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Andrew Pollack-Gray

Nursing Notes

Seizure Response

2 min read

When & Why?

Seizures result from abnormal electrical activity in the brain.
The priority is preventing injury, protecting breathing, and obtaining help when needed.
Common presentations:

  • Brief staring or impaired awareness.
  • Repetitive movements.
  • Loss of consciousness and convulsions.
  • Confusion or fatigue after the seizure.
    Status Epilepticus: A prolonged seizure or recurrent seizures without recovery; a convulsive seizure lasting five minutes or longer is an emergency.

Before You Start

  • Recognize seizure activity.
  • Ensure personal and resident safety.
  • Call for assistance and note when the seizure begins.
  • Follow any prescribed seizure action plan.

Steps

During a Seizure

  1. Stay calm and time the seizure.
  2. Protect the resident from nearby hazards.
  3. Cushion the head when appropriate.
  4. Do not restrain movements.
  5. Do not place anything in the mouth.
  6. Turn the resident gently onto their side when safe and appropriate.
  7. Activate emergency response for prolonged seizures or other emergency indicators.

After a Seizure

  1. Observe breathing and responsiveness.
  2. Maintain a safe position and provide reassurance.
  3. Allow recovery in a quiet environment.
  4. Report duration, movements, responsiveness, and injuries.
  5. Follow nurse directions for vital signs, hygiene, and ongoing observation.

Safety & Observations

Emergency assistance is needed for:

  • Seizure lasting five minutes or longer.
  • Repeated seizures without recovery.
  • Breathing difficulty or failure to regain consciousness.
  • Significant injury or a first-known seizure.
  • Other emergency criteria in the facility’s seizure protocol.

What Should I Remember?

  • Time → Protect → Do Not Restrain → Report.
  • Never place objects or fingers in the mouth.
  • Never offer oral food, fluids, or medication until the resident is fully alert and safe to swallow.
  • Follow individualized seizure response instructions.

Practice

  • Studied
  • Observed
  • Practiced
  • Passed checkoff

Sources

Flashcards

What two actions must you never do during a seizure?03-application / clinical-skills
Answer

Restrain movements or place objects in the mouth.

What seizure duration is an emergency threshold in the note?03-application / clinical-skills
Answer

Five minutes or longer for a convulsive seizure.

What should be documented after a seizure?03-application / clinical-skills
Answer

Duration, movements, responsiveness, and injuries.

Graph View

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