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Clinical Protocol Clinical Manual - Nursing Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: POLICY: Seizures: Care of the Patient 1. "Seizure precautions" are indicated if the patient: a. has been admitted with seizures or suspected seizures. b. has epilepsy with seizures. c. has experienced a seizure within the last 3 days. DEFINITIONS:

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Seizure precautions include padded side rails and ambulate with assistance.

DESIRED PATIENT OUTCOMES:

1. The patient will remain free of injury. 2. The patient and/or significant other will demonstrate understanding of the need for seizure precautions.

CLINICAL ASSESSMENT AND CARE:

1. Ascertain the patient's seizure history. a. Is there an aura (visual, auditory, gustatory)? b. Are there any triggers? c. What is the usual presentation/sequence of events? d. If on medication, how well are the seizures controlled? there been any recent changes in medication? e. What is the impact on ADLs? 2. If criteria are met, place patient on seizure precautions. 3. Assess LOC and vital signs. Notify MD/LIP of any change outside of patient's baseline parameters. 4. Monitor lab work as ordered, especially electrolytes, anticonvulsant blood levels, blood glucose. Notify MD/LIP of abnormal results. 5. Pad siderails of patient's bed using seizure pads. Keep in upright position as patient condition and assessment warrants. 6. Verify airway equipment readily available ­ oxygen delivery systems, nasal and oral airways, Ambu-bag, mask and suction equipment. IN THE EVENT OF A SEIZURE: 1. During the seizure (ictal phase): a. Remain with the patient until fully conscious. b. Loosen restrictive clothing. c. Protect patient's head from injury. Have

Clinical Protocol Clinical Manual - Nursing Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Seizures: Care of the Patient

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d. Note duration and type (i.e., tonic clonic) of seizure. e. Do not restrain the patient. f. As able, turn the patient onto his/her side, or prone with head elevated to prevent airway obstruction. g. Remove any furniture that is near the patient. h. Suction as needed. i. Utilize oxygen as per MD order. j. As able, provide for patient's privacy. k. Notify MD. l. Administer ordered medications. 2. After a seizure (post-ictal phase): a. Assess level of consciousness and obtain vital signs; report changes from baseline. b. Complete a full neurologic assessment as described in Protocol/Procedure for: Neurologic Assessment of the Adult Inpatient. c. Draw lab work as ordered. d. Continue to administer oxygen as ordered; assessing breathing pattern and lung sounds. e. Suction as necessary. Suction gently and as infrequently as possible to avoid an increase in intracranial pressure. f. If possible, avoid administration of sedatives or narcotics that may impair assessment of further neurologic changes. g. Assess skin for edema, pallor, rubor, cyanosis. Assess for and report any petechiae, bruising, abrasions or ulcerations that may have occurred. h. Assess ability to move all extremities and muscle strength; report changes from baseline. i. Assess for any involuntary movement. j. Assess for speech impairment, inability to answer questions; report changes from baseline. k. Assess short and long term memory. l. Assess gag reflex if applicable.

Clinical Protocol Clinical Manual - Nursing Practice Manual John Dempsey Hospital ­ Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Seizures: Care of the Patient

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PATIENT TEACHING:

1. Explain the need for "seizure precautions" to the patient and/or significant other. 2. Review anticonvulsant medication regime and side effects with patient and/or significant other. 3. Review need for routine follow-up and for serum drug levels to be drawn. 4. Explain need for "Medic-Alert" bracelet if applicable, signifying that patient has a seizure disorder. 5. Reinforce to the patient the need to maintain overall health and compliance with medication treatment.

APPROVAL: EFFECTIVE DATE: REVISION DATES: REVIEWED DATES:

Nursing Standards Committee 8/94 3/96, 10/97, 12/99, 11/02, 6/06, 10/10 3/09

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