A seizure is a burst of abnormal electrical activity in the brain that can cause jerking, staring, or loss of consciousness. During a seizure, your priorities are keeping the client safe and protecting the airway. Between seizures, focus on precautions, antiseizure medications, and teaching.
Each care plan below follows the nursing process (ADPIE).
Risk for Injury
- Uncontrolled muscle movements during a seizure
- Loss of consciousness
- Missed or low levels of antiseizure medication
- Triggers such as sleep loss, fever, alcohol, or flashing lights
- Client stays free of injury during any seizure activity this shift
- Seizure precautions are in place within 1 hour of admission
- Client and family describe how to keep the client safe during a seizure at home
- Client takes antiseizure medication every day as prescribed
- Seizure history, type, triggers, and warning signs (aura)
- Level of consciousness and neuro checks
- Antiseizure drug levels as ordered
- Environment for hazards
| INTERVENTION | RATIONALE |
|---|---|
| Keep the bed low and locked with side rails padded per policy | This lowers the risk of falls and injury from hitting hard surfaces. |
| Keep suction and oxygen set up and working at the bedside | The client may need the airway cleared and oxygen right after a seizure. |
| During a seizure, turn the client to the side, loosen tight clothing, and never put anything in the mouth | Side-lying lets secretions drain, and objects in the mouth can break teeth or block the airway. |
| Stay with the client and time the seizure | Duration guides treatment. A seizure lasting 5 minutes or longer, or back-to-back seizures, needs emergency treatment. |
| Give antiseizure medications on time and as ordered | Steady blood levels help prevent breakthrough seizures. |
EVALUATION
- Client remains free of injury
- Precautions are in place and equipment is working
- Client and family demonstrate side-lying positioning and timing a seizure
Risk for Ineffective Airway Clearance
- Tongue falling back or relaxed throat muscles during a seizure
- Increased oral secretions
- Decreased level of consciousness after a seizure
- Client keeps a clear airway during and after each seizure
- SpO2 stays at or above the ordered goal after a seizure
- Client has no aspiration pneumonia during the hospital stay
- Respiratory rate, pattern, and SpO2 during and after a seizure
- Breath sounds
- Color of lips and skin
- Level of alertness in the postictal phase
| INTERVENTION | RATIONALE |
|---|---|
| Turn the client onto the side during and after the seizure | Gravity drains saliva and vomit away from the airway. |
| Suction the mouth as needed after the seizure | Removing secretions lowers the risk of aspiration. |
| Give oxygen as ordered | Seizures increase oxygen demand and may briefly stop effective breathing. |
| Keep the client NPO until fully awake and able to swallow safely | Drowsiness after a seizure raises the risk of choking. |
EVALUATION
- Airway stays open and breath sounds are clear
- SpO2 meets the goal
- No signs of aspiration are present
Practice this in Priority Care
Decide which client needs you first when a seizure starts on your unit.
Play Priority CareQuick answers
What is the nurse's first action when a client starts having a tonic-clonic seizure?
Protect the client from injury and protect the airway. Turn the client to the side, move hard objects away, and time the seizure. Do not restrain the client or put anything in the mouth.
What is status epilepticus?
A seizure lasting 5 minutes or longer, or repeated seizures without the client waking up in between. It is a medical emergency, and a fast-acting benzodiazepine is usually given first as ordered.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.