Groundwork
The main aim of the nurse is to protect the patient from causing themselves harm or injury, whilst aiming to maintain patient's privacy and dignity.
The environment surrounding the patient needs to be made safe by clearing the area, and if patient is in danger they may need to be moved.
Procedure
In a patient taking a seizure, the first phase is normally associated with rigidity of the limbs and absence of breaths, and may only last for a short period. Another phase called the clonic phase usually consists of limb jerking, normally the jerking of the limbs is unilateral and, initially close together and decreasing in frequency. This phase is usually followed by a period of deep sleep and the patient can become difficult to rouse and their body limp.
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Protect the patient from injury, but do not restrain patient's movements.
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Use pillow to protect patient from injury, and remove furniture to remove risk of injury.
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Observe the patient during the seizure and note:
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Duration of each phase and recover time.
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Limbs involved.
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Whether movements are generalised or localised.
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Whether the patients jaw is clenched (do not insert anything into the patients mouth).
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Whether the patient is frothing at the mouth.
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Has the patient been incontinent of urine and/or faeces.
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What is the patients breathing pattern.
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During the period of deep sleep following the clonic phase, the patient should be placed in the recovery position and allowed to recover in their own time.
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It is now safe to suction the patient's mouth to remove food, and remove denture if necessary.
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If another seizure occurs in rapid succession then urgent medical intervention is required.
Post Procedure
Reassure patient and explain the seizure event and ask if the patient had any warning sign (aura) that a seizure was about to occur. Ensure patient is comfortable and offer the chance for the patient to wash, change clothing, etc. The nurse should document the event fully and report the instance to the medical staff if there is no previous knowledge of seizure activity.
References
Bavin, C., Bedford-Turner, S., Cronin, P., Nicol, M. and Rawlings-Anderson, K. (2002) Essential Nursing Skills. Edinburgh: Mosby.
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