A nurse is caring for an adult client with epilepsy who suddenly has a generalized tonic-clonic seizure on the inpatient unit. Which actions should the nurse take during the seizure and the immediate postictal period? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Stay with the client, time the seizure, lower the client safely if needed, and protect the head (Choice 4). Loosen tight clothing, clear nearby hazards, and use padding to reduce injury (Choice 6). After the convulsive phase ends, place the client side-lying to support secretion drainage and airway patency (Choice 5). A seizure lasting 5 minutes or recurrent seizures without recovery requires emergency response because it meets the operational threshold for status epilepticus (Choice 2). Do not place an object in the mouth because it can injure the teeth or obstruct the airway (Choice 1). Do not restrain the limbs because restraint can cause musculoskeletal injury (Choice 3).
Seizure Safety — During the Seizure 1. Stay and time the seizure (call for help) 2. Ease to floor if standing; protect the head with padding 3. Clear the area of hazards, loosen tight clothing 4. Nothing in the mouth — no tongue blade, no fingers 5. Do not restrain — let convulsions complete 6. Apply oxygen if available; suction PRN
Post-Ictal Period - Side-lying (recovery) position for airway and secretion drainage - Suction as needed - Reorient gently — confusion, fatigue, headache common - Allow rest; document characteristics (onset, duration, body parts involved, autonomic signs, post-ictal state) - Assess for tongue laceration, falls injury, incontinence
Status Epilepticus Seizure > 5 min OR repeated without recovery = neurologic emergency. IV lorazepam (or diazepam, midazolam) first-line. Notify provider STAT, prepare airway, IV access, glucose check.
Memory Tip "SAFE": Stay & time, Airway side-lying after, Free of hazards, End-of-seizure documentation.
ScenarioAdult, history of epilepsy, on levetiracetam. Suddenly begins generalized tonic-clonic seizure while ambulating in the hallway. Falls to the floor, full convulsions begin.
Immediate Action (During)1. Call for help2. Time the seizure from onset3. Protect head with pillow or hands4. Move objects away, loosen collar5. Do NOT insert anything in mouth6. Do NOT restrain
After Seizure (Post-Ictal)- Side-lying recovery position- Suction secretions, oxygen PRN- Vital signs, neuro check, fingerstick glucose- Reorient gently, do not give food or fluids until fully awake- Document: time, duration, characteristics, post-ictal duration, injuries
When to Escalate- Seizure > 5 min or repeated → STATUS EPILEPTICUS — IV benzodiazepine, 911 if outpatient- New focal neurological deficit (Todd paralysis vs stroke)- Injury (head, tongue, fall)- Aspiration suspected
Generalized tonic-clonic seizure — Bilateral seizure with loss of consciousness, tonic phase (rigid muscle contraction, often with cry, apnea), then clonic phase (rhythmic jerking). Typically lasts 1-3 minutes. Followed by post-ictal period with confusion, fatigue, headache, sometimes Todd's paralysis (transient focal weakness). > 5 min = status epilepticus.
Status epilepticus — Continuous seizure activity > 5 minutes OR repeated seizures without recovery of consciousness between them. Neurologic emergency due to risk of permanent neuronal damage and aspiration. First-line treatment: IV lorazepam 2-4 mg (or IM/intranasal midazolam, rectal diazepam if no IV). Maintain airway, oxygen, fingerstick glucose, IV access.
Post-ictal nursing care — Recovery period after a seizure. Place client side-lying to protect airway and allow secretion drainage; assess and maintain ABCs; monitor vital signs and neurologic status; reorient gently as confusion is common; assess for injuries; do not offer food or fluids until fully awake. Document characteristics of the seizure thoroughly.