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PURPOSE
This protocol outlines safety precautions to implement for patients at risk for seizures and how to respond if a patient has a seizure.
The priorities when caring for a patient who is seizing are to maintain a patent airway, protect the patient from injury, provide care during and following the seizure and documenting the event in the health record.
POLICY STATEMENTS
Most seizures last less than 2 to 3 minutes and in patients with a known seizure disorder are not a medical emergency. All seizures require the patient to be monitored and protected until patient has returned to pre-seizure level of consciousness.
All children with a history of, or who are considered at risk for seizures will have seizure safety precautions initiated on admission and maintained throughout hospitalization.
A seizure log will be maintained on all children with a known or suspected seizure disorder.
Health Care Providers are responsible for documenting on the seizure log any suspected seizure activity they observe. Parents/caregivers are instructed to make entries on the seizure log if they observe suspected seizure activity.
It is the nurse’s responsibility to instruct parents/caregivers on how to clearly describe seizure activity (i.e. a description of body movements observed rather than naming the type of seizure). Ensure parents are aware that any information that they can provide about what led up to the seizure, what happened during the seizure, and what happened after will help in the management of their child’s seizures.
It is the nurse’s responsibility to review the basic seizure safety precautions with the caregivers at the start of each shift.
Care should be escalated and the physican notified if: the patient has no known history of seizures, or is unknown to the responders. the seizure is unresponsive to rescue medications the patient has another seizure shortly after the first one and is not responsive to rescue medications the patient has a history of other medical issues e.g. Diabetes, brain tumour, hydrocephalus, etc.
A Code Blue should be initiated in any of the following circumstances: the patient’s airway becomes compromised or shows signs of respiratory distress (apnea, cyanosis) the patient remains unconscious after the seizure has stopped
SITE APPLICABILITY
Applicable to all clinical areas.
PRACTICE LEVEL/COMPETENCIES
Implementing seizure precautions and caring for patients during and following seizures are foundational level competencies for nurses (RN, LPN, RPN).
DEFINITIONS
Aura: perceptual disturbance experienced by some people with epilepsy before or after a seizure. It often manifests as the perception of a strange light, an unpleasant smell or confusing thoughts or experiences.
Postictal: the altered state of consciousness that a person enters after experiencing a seizure. It usually lasts between 5 and 30 minutes, but sometimes longer (up to 48 hours) in the case of larger or more severe seizures and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms. Additionally, emergence from this period is often accompanied
by amnesia or other memory defects. It is during this period that the brain recovers from the trauma of the seizure.
Seizure watch: close observation of child at risk for seizures.
Status Epilepticus: Non-convulsive or convulsive seizures that last longer than 5-10 minutes (some literature defines as 30 minutes or more) or two or more sequential seizures that the patient does not recover from. This kind of seizure requires increased metabolism and muscle activity and will result in inadequate glucose and oxygenation to the brain with the potential of permanent hypoxic damage. Status epilepticus is considered a medical emergency and requires immediate intervention.
EQUIPMENT
Seizure pads for bedrails or crib Floor mats (if applicable) Helmet (if applicable)
SAFETY PRECAUTIONS
- PLACE seizure pads on side rails or crib sides to prevent injury.
- ENSURE side rails or crib sides are up at all times when child is in bed.
- ENSURE all objects that can cause injury are removed from the bed (i.e. sat monitors etc.)
- SUPERVISE child during bathing, meals, when ambulating or participating in potentially hazardous activities.
- ENSURE suction and oxygen devices are functional each shift.
- SECURE child with lap belts when up in wheelchair or neuro chair etc.
- If patient already wears a helmet due to their seizure type, ENSURE helmet is worn at all times during activity to prevent possible head trauma.
- MAINTAIN bed at the lowest position at all times.
- PLACE mats (available from physiotherapy department) around bed if child at risk for climbing out.
- ENSURE seizure supply kit intact and available in medication room and seizure medication kit available in Pyxis medstation.
- PLACE child on seizure watch as ordered: a. Parents/caregivers may perform seizure watch and notify nurse when a seizure occurs b. If child is alone, ensure frequent visual checks done on child or he/she can be brought out to the nursing desk for close observation c. If child has historically consistent time of seizure activity, ensure parent/caregiver/nurse is present during those times (i.e. on waking or falling asleep) d. Children who do not have a parent/caregiver present will be placed in room close to nursing station to facilitate frequent visual checks and close observation whenever possible and consider continuous monitoring.
DURING A SEIZURE
1. KEEP CALM:
Seizures may appear frightening to the onlooker. They usually last only a few minutes and generally do not require medical attention. Remember that the person having a seizure may be unaware of their actions and may or may not hear you. Provide privacy. Use a calm approach and remove onlookers.
- REFER patient/family to the clinic nurse, if appropriate.
DOCUMENTATION
DOCUMENT seizure activity on seizure log: a. Date and time of onset b. Alterations in behaviour (cry or change in facial expression, motor abilities, sensory alterations prior to the seizure that may indicate an aura) c. Length of seizure activity d. Description of movements e. Changes in colour (pallor, cyanosis) f. Position of mouth, any injury to mouth or tongue, inability to swallow, or excessive salivation g. Loss of bladder or bowel control h. State of consciousness during seizure i. Interventions implemented for control or management of symptoms
DOCUMENT neurovital signs if head injury occurred or if monitoring of neurological signs is indicated.
DOCUMENT vital signs and other observations as necessary on Patient Care Flowsheet.
DOCUMENT postictal state in nurse’s notes or seizure log: a. State of consciousness after seizure b. Assessment of orientation to person, place, and time; motor abilities; speech; alterations in sensation; headache; behaviour changes c. Duration of postictal state
DOCUMENT any medications given during the seizure on the MAR.
DOCUMENT teaching done with patient/family on Teaching Flowsheet.
REFERENCES
Aronyk, K.E. and Neufeld, S. (2013). Nursing Care of the Child with a Neurologic Disorder. In Ateah, C.A., Scott, S.D. and Kyle, T. (Ed.), Canadian Essentials of Pediatric Nursing (pp.337-365), Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
BC Children’s Hospital Emergency Clinical Practice Guideline: Management of Convulsive Status Epilepticus in Infants and Children. August 23, 2008. Vancouver, BC, Author.
Krauss, G. and Theodore, W.H. (2010). Treatment Strategies in the Postictal State. Epilepsy Behaviour, 19 (2):188-190.
Vancouver Coastal Health & Providence Health Regional Policy. Seizure Management (Adult/Pediatric). November 2011. Vancouver, BC, Author.
Waypoint Centre for Mental Health Care. Care of Seizuring Person Nursing Policy and Procedure. March 17, 2010. Penetanguishene, Ontario. Author.
