Nursing Interventions Seizure

Nursing Interventions Seizure

Seizures are a medical condition that can be caused by an abnormal burst of electrical activity in the brain. The abnormal electrical activity causes a variety of symptoms, including changes in behavior and sensation, uncontrolled muscle movements (convulsions), and loss of consciousness. The type, location and severity of seizure will determine how you manage the patient during this event. Nursing interventions for patients experiencing seizures may include:

Facilitate patient safety by ensuring that no hazardous items are in reach.

As a nurse, you should make sure that no hazardous items are in reach. You should also ensure that the patient is never left alone. When you leave the room, even briefly, make sure someone else comes in and stays with your patient.

Never leave your patient unattended for any reason! If you have to go to another room or take a break from your shift, notify someone else who will stay with them until you return.

Place patient on padded surface to minimize trauma from seizures.

Place the patient on a padded surface to minimize trauma.

  • Place the patient on a firm surface that is not slippery, warm, cold, or soft.

Do not restrain the seizure activity.

  • Do not restrain the seizure activity.
  • Do not restrain the patient.
  • Do not restrain the patient’s arms or legs.
  • Do not restrain the patient’s head.
  • Do not restrain the patient’s body, unless there is potential for harm to self or others (e.g., hitting something).
  • Do not restrain the feet or hands if they will be used to hit someone or something during a seizure, such as a wall or doorframe, but keep them out of harm’s way by moving them away from sharp objects on nearby surfaces like tables and countertops in case they fall off while seizing (if this happens).

Ensure an airway is clear and a breathing apparatus is available, such as an oral airway or bag-valve mask ventilation device.

Ensure an airway is clear and a breathing apparatus is available, such as an oral airway or bag-valve mask ventilation device.

Ensure oxygen is available.

Record vital signs every 15 minutes for at least 1 hour after the seizure subsides, then every 30 minutes for 2 hours, then hourly until discharge from the ED. Document any other interventions taken, including administration of medication and intravenous fluids.

Do not force anything into oral cavity unless instructed to do so by a physician.

Do not force anything into oral cavity unless instructed to do so by a physician.

Do not use a tongue depressor or spoon, piece of paper, pencil, pen, or stick.

Assist with administering oxygen per the physician’s orders.

Provide oxygen per the physician’s orders.

Assess the patient’s oxygenation status and administer oxygen if necessary. If oxygen is not available, place the patient in a position of comfort and keep him or her warm. The nurse may need to assist with suctioning if it is indicated by the physician’s orders, until a respiratory therapist arrives at your facility or until you are able to reach another nurse who can perform this task.

After a seizure has stopped, turn patient onto his side to prevent aspiration of secretions.

As soon as the seizure stops, turn the patient on his side to prevent aspiration of secretions. More than one-half of patients who have had seizures will have some degree of confusion afterward and may not be able to follow commands. Turn onto the side that doesn’t have an IV or catheter to ensure that they do not get dislodged during this time. If there is a tongue-tie, make sure it’s released before turning him onto his side.

Monitor vital signs as ordered and document findings and interventions.

Monitor vital signs as ordered and document findings and interventions.

  • Vital signs should be monitored for at least 30 minutes after the seizure has stopped.
  • Vital signs should be monitored for at least 24 hours after the seizure has stopped.
  • Vital signs should be monitored for at least 48 hours after the seizure has stopped.

Your nursing interventions may make all the difference in the outcome of a seizure.

Nursing interventions during a seizure are important for the patient’s safety, as well as to prevent injury. Here are some of the interventions you could employ:

  • Ensure safe environment by turning off sharp objects and removing items that may be a hazard to the patient.
  • Prevent injury by keeping people away from the patient during the seizure. Close the door to protect privacy and ensure safety if there is no nurse present at this time.
  • Prevent aspiration by leaning forward and supporting the head with one hand, while using your other hand to clear saliva that may dribble from your mouth or onto clothing during an episode of coughing spasms associated with seizures—this can happen even though you do not feel pain or discomfort during a seizure. If possible, keep a towel handy so that you may wipe away excess saliva before it dries on clothing or skin surfaces; otherwise lean forward until most of it has drained into a bowl placed underneath your chin if possible (especially if bedridden).

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