Skill 17-2

Employing Seizure Precautions and Seizure Management

Seizures occur when the electrical system of the brain malfunctions. Sudden uncontrolled electrical disturbance in the brain from abnormal and excessive discharge from cerebral neurons results in episodes of abnormal motor, sensory, autonomic, or psychic activity or a combination of these (Hickey & Strayer, 2020; Mayo Foundation for Medical Education and Research [MFMER], 2021b). A seizure manifests as an alteration in sensation (vision, hearing, taste), behavior, movement, perception, mood, cognitive abilities, or consciousness that may be barely noticeable to abnormal, involuntary contractions and rapid shaking (convulsion) with loss of consciousness (Centers for Disease Control and Prevention [CDC], 2020a; Hinkle et al., 2022; World Health Organization [WHO], 2017).

During a seizure, patients are at risk for hypoxia, vomiting, and pulmonary aspiration. Patients who are at risk for seizures and those who have had a seizure(s) are often placed under seizure precautions to minimize the risk of physical injury. Most seizures last from 30 seconds to 2 minutes; a seizure that lasts longer than 5 minutes is a medical emergency (MFMER, 2021b). Causes of seizures include cerebrovascular disease, hypoxemia, head injury, hypertension, central nervous system infections, metabolic and toxic conditions, brain tumor, drug and alcohol withdrawal, allergies, coronavirus infection, and a history of epilepsy (seizure disorder) (Hinkle et al., 2022; MFMER, 2021b). Seizure management includes interventions by the nurse to prevent aspiration, protect the patient from injury, provide care after the seizure, and observe and document the details of the event (Hickey & Strayer, 2020; Hinkle et al., 2022). Figure 1 illustrates nursing measures to protect the patient from injury.

Delegation Considerations

The implementation of seizure precautions may be delegated to assistive personnel (AP). The implementation of seizure management may not be delegated to AP. Implementation of seizure precautions as well as seizure management may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

PPE, as indicated
Portable or wall suction unit with tubing
A commercially prepared suction kit with an appropriate size catheter or:
- Sterile suction catheter with Y-port of the appropriate size (adult: 10 to 16 Fr)
- Sterile disposable container
- Sterile gloves
Oral airway
Bed rail padding
Oxygen apparatus
Nasal cannula or mask to deliver oxygen
Handheld bag valve/resuscitation bag

Assessment

Assess for preexisting conditions that increase the patient's risk for seizure activity. For example, assess for a history of seizure disorder or epilepsy, cerebrovascular disease, hypoxemia, head injury, hypertension, central nervous system infections, metabolic conditions (e.g., renal failure, hypocalcemia, hypoglycemia), brain tumor, drug/alcohol withdrawal, and allergies. Assess circumstances before the seizure, such as visual, auditory, olfactory, or tactile stimuli; emotional or psychological disturbances; sleep or hyperventilation. Assess for the occurrence of an aura . Note where the movements or stiffness and the gaze position and position of the head when the seizure begins. Assess the body part(s) and the type of movement(s) involved in the seizure. Assess pupil sizes, whether the eyes remained open during the seizure, and whether the eyes or head turned to one side. Assess for the presence or absence of repeated involuntary motor activity (e.g., repeated swallowing); incontinence of urine or stool; duration of seizure; presence of unconsciousness and duration; obvious paralysis or weakness of arms or legs after the seizure; and inability to speak, movements, sleeping, and/or confusion after the seizure. Assess the patient's neurologic status (refer to Fundamentals Review 17-2 and Chapter 3) and for injury after the seizure is over.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Injury risk
Aspiration risk
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve when implementing seizure precautions and seizure management are that the patient remains free from injury and that the sequence of signs and symptoms is observed and recorded. Other specific outcomes will be formulated depending on the identified actual or potential health problem(s) or need(s).

Implementation

Action	Rationale
1. Review the health record and plan of care for conditions that would place the patient at risk for seizures. Review the health record and the plan of care for a prescribed intervention for seizure precautions.	Reviewing the prescribed interventions and care plan validates the correct patient and correct procedure.
Seizure Precautions
2. Gather the necessary supplies.	Preparation promotes efficient time management and an organized approach to the task.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Assemble equipment on the bedside stand, overbed table, or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
7. Place the bed in the lowest position with two to three side rails elevated. Apply padding to the side rails.	The bed in the lowest position promotes safety and decreases risk of injury. Rail padding decreases the risk of injury (Kyle & Carman, 2021).
8. Attach the oxygen apparatus to the oxygen access in the wall at the head of the bed. Place the nasal cannula or mask equipment in a location where it can be easily reached, if needed.	During a seizure, patients are at risk for hypoxia, vomiting, and pulmonary aspiration. Ready access ensures availability of oxygen in the event of a seizure.
9. Attach the suction apparatus to the vacuum access in the wall at the head of the bed. Place the suction catheter, oral airway, and resuscitation bag in a location where they are easily reached, if needed.	During a seizure, patients are at risk for hypoxia, vomiting, and pulmonary aspiration. Ready access ensures availability of suction in the event of a seizure. The oral airway and resuscitation bag ensure availability of emergency ventilation in the event of respiratory arrest.
10. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Seizure Management
11. For patients with known seizures, be alert for the occurrence of an aura, if known. If the patient reports experiencing an aura, have them lie down. If possible, provide a safe, private place, away from curious onlookers (Lawal et al., 2018).	Some patients report a warning or premonition before seizures occur; an aura can be a visual, auditory, or olfactory sensation that indicates a seizure is going to occur. Lying down prevents injury that might occur if the patient falls to the floor. Providing a private place ensures patient privacy.
12. Once a seizure begins, if in a health care facility, close the curtains around the bed and close the door to the room, if possible.	Closing the door or curtain provides for patient privacy.
13. If the patient is seated, ease them to the floor.	Getting the patient to the floor prevents injury that might occur if the patient were to fall.
14. Remove the patient's eyeglasses. Loosen any constricting clothing (Lawal et al., 2018). Place something flat and soft, such as a folded blanket, under their head. Push aside furniture or other objects in area.	Removing objects and loosening clothing prevent possible injury. The blanket prevents injury from striking a hard surface (floor).
15. If the patient is in bed, remove the pillow, place the bed in the lowest position, and raise the side rails (Lawal et al., 2018).	These precautions prevent injury.
16. Do not restrain the patient. Guide their movements, if necessary. Do not try to insert anything in the patient's mouth or open their jaws (Lawal et al., 2018).	Restraint can injure the patient. Guiding movements prevents injury. Attempting to open their mouth and/or insert anything into their mouth can result in broken teeth and injury to their mouth, lips, or tongue.
17. If possible, place the patient on their side with their head flexed forward and the head of the bed elevated 30 degrees. Begin administration of oxygen, based on facility policy. Clear the airway using suction, as appropriate (refer to Skill 14-7 in Chapter 14).	During a seizure, patients are at risk for hypoxia, vomiting, and pulmonary aspiration. This position allows the tongue to fall forward, facilitates drainage of saliva and mucus, and minimizes risk for aspiration. Oxygen supports the increased metabolism associated with neurologic and muscular hyperactivity. A patent airway is necessary to support ventilation.
18. Provide supervision throughout the seizure and time the length of the seizure.	Supervision of the patient ensures safety. Timing of the event contributes to accurate information and documentation.
19. Establish/maintain intravenous access, as necessary. Administer medications, as appropriate, based on the prescribed intervention and facility policy.	Pharmacologic therapy may be appropriate, based on patient history and health status. Intravenous access is necessary to administer emergency medications.
20. After the seizure, place the patient in a side-lying position. Clear their airway using suction, as appropriate.	The side-lying position facilitates drainage of secretions. A patent airway is necessary to support ventilation.
21. Monitor vital signs, oxygen saturation, response to medications administered, and capillary glucose, as appropriate.	Monitoring of parameters provides information for accurate assessment of patient status.
22. Place the bed in the lowest position. Make sure the call bell is in reach.	The bed in the lowest position and access to the call bell contribute to patient safety.
23. Reassess the patient's neurologic status and comfort level.	Reassessment helps to evaluate the effects of the event on the patient.
24. Allow the patient to sleep after the seizure. On awakening, orient and reassure the patient. Reassess, as indicated.	The patient will probably experience an inability to recall the seizure; patients may also experience confusion, anxiety, embarrassment, and/or fatigue after a seizure. Reassessment helps to evaluate the effects of the event on the patient.
25. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has remained free from injury, and the sequence of signs and symptoms has been observed and recorded. Other specific outcomes should be evaluated depending on the identified actual or potential health problem(s) or need(s).

Documentation

Guidelines

Document initiation of seizure precautions, including specific interventions put in place. Document if the beginning of the seizure was witnessed. If so, record noted circumstances before the seizure, such as visual, auditory, or olfactory stimuli, tactile stimuli, emotional or psychological disturbances, sleep, or hyperventilation. Note the occurrence of an aura and where the movements or stiffness, gaze position, and position of the head were when the seizure began. Record the body part(s) and the type of movement(s) involved in the seizure. Document pupil sizes; whether the eyes remained open during the seizure; whether the eyes or head turned to one side; the presence or absence of repeated involuntary motor activity (e.g., repeated swallowing); incontinence of urine or stool; duration of the seizure; the presence of unconsciousness and duration; obvious paralysis or weakness of arms or legs after seizure; and the inability to speak, movements, sleeping, and/or confusion after the seizure. Document oxygen administration, airway suction, safety measures, and medication administration, if used. If the patient was injured during the seizure, document assessment of injury. Document follow-up interventions.

Sample Documentation

1/22/25

0745 Patient bathing with assistance. Stated “I don't feel right.” Patient suddenly verbally unresponsive, stiff contractions of legs and arms, with arms extended, lasting approximately 15 seconds; 5-second period of apnea; and bladder incontinence. Continued with approximately 30 seconds of muscle contraction of extremities; eyes closed, facial grimacing. Patient then appeared to sleep; BP 102/68; P 88; R 16; oxygen saturation 94%. Patient awakened after 20 minutes, reporting headache and fatigue and returned to sleep. Dr. Mason notified of events and assessment. Seizure precautions implemented.

—D. Tyne, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You enter room and find patient in the midst of a seizure: Initiate seizure management interventions outlined above. Note in documentation that the seizure onset was not initially witnessed.

Special Considerations

General Considerations

The average seizure stops within 2 minutes without requiring medication (Burns & Delgado, 2019). First-line treatment for patients with prolonged seizures or status epilepticus (seizure lasts longer than 5 minutes or seizures occurring close together without recovery by the patient between seizures) is administration of a benzodiazepine (Burns & Delgado, 2019).

Infant and Child Considerations

Most seizures in children are caused by disorders that originate outside of the brain, such as high fever, infection, head trauma, toxins, or cardiac arrhythmias (Kyle & Carman, 2021). Febrile seizures are the most common type of seizure in children younger than age 5 years (Kavanagh et al., 2018; Millichap, 2018).
Seizures in newborns are associated with underlying conditions, such as hypoxic ischemic encephalopathy, hypoglycemia, hypocalcemia, meningitis, encephalitis, cerebral infarction, and intracranial hemorrhage (Kyle & Carman, 2021). The prognosis depends on the underlying cause and severity of the seizure (Kyle & Carman, 2021).
Children with recurrent seizures should wear a medical alert bracelet (Kyle & Carmen, 2021).
Provide education regarding prescribed medications, including administration, potential side effects, and the importance of not running out of medication (El-Radhi, 2015).
Encourage patients and their families/caregivers to keep a seizure diary (El-Radhi, 2015). The Epilepsy Foundation (2016) provides an online self-management tool and companion app for seizures and epilepsy with a focus on self-monitoring, tracking seizures and other symptoms, managing medication and other therapies, recognizing triggers, and communicating with their health care providers.
Encourage supervision during bathing, swimming, ambulation, and other potentially hazardous activities (Kyle & Carman, 2021).
Encourage regular sleep and avoidance of fatigue (El-Radhi, 2015; Kyle & Carman, 2021; Smith et al., 2015).
Emergency assistance should be obtained for multiple or prolonged (>5 minutes in duration) seizures (CDC, 2020b).
Provide information about support groups for children, parents, and families adjusting to a diagnosis of epilepsy.
Suggest that families have a seizure action/response plan and periodic “seizure drills” to practice what every family member/caregiver should do if the child has a seizure (Epilepsy Foundation, 2014b; Epilepsy Foundation, 2020; Smith et al., 2015).

Community-Based Care Considerations

Include patient and family/caregiver teaching for patients with documented seizures as well as those at risk for seizures. Teaching should include basic first aid management and the following tips (CDC, 2020b):
- Help the person to lie down.
- Remove eyeglasses and loosen constrictive clothing.
- Clear the area around the person of anything hard or sharp.
- Place something flat and soft (e.g., a folded jacket) under their head. Turn the person gently on their side, if possible.
- Do not try to force anything into the patient's mouth.
- Stay with the person during the seizure.
- Remain calm.
- Time the seizure.
- After the seizure, place the person on their side and stay with them until consciousness is regained; reorient as necessary.
Encourage patients and their families/caregivers to keep a seizure diary. The Epilepsy Foundation (2016) provides an online self-management tool and companion app for seizures and epilepsy with a focus on self-monitoring, tracking seizures and other symptoms, managing medication and other therapies, recognizing triggers, and communicating with their health care providers.
Suggest that families have a seizure action/response plan and periodic “seizure drills” to practice what every family member/caregiver should do in the event of a seizure (Epilepsy Foundation, 2014b; Epilepsy Foundation, 2020).
Teach the patient and family/caregiver guidelines about when to call 911 or otherwise seek emergency medical assistance (CDC, 2020b):
- If the seizure lasts longer than 5 minutes
- If the person has never had a seizure before
- If the person has difficulty breathing or waking after the seizure
- If the person has another seizure soon after the first; the person is hurt during the seizure; if the seizure happens in water; or if the person has another health condition such as diabetes, heart disease, or is pregnant
Patients with recurrent seizures should wear a medical alert bracelet.

EVIDENCE FOR PRACTICE

Students With Seizures and Epilepsy

Related Guideline

Lepkowski, A. M., & Maughan, E. D. (2019). School nursing evidence-based clinical practice guideline: Students with Seizures and Epilepsy. https://www.pathlms.com/nasn/courses/8992

The National Association of School Nurses' (NASN). School Nursing Evidence-Based Practice Clinical Guideline: Students with Seizures and Epilepsy provides recommendations based on the available evidence and expert consensus for provision of high-quality care of students with seizure disorders to improve the health and safety of students. The Guideline is a decision-making tool to be implemented in conjunction with the use of nursing judgment.

EVIDENCE FOR PRACTICE

Parents' Knowledge and Fears

Providing children and their parents/family/caregiver support and education are important aspects of nursing care related to seizures (Kyle & Carman, 2021). Parents of children with seizures and seizure disorders face uncertainty and need knowledge and skills to care for their children and deal with fears related to helping their child live with this health issue (Fowler et al., 2021). Assessment of parents' knowledge and concerns/fears provides important information to assist nurses in planning and providing person- and family/caregiver-centered care.

Related Research

Fowler, S. B., Hauck, M. J., Allport, S., & Dailidonis, R. (2021). Knowledge and fears of parents of children diagnosed with epilepsy. Journal of Pediatric Nursing, 60, 311-313. https://doi.org/10.1016/j.pedn.2021.08.008

The purpose of this descriptive comparative study was to describe and compare the knowledge and fears of parents of children diagnosed with epilepsy in the hospital and clinic settings. The convenience sample consisted of parents of children receiving health care at the neuro/ortho unit of a pediatric hospital or pediatric neurology clinic for children diagnosed with epilepsy. Parents completed two surveys. The Epilepsy Knowledge Scale (Chronbach alpha 0.755) was used to measure knowledge levels about epilepsy. The Epilepsy-related fears in Parents Questionnaire (EEPQ) (Chronbach alpha 0.92) were used to measure fears related to epilepsy. Forty parents completed the two surveys; 80% identified as mothers. The percentage of correct responses to the Epilepsy Knowledge Scale questions ranged from 31% to 100% (mean = 75%). Responses to the EEPQ indicated parents had many fears, including short-term and future long-term fears. Parents indicated they were afraid when their child was in the care of others, and they had fears of negative outcomes that included death if their child would have a seizure while being cared for others. There was no statistically significant difference in responses between hospital or clinic parents. The researchers concluded that participating parents had knowledge of seizures and epilepsy but were fearful with immediate and long-term concerns. The authors suggested nurses need to provide verbal and written educational materials, talk to parents about their fears related to epilepsy, and validate parents' skills in responding to a seizure.

Relevance to Nursing Practice

Nurses play a key role in providing patient and family/caregiver support. Nurses must include patient/family/caregiver education and support; allow parents to share their thoughts and feelings; and integrate collaboration with support services, such as support groups, psychologists, and/or social workers, as necessary. Nurses should speak with families about their concerns and fears in order to assist them to achieve the best outcomes possible.

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Skill 17-2

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE