Wee 5: Nursing Management of Seizures Flashcards Preview

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Flashcards in Wee 5: Nursing Management of Seizures Deck (14):
1

With seizure activity, staff should notify the nurse immediately if?

The individual continues to seize for more than two consecutive minutes or the individual experiences two or more generalized seizures without full recovery of consciousness between seizures

2

When a seizure occurs, observe and document?

a. Date, time of onset, duration
b. Activity at the time of onset
c. Level of consciousness (confused, dazed, excited, unconscious)
d. Presence of aura (if known)
e. Movements
1. Body part involved:
-progression an sequencing of activity
-symmetry of activity
-unilateral or bilateral
2. Type of motor activity:
-clonic (jerking)
-myoclonic (single jerk of muscle or limb)
-tonic (stiffening)
-abnormal posturing movements
-dystonia
-eyes: eye deviation, open, rolling or closed, eyelids flickering
-head turning
-twitching
f. Respirations (impaired/absent;rhythm and rate)
g. Heart (rate and rhythm)
h. Skin changes
-color/temp
-pale/cyanotic (also check lips, earlobes, nailbeds)
-cool/warm
-perspirations/clammy
i. Gastrointestinal
-belching, flatulence, vomiting
j. Pupillary size, symmetry, and reaction to light
k. Changes in sensory awareness (auditory, gustatory, olfactory, vertiginous, visual)
l. presence of other unusual and/or inappropriate behaviors

3

Ventilation when a seizure occurs

a. Loosen clothing, postural support devices and/or restrains
b. Do not try to force an airway or tongue blade through clenched teeth
c. Turn the person into a side-lying position as soon as convulsing has stopped

4

After a seizure, record the presence of what conditions and their duration in the individuals record? Continue to assess until the person returns to baseline.

a. Gag reflex
b. Headache (character, duration, location, severity)
c. Incontinence (bladder/bowel)
d. Injury (bruises, burns, fractures, lacerations, mouth trauma)
e. Residual deficit (behavior change, confusion, language disturbance, poor coordination, weakness/paralysis of body part(s), sleep pattern disturbance

5

With seizures the individual may experience amnesia. ? once the individual ? helps regain a sense of control and help reduce anxiety.

Reorientation once the individual awakens helps regain a sense of control and help reduce anxiety

6

What does the post seizure evaluation consist of?

1.What was the person doing prior to the seizure?
2.Was this the first seizure?
3. Review current meds including recent changes in medicine and/or dose
4. Other illnesses?
5. Possible precipitating factors

7

Type of Seizure?
-No loss of consciousness
-May involve motor, sensory and/or autonomic symptoms

Focal seizure

8

Type of Seizure?
-May be preceded by an aura
-At onset there will be a consciousness change
-ends with a post-ictal period

Psychomotor, temporal lobe seizure

9

Type of Seizure?
-Sudden loss of body tone or body movement

Atonic or Akinetic Seizure

10

Type of Seizure?
-Sudden onset and cessation or loss of responsiveness
-no post ictal symptoms

Petit Mal Seizure

11

Type of Seizure?
-Pre-ictal symptoms may involve focal seizure
-Loss of consciousness at onset of seizure with increased muscle tone (rigid flexed and rigid extended postures)
-Bilateral rhythmic jerks follow and become further apart
-Post-ictal period follows

Grand Mal or Tonic-Clonic seizure

12

Type of Seizure?
-Generalized tonic-clonic seizure lasting longer than 30 minutes or failure of patient to regain consciousness between a series of seizures

Status Epilepticus

13

Medication management of seizures

-Always provide oxygenation
-Medications are administered if seizure does not end in 5-10 minutes
-Initial drug of choice is benzodiazepine Lorazapam, IVP 2-4 mg over 1 minute. Dose may be repeated again after 5-10 minutes if the seizure has not stopped.
-Phenytoin (Dilantin): 10-20 mg/kg loading does with max (max dose 1.5 gm). Can take 15-20, usually administered concominantly with benzo. DO NOT give with dextrose. Flush with NS before and after. IVP no faster than 25-50 mg a minute.

14

If seizures goes on for more than 20-30 minutes, then?

The pt. is:
-intubated
-foley catheter
-EEG
-monitor temp