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Seizure Precaution
Implementation and
Management Policy and
Procedure
Chandra Brower, BSN, RN
Mary Larson, DNP, APRN, FNP‐C
Learning Objectives
Self-report a greater
understanding of
evidence-based practice
as a result of this
learning activity
To educate and share
information with nurses
and other healthcare
providers focused on
evidence-based
practice.
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Seizure Types
•Produced by electrical impulses from both
hemispheres of the brain
Generalized
•Produced (at least initially) by electrical impulses
in a relatively small part on one side of the brain
Focal
Main variants of generalized seizures
Tonic-clonic (Grand Mal)
Absence
Myoclonic
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Myoclonic Seizure
Sporadic jerks
Usually on both sides of the body
May result in dropping or involuntarily throwing objects
People may have myoclonus that is not due to seizure
activity-myoclonic simply describes the movement
Focal Onset
Seizure
2 Types of Focal Onset Seizures
Focal Aware
Focal Impaired Awareness
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Focal Aware Seizure
Patients retain awareness
Jerking, muscle rigidity, spasms, head-
turning
Unusual sensations affecting either the
vision, hearing, smell, taste, or touch
Memory or emotional disturbances
Focal Impaired Awareness
Patient loses awareness
Patients seem to be "out of touch," "out of it," or "staring
into space“
Automatisms consist of involuntary but coordinated
movements that tend to be purposeless and repetitive
Automatisms such as lip smacking, chewing, fidgeting,
walking and other repetitive, involuntary but
coordinated movements
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Tonic Seizure
Stiffening of
the muscles
Short
duration
Usually occur
during sleep
Atonic Seizures
Sudden and general loss of muscle
tone, particularly in the arms and
legs, which often results in a fall
Falls may result in head injuries
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- Both focal and generalized seizures can lead to a
condition known as status epilepticus.
- Two or more epileptic seizures following one
another without recovery between them.
- May be convulsive: seizure activity is noticeable.
- May be non‐convulsive: seizure activity is not
noticeable.
Status Epilepticus
Patient Care During & Post Seizure
- Make sure the camera is not obstructed. Turn on the lights. Speak loudly and perform your assessment clearly and accurately.
- Part of the EEG includes a video monitor
- Monitor is not just important to “see” the seizure
- see our nursing assessment of the patient during and following the seizure
- Not to “spy” on our staff at all
- BEST PRACTICE to care for our patients
- The VOA (video observation assistant) camera is not the same as the EEG camera
- Stay out of the way of the EEG camera during event
- LPNs & RNs: STAY WITH your patient and complete the assessments as noted below.
- The RN will need to be aware of what is going on (obviously)
- the LPN is able to complete these assessments
- Nursing assistants: STAY WITH the patient while you phone your RN or LPN
- The video camera in the room records both the seizure event AND nursing staff’s response and assessment to the seizure.
- Important to the physicians reading the EEG to interpret the EEG recording
- Determine the patient’s neurologic state following the seizure
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Why was this a problem?
No standardized seizure
precaution procedure or
management policy existed
at the St. Cloud Hospital.
Even though seizure
precautions could be
ordered in the patient’s
electronic medical record by
a healthcare provider, there
was no standardized or
official seizure precautions
policy.
The Neuroscience and Spine
Unit had its own unit
specific guidelines for those
inpatients placed in seizure
precautions; however, no
other unit in the hospital
had these guidelines.
Interprofessional Team – Task Force
Doctor of Nursing Practice (DNP) student
Neurologist
Core Charge Nurse
Educator
Coordinator
Registered Nurse
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Shareholders
A clinical value
analysis specialist
The Neuroscience
and Spine/Neuro
Progressive Care
Unit (NPCU)
director
The Medical Unit 2
director
The Medical
Progressive Unit
(MPCU) director
The Medical Unit
2/MPCU educator.
Committee Approvals Required
The Product
Value Analysis
Committee (PVAC)
The Education
Council committee
The Administrative
Patient
Care Council
(APCC) committee
The Clinical Patient
Care Committee
(CPCC),
The Nursing
Research Review
Board (NRRB)
The Institutional
Review Board (IRB)
at the College of St.
Scholastica.
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- Establish and implement a standardized seizure
precaution policy based on evidence‐based practice and
best practice recommendations.
- Ensure that all adult inpatients with a seizure precaution
order had all of the appropriate supplies at their bedside
in the event that a seizure occurred during their
hospitalization.
Goals
- Create a seizure precaution policy based on the best
evidence‐based practice
- Educate the hospital staff of the new seizure precautions
policy.
- Evaluate learning with a pre‐ and post‐ survey.
- Obtain approval from necessary committees to ensure
proper seizure precaution supplies were ordered prior to the
implementation.
- Evaluate the hospital staff’s understanding of supplies with a
pre‐ and post‐ checklist.
Objectives
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Sample Size
for pre‐ and
post‐survey
All 170 registered nurses on the
Neuroscience and Spine Unit,
NPCU, Medical 2 Unit, and MPCU
were encouraged to participate in
the pre- and post-survey.
Seizure Precaution Policy
Original: 12/15 Minor Review: Full Review: Replaces: Responsible Person: Coordinator, Neuroscience Support Services Approving Committee: Clinical Patient Care Committee Category: Patient Care Cross Reference: EEG Monitoring, Continuous; Transport to/from Procedures, Intrahospital Type: Procedure
- PURPOSE To provide seizure precautions for adult patients.
- POLICY Seizure precautions will be implemented in the event of a seizure, a seizure history (within last 3 months), and/or a high risk of seizures.
- DEFINITIONS •Aura: A warning of an approaching seizure. •Epilepsy: Recurrent, unprovoked seizures caused by biochemical, anatomical, and physiological changes. •Postictal Phase: The interval immediately following the seizure. •Seizure: A clinical presentation of the central nervous system characterized by abnormal cerebral electrical discharges. •Status Epilepticus: Recurrent seizures without complete recovery of consciousness between attacks or virtually continuous seizure activity for more than 30 minutes, with or without impaired consciousness.
- STANDARD OF PRACTICE Patient care staff will be knowledgeable about seizure precaution measures.
- OUTCOME STANDARD Patients can expect a safe environment in the event of a seizure.
- PROCEDURE •Set-up suction head with canister and tubing. Have Yaunker suction available in room next to suction head. •Set-up oxygen with flow meter and green adapter. Have non-rebreather mask available in room next to oxygen set-up. •Ensure that the patient has an IV access. •Apply seizure pads to upper side rails. •Inspect environment for potential safety hazards and remove from surroundings (examples: sharp objects, hot drinks, breakable items, etc.). •Consideration will be given for performing procedures at the bedside whenever possible.
- REFERENCES National Guidelines/National Standards/Regulatory American Association of Neuroscience Nurses. (2009). Care of the patient with seizures (2 nd^ ed.): AANN clinical practice guidelines series. From www.aann.org/pdf/cpg/aannseizures.pdf Literature Cross, C. (2004). Seizures regaining control. RN, 67 (12), 44-50. Schrub, E. & Caple, C. (2014). Seizure precautions for adults: Initiating and maintaining. CINAHL Nursing Guide. Disclaimer: The policies and procedures posted on CentraNet are for internal use only. They may not be copied by independent companies or organizations that have access to CentraNet, as this large Central Minnesota Hospital cannot guarantee the relevance of these documents to external entities
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0.75 (^) 0.
0 0.
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Pre-Survey Seizure precautions include which of the following? Select all that apply.
Pre‐ and Post‐Survey Data
Question 7. Seizure precautions include which of the following? Select all that apply.
0.9048 0.
0 0.
1
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Post- Survey Seizure precautions include which of the following? Select all that apply.
There was an overall improvement in correct responses for seizure precautions seen on the post-survey. However, there is still room for
improvement due to not all of the correct responses are at 100%.
Table 2.
Percentage of rooms that were correctly equipped with supplies pre- versus post- seizure precaution policy implementation
Oxygen Suction IV Access Seizure Pads Environment*
Unit Pre Post Pre Post Pre Post Pre Post Pre Post
Medical Unit 2 57% 71% 14% 57% 86% 100% 100% 100% 100% 100%
MPCU 100% 67% 0% 100% 100% 100% 50% 100% 100% 100%
Neuroscience and Spine 73% 79% 73% 93% 93% 100% 100% 100% 100% 100% NPCU 67% 75% 83% 75% 100% 100% 100% 100% 100% 100%
Total 70% 79% 60% 82% 93% 100% 97% 100% 100% 100%
Note. Neuroscience and Spine Unit/NPCU had a unit standard pre-implementation to have seizure pads, IV access, oxygen and suction set-up in room, whereas Medical Unit 2 /MPCU did not have a unit standard.
*On the pre-evaluation, any type of oxygen present in room was counted as correct, however during the post-evaluation only a non-rebreather mask was considered correct.
Pre‐ and Post‐ Implementation Checklist
Table 2. Percentage of rooms that were correctly equipped with supplies
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- The population for this quality improvement project did not include vulnerable adults or pediatric, aged
17 years of age and younger, inpatients seen at this Central Minnesota hospital.
- There were no proposed risks to the participants of this quality improvement project.
- No identifiable patient data was collected when conducting the pre‐ and post‐ implementation checklist;
the only information recorded was the seizure precaution supplies at the patient’s bedside and what unit
they were on.
- There was also no proposed risks to the hospital staff who completed the pre‐ and post‐survey due to no
identifiable data was collected. The only information gathered about the registered nurses was which
hospital unit they currently worked on and how long they had been a registered nurse.
Ethical Considerations
Discussion
There was a noted difference in the observed
outcomes and the anticipated outcomes as noted by
a decreased percentage of oxygen present in the
post-evaluation checklist audit.
This quality improvement project created a
standardized seizure precaution policy which was
aimed at improving safe patient care by having the
necessary supplies available at the patient’s bedside;
while also increasing nursing staff knowledge.
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Magnet
Story
Questions??
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- American Association of Neuroscience Nurses. (2009). Care of the patient with seizures (2 nd^ ed.): AANN clinical practice guidelines series. Retrieved from www.aann.org/pdf/cpg/aannseizures.pdf
- Centers for Disease Control and Prevention. (2015). Chronic disease prevention and health promotion: Targeting epilepsy. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/AAG/epilepsy.htm
- Cross, C. (2004). Seizures regaining control. RN, 67 (12), 44‐50.
- Cullen, L., Hanrahan, K., Tucker, S., Rempel, G., & Jordan, K. (2012). Evidence‐based practice building blocks: Comprehensive strategies, tools, and tips. Iowa City, IA: Nursing Research and Evidence‐Based Practice Office, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics.
- Epilepsy Foundation Minnesota. (n.d.). What is epilepsy. Retrieved from https://www.epilepsyfoundationmn.org/resources/what‐epilepsy/
- Kralj‐Hans, I., Goldstein, L. H., Noble, A. J., Landau, S., Magill, N., McCrone, P., ... Ridsdale, L. (2014). Self‐management education for adults with poorly controlled epilepsy (SMILE (UK): A randomized trial protocol. BioMed Central Neurology, 14 (69). doi:10.1186/1471‐2377‐14‐
- Labiner, D. M., Bagic, A. I., Herman, S. T., Fountain, N. B., Walczak, T. S., & Gumnit R. J. (2010). Essential services, personnel, and facilities in specialized epilepsy centers – Revised 2010 guidelines. Epilepsia, 51 (11), 2322‐2333.
References
- Pallin, D. J., Goldstein, J. N., Moussally, J. S., Pelletier, A. J., Green, A. R., & Camargo, C. A. (2008). Seizure visits in US emergency departments: Epidemiology and potential disparities in care. Journal of Emergency Medicine, 1 (2), 97‐105. doi: 10.1007/s12245‐008‐0024‐
- Perkins, A. M. & Buchhalter, J. R. (2006). Optimizing care in the pediatric epilepsy monitoring unit. Journal of Neuroscience Nursing, 38 (6), 416‐
- Sanders, P. T., Cysyk, B. J., & Bare, M. A. (1996). Safety in long‐term EEG/video monitoring. Journal of Neuroscience Nursing, 28 (5), 305‐313.
- Sauro, K. M., Macrodimitris, S., Krassman, C., Wiebe, S., Pillay, N., Federico, P., ... Jette, N. (2014). Quality indicators in an epilepsy monitoring unit. Epilepsy & Behavior, 33, 7‐11.
- Schrub, E. & Caple, C. (2014). Seizure precautions for adults: Initiating and maintaining. CINAHL Nursing Guide.
- Shafer. P. O., Buelow, J. M., Noe, K., Shinnar, R., Dewar, S., Levisohn, P. M., … & Barkley, G. L. (2012). A consensus‐based approach to patient safety in epilepsy monitoring units: Recommended for preferred practices. Epilepsy & Behavior, 25, 449‐456.
- Spanaki, M. V., McCloskey, C., Remedio, V., Budzyn, D., Guanio, J., Monroe, T., … Schultz, L. (2012). Developing a culture of safety in the epilepsy monitoring unit: A retrospective study of safety outcomes. Epilepsy & Behavior, 25, 185‐188.
References
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