Nursing Diagnosis: High risk for injury related to internal chemical regulatory function caused by seizure activity (uncontrolled movements) resulting in musculoskeletal, oral tissue trauma.
Expected outcomes: Absence of injury during and after seizure evidenced by inspection revealing no damage to mouth or tongue, bone or soft tissue breaks or bruising; control of seizures.
Nursing intervention and rationale:
I. Assess for:
- All aspects of the seizures such as predisposing event, when occurred and length of each phase, what occurred during each phase, which body part affected, and how and what sequence, tongue bitting, loss of consciousness, stiffening, jerking, loss of muscle tone, excessive saliva, flushing, cyanosis, diaphoresis, incontinence. Seizure description is essential for appropriate treatment.
- Level of consciousness, memory loss, muscle soreness, aphasia, dysarthria, weakness or paralysis, and sleep period (include duration of each effect). Possible effects of seizures to be assessed.
- Anticonvulsives (phenyoin, valproic acid). Acts to reduce voltage and spread of electrical discharges in the motor cortex to prevent seizure.
- Pad sides rails, placed in raised position, tape padded tongue blade or away to bed, remove harmful objects from immediate environment, O2 and suction available. Precautions taken to prevent injury during seizure.
- Stay until seizure is over, speak calmly without restraining unless may be injured. Provides support and prevents injury.
- Ease to floor, place cloth between teeth, place pillow under head, or place head in lap. Prevents injury if not in bed.
- Avoid restraining, forcing object between teeth if clenched; insert padded blade if safe to do so. Prevents possible injury damage to mouth and teeth.
- Loosen tight clothing, roll to side to drain secretions from mouth during relaxation, or suction secretions if needed. Prevents aspiration.
- Reorient to events, provide rest and reassurance, cleanse oral cavity. Promotes comfort and relaxation following seizures.
- First-aid treatment of seizures and when to call emergency service. Promotes appropriate treatment and prevents injury.
- Suggest weaning of medical alert brace or use of identification card. May be beneficial or a burden depending on patient.
- Avoid physical and emotional stress, get proper rest, diet, kinds of stimulation to avoid that may trigger seizure (internal, drugs or external, environmental noise, lights). Prevents seizure activity.