, the patient is asse...

10/24/23, 3:36 PM Realizeit for Student Nursing Management During a Seizure A major responsibility of the nurse is to observe and record the sequence of signs. The nature of the seizure usually indicates the type of treatment required (AANN, 2016a). Before and during a seizure, the patient is assessed and the following items are documented: Circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation) Occurrence of an aura (a premonitory or warning sensation, which can be visual, auditory, or olfactory) First thing the patient does in the seizure—where the movements or the stiffness begins, conjugate gaze position, and the position of the head at the beginning of the seizure. This information gives clues to the location of the seizure origin in the brain. (In recording, it is important to state whether the beginning of the seizure was observed.) Type of movements in the part of the body involved Areas of the body involved (turn back bedding to expose patient) Size of both pupils and whether the eyes are open Whether the eyes or head are turned to one side Presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing) Incontinence of urine or stool Duration of each phase of the seizure Unconsciousness, if present, and its duration Any obvious paralysis or weakness of arms or legs after the seizure Inability to speak after the seizure Movements at the end of the seizure Whether or not the patient sleeps afterward Cognitive status (confused or not confused) after the seizure In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient, not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient. After a Seizure After a patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure and to prevent complications (e.g., aspiration, injury). The patient is at risk for hypoxia, vomiting, and pulmonary aspiration. To prevent complications, the patient is placed in the sidelying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration (see Chart 61-5 ). Seizure precautions are maintained, including having available functioning suction equipment with a suction catheter. The bed is placed in a low position with two to three side rails up and padded, if necessary, to prevent injury to the patient. The floor may be padded as an additional safety measure. The patient may be drowsy and may wish to sleep after the seizure; they may not remember events leading up to the seizure and for a short time thereafter. Chart 61-5 https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUAYD8aTcEKqA9iFsBPwk2RFvtNozNlLKTVk0W5HMqg… 1/3 10/24/23, 3:36 PM Realizeit for Student Care of the Patient During and After a Seizure Nursing Care During a Seizure Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura may have time to seek a safe, private place.) Ease the patient to the floor, if possible. Protect the head with a pad to prevent injury (from striking a hard surface). Loosen constrictive clothing and remove eyeglasses. Push aside any furniture that may injure the patient during the seizure. If the patient is in bed, remove pillows and raise side rails. Do not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything in the mouth during a seizure. Broken teeth and injury to the lips and tongue may result from such an action. Do not attempt to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Nursing Care After the Seizure Keep the patient on one side to prevent aspiration. Make sure the airway is patent. On awakening, reorient the patient to the environment. If the patient is confused or wandering, guide the patient gently to a bed or chair. If the patient becomes agitated after a seizure (postictal), stay a distance away, but close enough to prevent injury until the patient is fully aware. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUAYD8aTcEKqA9iFsBPwk2RFvtNozNlLKTVk0W5HMqg… 2/3 10/24/23, 3:36 PM Realizeit for Student Adapted from American Association of Neuroscience Nurses (AANN). (2016a). Care of adults and children with seizures and epilepsy: AANN clinical practice guideline series. Chicago, IL: Author. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUAYD8aTcEKqA9iFsBPwk2RFvtNozNlLKTVk0W5HMqg… 3/3