Answer:
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.