John Moore, a 22-year-old patient weighing in at 150 pounds, arrived at the emergency department (ED) after being thrown from his horse and passing out for a few minutes; later he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. His respirations were very shallow, and his lips and nail beds turned blue. The patient lost control of his bladder and bowel. The patient bit his tongue and was bleeding from his mouth. The radiology department called and was now ready for the patient. Required:
a. List the correct order of actions that should be taken by the nurse.
b. Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure, and the specific nursing care for each stage.

Explanation:

A) List in the correct order the actions that should be taken by the nurse.

Answer

Before and during a seizure, the patient is assessed and the following items are documented:

The circumstances before the seizure

The occurrence of aura

The first thing the patient does in the seizure – where movements or stiffness begins, conjugate gaze position, position of head

The type of movements in the part of the body involved

The areas of the body involved

The size of the pupils and whether the eyes are open

Whether the eyes or the head are turned to one side

The presence or absence of automatisms

Incontinence of urine or stool

Unconsciousness and its duration

Any obvious paralysis or weakness of arms or legs after the seizure

Inability to speak after the seizure

Movements at the end of the seizure

Whether or not the patient sleeps or not afterwards

Cognitive status after the seizure

In addition to providing data about the seizure, nursing care is directed at preventing injury and supporting the patient not only physically but also psychologically. Consequences such as anxiety, embarrassment, fatigue, and depression can be devastating to the patient.

After the patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure to prevent complications.

2) Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure and the specific nursing care for each stage.

Answer

The patient had a tonic-clonic (gran mal) seizure. There are three phases namely the aura, the tonic and the clonic phase.

In the aura phase is the forewarning of an epileptic attack. It characterized by episodes of Déjà vu or Jamais vu. The client may also have auditory, olfactory, or even visual hallucinations, abnormal tastes, and tingling sensations. Physical symptoms include dizziness, headache, lightheadedness, nausea, numbness. Though in this case, the client did not show signs of the aura phase.

●Provide privacy and protect the patient from curious onlookers

Patients who have an aura may have time to seek a safe, private place

Ease the patient to the floor, if possible

Loosen constrictive clothing

Push aside any furniture that may injure the patient during a seizure

If an aura precedes the seizure, insert an oral airway to reduce the possibility of the patient’s biting the tongue

The next is the tonic phase. It is usually the shortest part of the seizure, lasting not more than only a few seconds. In this case, it is when the patient had an epileptic cry, became unconscious and stiffened his entire body.

●Protect the head with a pad to prevent injury from striking a hard surface

If the patient is in bed, remove pillows and raise side rails

The last is the clonic phase. It is when the client had violent muscle contractions, very shallow respirations, the lips and nail beds became blue, lost control of bladder and bowel and bit his tongue.

●Do not attempt to pry open jaws that are clenched in a spasm or to insert anything. Broken teeth and injury to the lips and tongue may result from such an action.

No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can cause injury

If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use if necessary to clear secretions.

what are the choices?

the answer is a