Clinical Findings
Neuro: LOC (blank stare if petit mal seizure).
Resp: Inability to breathe adequately, apnea.
Skin:Cyanosis, coolness and moisture, or warmth and flushing.
MS: Repetitive jerking movements of upper and lower extremities, blinking, deviation of eyes and/or tongue.
GI/GU: Urinary or fecal incontinence.
Seizure Progression
- Aura (before 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 seizure has subsided): AMS, extreme confusion, fatigue, fear, and disorientation.
Create a Safe Environment-Before a Seizure
- Maintain bed in lowest position with side rails raised at all times.
- Install seizure pads to side rails, headboard, and footboard-bath blankets can be used if commercial pads are not available.
- Ensure suction and basic airways (oral or nasal) are readily available at the bedside and in working order.
- Instruct family and visitors on use of call bell.
- Transfer or admit Pt to a room closest to nurse's station.
- Establish an IV in Pts with a known seizure history and whose seizures are known to be frequent or prolonged.
Protect the Pt-During a Seizure
- If Pt is in bed: Lower head of bed and raise side rails. Place pillows or blankets between Pt and rails if seizure pads have not already been installed, and call for help.
- If Pt is out of bed: Assist Pt to floor, protect from injury by placing pillow or something soft under Pt's head, clear area of hard or sharp objects (e.g.,furniture), and call for help.
- Position Pt on his or her side to facilitate drainage of secretions, and prevent Pt's tongue from obstructing airway.
- Do not attempt to restrain Pt during seizure.
- Do not insert anything into Pt's mouth or attempt to hold open the airway or jaw. An oral airway may be inserted for prolonged seizure or signs of hypoxia (e.g., cyanosis), but do not force airway into place-consider a nasal airway.
Recovery-After the Seizure
- Keep Pts on their side until able to protect their own airway.
- Suction oropharynx to clear secretions as needed.
- Examine for injuries-change bedding and clothing if soiled.
- Stay with Pt and withhold food or drink until fully alert.
- Reorient and reassure Pt-allow Pt to sleep if tired.
- Assess mental status and VS every 15 min.
- Monitor labs (seizure medication levels, blood sugar, etc.).
- Document type of seizure and duration.
Subtopic(s)