What should be documented during a seizure?

Seizure precautions are an integral part of the fundamentals of nursing; learning them will help you ensure your future patient’s health and safety.

Índice Show

What You Need to Know About Seizures: Categories of Seizures
Nursing Seizure Precautions and Examples
Seizure Protocol for Nurses
Nursing Interventions for Seizure Activity
Seizure Monitoring

Remembering the nursing seizure precautions and interventions is not only important for passing your classes in nursing school and dominating the NCLEXⓇ, it’ll come in handy in your furure RN or LPN career. So, let’s cover the basics, shall we?

What You Need to Know About Seizures: Categories of Seizures

A seizure is a sudden, uncontrolled electrical disturbance in the brain resulting in changed behavior, function, and impaired consciousness. Seizures are categorized into two groups: generalized and focal.

Generalized: There are different subtypes of generalized seizures; the most common subtype is tonic-clonic seizures. Generalized seizures arise from both hemispheres of the brain. Consciousness is lost from these seizures, and they are often caused by metabolic or genetic disorders.

Focal: Focal seizures are also known as partial seizures. Partial seizures occur in one local area from one hemisphere of the brain. Consciousness is impaired during these seizures and can be lost entirely. Symptoms of focal seizures may include changes in sensory sensations and abnormal body movements.

MASTER THE 3 TYPES OF SEIZURES WITH THIS PICMONIC

Nursing Seizure Precautions and Examples

Seizure precautions are safety measures taken before a patient experiences a seizure. These precautions should be implemented every day for individuals who have epilepsy or in hospitals for those who are at risk of seizures.

In everyday life, individuals must take precautions when bathing, cooking, and even driving. As a nurse, you must educate your patient on how to take the proper precautions when they’re at home. For example, people with epilepsy can put chairs in their shower or cook on the back burner to prevent potential injury.

On the other hand, seizure precautions in the hospital setting are quite different. Precautions vary from hospital to hospital, but there are several precautions every nurse must take to minimize harm in seizure-prone patients.

At the patient’s bedside, healthcare professionals have the following:

Full resuscitation equipment
Cardiac monitoring in case of cardiac dysfunction
Bag and oxygen in case of oxygen deprivation
Padded bed frame in case of uncontrollable body movement
Bed frame positioned closer to the floor in case of fall
Suction in case of aspiration

Seizure Protocol for Nurses

A seizure protocol is followed by nurses to ensure the patient’s safety before and after the seizure. Nurses must prevent trauma or injury during the seizure, promote airway clearance, provide privacy, and enforce patient education after the seizure. Educating your patient and their family members about at-home seizure precautions, drug administration, and triggers will help your patients be healthy and safe!

During a seizure, remember to stay with the patient at all times. An unmonitored patient can get hurt, so you can yell for help if needed. Use the following nursing interventions during the seizure to help your patient.

Nursing Interventions for Seizure Activity

Turn your patient to the side to reduce the risk of choking.
Loosen clothing from the neck, chest, or abdominal areas.
If your patient is standing or sitting while experiencing a seizure, move them gently to the floor.
Move furniture to provide adequate space for the patient.
Support their head with a pillow or soft cushion to reduce the risk of head injury.
Provide supplemental oxygen if the patient is struggling to breathe.
Administer drug therapy (usually benzodiazepines) to control seizures.

For more information, read Picmonic’s helpful lesson highlighting seizure interventions.

Seizure Monitoring

Nurses should keep an eye out for warning signs such as:

Staring
Jerking movements
Confusion or haziness
Rhythmic, uncontrollable movements
Rapid eye blinking
Unresponsiveness
Breathing issues
Stiffness of the body

Nurses must monitor the seizure activity, length, events before and after, and patient status. All of this important information should be documented accurately and descriptively.

We understand this is a lot of information to digest, and you’ll need it to succeed in nursing school! To help you remember your nursing seizure precautions and interventions, use Picmonic’s visual learning system. Memorable stories and characters will help you retain the information you need to pass your course, take exams like the NCLEX, and be an amazing nurse.

CLICK HERE TO TRY PICMONIC FREE

Download our mobile app and take Picmonic on the go!

(Visited 201 times, 1 visits today)

Accurate recording of seizure descriptions by witnesses is an important part of managing a person’s epilepsy. There are no definitive diagnostic tests for epilepsy or for determining a particular seizure type. Therefore, doctors rely on accurate accounts and recording of frequency and severity of seizures, to:

make a diagnosis
guide treatment
determine potential triggers
differentiate seizure types or new seizure presentations

For more information click below to download the ‘How to best record seizures’ fact sheet.

Before you can track seizures, you need to know what to look for. Seizures can be broken down into 4 phases:

Prodrome: behaviors or feelings that occur hours to days before a seizure
Aura: the actual start of a seizure and may be thought of as a 'warning'
Ictus: the seizure event
Postictal: the recovery period after the seizure

When watching a seizure, try to note what happens in each phase of the seizure – before, during and after the event. Write down what happens as soon as you can – it’s easy to forget details when you don’t write them down. Here’s a list of things that may happen during a seizure. Remember that what you see will depend on the type of seizure that occurs.

Behavior before the seizure:

What was the person doing at the time of the event?
Was there a change in mood or behavior hours or days before?
Was there a warning or aura right before the seizure?

When the event occurs: Note date and time.

Possible triggers: Note patterns or any factors that may make event more likely to occur.

Time of day or month
For females, note the day of your menstrual cycle, if pregnant, on any birth control or other hormonal treatment
Missed or late medicines, changes in medicine doses
Not sleeping regularly, not enough sleep, other sleep problems
Not eating regularly, bothered by specific foods
During or after exercise, note the kind of exercise such as jogging
During or after fast breathing
Alcohol or other drug use
Emotional stress, worry, excitement
Sounds, flashing lights or patterns, bright sunlight
Other illnesses or infections
When taking other medicines, over-the-counter products, or supplements

What happens during the event: Note changes in the following...

Awareness, alertness, confusion
Ability to talk and understand – clear speech, responds with only a few words or noises, speech doesn’t make sense, unable to talk
Thinking, remembering, emotions, perceptions
Seeing, hearing, tasting, smelling, feeling - May have different or unusual sensations, or may sense something that is not really there
Facial expression – staring, twitching, eye blinking or rolling, drooling
Muscle tone – body becomes stiff or limp
Movements - jerking or twitching movements, unable to move, body or head turning to one side, falls
Automatic or repeated movements – lipsmacking, chewing, swallowing, picking at clothes, rubbing hands, tapping feet, dressing or undressing
Walking, wandering, running
Color of skin, sweating, breathing
Loss of bladder or bowel control

Part of body involved: Note where the symptoms started, whether it stayed in that area or spread to other parts of the body, and which side of the body was involved (right, left, or both).

What happens after the event (postictal or recovery period): Is the person...

Able to respond to voice or touch
Aware of their own name, observer’s name, place, time
Able to remember what happened
Able to talk or communicate
Weak or numb in any part of the body
Having a change in mood or behavior
Tired or need to sleep
Other symptoms – for example headache, upset stomach, pain

How long it lasted:

Length of aura or warning
Length of seizure – from beginning to end, but not counting the recovery period
Length of recovery or postictal period - how long before the person returns to normal activity

For more information: