COALINGA STATE HOSPITAL. Effective Date: August 31, To provide a reference on action steps to take when Individual exhibits seizure activity.

Transcription

1 COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Emergency Procedures POLICY NUMBER: 703 Effective Date: August 31, 2006 SUBJECTS: SEIZURES 1. PURPOSE: To provide a reference on action steps to take when Individual exhibits seizure activity. 2. POLICY: 1. Nursing staff shall immediately evaluate the Individual to determine the medical emergency status (LIFE THREATENING call 7119; NON-LIFE THREATENING call 7119) and take appropriate action as outlined in NPPM #700 Medical Emergency. 2. All available physicians and nursing staff shall respond to all medical emergencies in a prompt and competent manner. 3. An I.V. of Normal Saline or D5W TKO (to keep vein open) may be started by RN s who are I.V. proficient prior to a physician s order in life threatening emergencies. A physician s order must be obtained ASAP thereafter. 4. Registered Nurses may give I.V. Push medication in the presence of the physician (see NPPM #547 Administration of Medication &Fluids by Intravenous Route ). 5. A record shall be made of each seizure which the Individual exhibits or when the nursing staff has reason to believe that the Individual has experienced a seizure. 6. The Seizure Record form (MH 5601), shall be filled out immediately after the seizure and on the shift which the seizure occurred. 7. The Seizure Record shall be used to maintain a log of all seizures and to indicate the characteristics of each seizure. 8. The Shift Lead or designee shall assure that all necessary and appropriate medical emergency response equipment and supplies are brought to the scene which includes the Emergency Cart, emergency drug box, the AED, -1-

2 pulse oximeter, and an extra oxygen tank. (In an emergency, IV Start-Kit found in the Emergency Drug Box). 3. GENERAL INFORMATION: A seizure is the response to an abnormal electrical discharge in the brain. The term seizure describes various experiences and behaviors. Anything that irritates the brain can produce a seizure. Precisely what happens during a seizure depends on what part of the brain is affected by the abnormal electrical discharge. The discharge may involve a tiny area of the brain and lead only to the Individual noticing an odd smell or taste, or it may involve large areas and lead to a convulsion - jerking and spasms of muscles throughout the body. The Individual may also have brief attacks of altered consciousness; lose consciousness, muscle control, or bladder control; and become confused. A seizure usually lasts for 2 to 5 minutes. When it stops, the Individual may have a headache, sore muscles, unusual sensations, confusion, and profound fatigue (called a postictal state). The Individual usually cannot remember what happened during the seizure. Seizures usually progress through three phases. During the first phase, the preictal period, the Individual may undergo mood or behavioral changes. This phase may also precede the actual seizure by minutes or days. Some Individuals may experience an aura (a sensory warning) during this phase. Auras are most often described as a flash of light, a strange taste, an unusual odor, a sudden headache, dizziness, a strange feeling in the stomach (butterflies), or even an intense overwhelming feeling of fear. The clinical manifestations of the aura can often provide helpful clues to the seizure s origin. Accurately charting a Individual s report of an aura can provide information to help the neurologist diagnose the seizure s origin. The second phase, the ictal phase, refers to the actual seizure activity. A cry, resulting from the forceful expulsion of air from the throat, may introduce the seizure. A nurse s presence during the ictal phase can be a tremendous benefit to both the Individual and the neurologist; the nurse s accurate charting of the seizure s onset and pattern can assist the neurologist in pinpointing the origin of the seizure. The final phase is the postictal phase, the often slow recovery period that immediately follows a seizure. This period widely varies among Individuals and depends on a variety of factors, such as type, duration, and intensity of the seizure. For example, absence seizures are generally not followed by any symptoms. Once the seizure ends, the Individual resumes activity just as if nothing happened. However, after most complex partial seizures, the Individual is somewhat confused and tired, and this typically lasts from minutes to hours. After tonic-clonic seizures, the Individual is often confused -2-

3 and exhausted. Most Individuals say they require several hours of sleep to fully recover. Other common complaints include headache, muscle soreness, fatigue, and a sore cheek or tongue if these were bitten during the seizure. During the postictal period Individuals may experience any of the preceding complaints or other impairments such as changes in vision or touch sensation, muscle weakness on one side of the body, or difficulties with language. Often the postictal symptoms can also help to identify the area from which a seizure originated. For example, weakness in the left arm or leg may follow a seizure that began in the motor area of the right hemisphere of the brain. 4. DEFINITIONS/SEIZURE TYPES: The classification system for seizures has changed over the past decade. The new system classifies seizures according to whether the abnormal discharges arise from abnormal neurons on both sides of the brain (generalized seizures) or just one part of the brain (partial seizures). Partial seizures may or may not be associated with impairment of consciousness, depending on their location and the involvement of other brain structures. Partial seizures are further broken down into simple partial and complex partial. Simple partial seizures do not involve any change in consciousness. Partial seizures that involve any alteration in consciousness are now called complex partial instead of temporal lobe or psychomotor. In contrast, generalized seizures affect both sides of the brain and cause an abrupt loss of consciousness at the onset of the seizure. These seizures may or may not be convulsive. (During a convulsive seizure, a Individual also exhibits shaking or violent, involuntary contractions of single or multiple groups of muscles). A variety of seizures are classified as generalized seizures; however, their new classifications may not be familiar. The term grand mal has been replaced by tonic if the body becomes stiff, clonic if the body jerks, and tonicclonic if the body stiffens and jerks. Seizures that cause a brief loss of awareness, staring, or blinking are not longer termed petit mal, but are called absence. Status epilepticus is generally defined as more than 30 minutes of continuous seizure activity or two or more seizures without recovery of baseline consciousness in between. Convulsive (tonic-clonic) STATUS EPILEPTICUS IS A MEDICAL EMERGENCY that is LIFE-THREATENING and may cause broken bones, cardiac arrhythmias, anoxia, permanent neurologic injury, or even death if treatment is delayed or ineffective. The most common cause is -3-

4 Individual noncompliance with medications (Refer NPPM #700 Medical Emergency. 5. CLASSIFYING SEIZURES: A QUICK REFERENCE GUIDE: PRIMARY GENERALIZED SEIZURE: may be convulsive or non-convulsive 1.1 ABSENCE Brief loss of consciousness (5 to 30 seconds) Blank stare or eye blinking No postictal period - person automatically returns to previous activity 1.2 MYOCLONIC Short abrupt muscle contractions of arms, legs, or torso Possibility of muscle contractions strong enough to cause a fall. Individual may drop objects, spill beverages, or be propelled out of a chair Symmetrical, asymmetrical, synchronous, or asynchronous contractions Lasts seconds 1.3 CLONIC Muscle contraction and relaxation; jerking movements Both sides of body involved May last several minutes 1.4 TONIC Sudden stiffening movements of the body, arms, and legs Involves both sides of the body; flexion of arms and extension of legs Common during sleep PARTIAL SEIZURES: 1.7 SIMPLE PARTIAL May be preceded by an aura Consciousness maintained Motor symptoms: abnormal unilateral movement of arm, leg, or both Sensory symptoms: may sense abnormal sounds, smells, or body sensation Autonomic symptoms: changes in heart rate, respiratory rate, or both. Skin flushing or epigastric discomfort Psychic symptoms: Individual may report intense feeling of fear or deja vu. Lasts seconds to minutes 1.8 COMPLEX PARTIAL Possible progression to secondarily generalized tonic-clonic seizure Consciousness impaired, not lost Eyes may be wide open Possibility that Individual may be unable to respond to questions or commands or respond inaccurately or inappropriately Automatisms such as lip smacking or picking at clothes Possible bizarre behaviors: running, screaming, or disrobing Jumbled speech or repetitive phrases Possible posturing or jerking movements Lasts seconds to minutes Postictal confusion and amnesia common -4-

5 Usually lasts less than 20 seconds 1.5 TONIC-CLONIC Loss of consciousness A cry caused by contraction of respiratory muscles forcing exhalation Body stiff - patent falls to the ground Tonic phase: eyes may roll up or to the side, Individual may bite tongue; symmetrical extension of extremities Clonic phase: jerking of head, face, arms, and legs. End of clonic phase: Person becomes flaccid Urinary, fecal incontinence Exhaustion and confusion; hours of sleep for recovery 1.6 ATONIC Abrupt loss of muscle tone-individual falls to ground Lasts seconds Postictal confusion 6. CAUSES OF SEIZURES: High fever: Heatstroke Infection Brain infections: AIDS Malaria Rabies Syphilis Tetanus Toxoplasmosis Viral encephalitis Metabolic disturbances: Hypoparathyroidism High levels of glucose or sodium in the blood Low levels of glucose, calcium, Destruction of brain tissue: Brain tumor Head injury Intracranial hemorrhage Stroke Other illnesses: Hypertensive encephalopathy Lupus erythematosus Exposure to toxic drugs or substances: Alcohol (large amounts) Amphetamines Cocaine overdose Withdrawal after heavy use: Alcohol Sleep aids -5-

6 magnesium, or sodium in the blood Kidney or liver failure Insufficient oxygen to the brain Carbon monoxide poisoning Inadequate blood flow to the brain Near drowning Near suffocation Stroke Tranquilizers Adverse reactions to prescription drugs 7. INTERVENTIONS: SEIZURE ACTIVITY: NURSING ACTION A. Protect airway patency. Protect Individual from injury. KEY POINTS A. Direct available staff to obtain Emergency Cart, emergency drug box, AED, pulse oximeter, and an extra oxygen tank. B. Assess type and extent of seizure. B. Refer to classifying seizures: a quick reference guide. C. If possible, place Individual on his/her side to facilitate drainage of secretions. D. Have staff notify the physician and NOD/RN STAT. D. Dial 7119" for medical assistance. Dial 7119" for paramedics. E. Perform a brief neurologic assessment once the postictal period has passed. -6-

7 8. STATUS EPILEPTICUS: NURSING ACTION A. Quickly assess the Individual to determine his/her status. Activate EMS (Emergency Medical System). Call KEY POINTS A. Status Epilepticus is a Life- Threatening Medical Emergency requiring immediate medical attention B. Maintain an open airway and protect the Individual from injury. C. Have staff call for physician and RN STAT. D. Direct staff to bring the Emergency Cart, drug box, monitor/ defibrillator, pulse oximeter, and an extra oxygen tank to the scene. E. Set up suction, open emergency drug box, and set up for possible IV insertion and drug administration. E. An RN may start an I.V. of Normal Saline or D5W TKO (to keep vein open) without a physician order in a life threatening emergency. RN may give I.V. PUSH medication in the presence of a physician. (In an emergency, IV supplies are found in the Emergency Drug Box). F. Obtain physician s orders for: a) IV (fluid and rate); b) Arrange for medical transportation to outside medical facility. G. Prepare Individual for transport. Coalinga Transfer form. G. In medical emergencies, an Coalinga Transfer form shall accompany the Individual -7-

8 1.8.1 TIPS TO REMEMBER Keep in mind the following when caring for a Individual during a generalized tonicclonic seizure: Keep calm. Reassure others nearby. Clear the area around the Individual of anything dangerous. Loosen anything around the Individual s neck that may make breathing difficult. Place something soft under the Individual s head (e.g. a blanket). If possible, turn the Individual gently on his or her side to help keep the airway clear. (Some Individuals may produce copious amounts of secretions during a seizure. Others may vomit). Stay with the Individual until the seizure ends. Reassure the Individual as consciousness returns. Speak softly and calmly. Do not attempt to force anything into the Individual s mouth. Do not attempt to hold the Individual down or to restrain movement. Do not attempt CPR during a seizure. Wait until the seizure has stopped, then asses ABC s. 10. PREICTAL PERIOD: Begin by asking and identifying what happened before the seizure. 1. Precipitating Factors: Did the Individual have some type of emotional upset? Did anyone notice any unusual behavior or mood changes before the seizure? Did some type of environmental stimulus, e.g. unusual light, pattern, or noise, start seizure? Did the Individual miss medication? 2. Aura: Was the Individual aware that attack was coming? How? Did the Individual have any unusual taste, smell, or visual change before seizure occurred? 11. ICTAL PERIOD: (See Classifying Seizures: Quick Reference Guide to best describe observation) 1. Point of Origin: What motor movements were observed? Where did muscle movements originate? How did the seizure progress? Was one side of the body affected or both? For example, if the movement started in the face, did it spread to the arms or legs? -8-

9 Did the Individual display automatisms, such as lip smacking? Duration? How long did it last? Did the Individual fall? 2. Involvement: Was seizure type generalized or partial? Did position of body change? Were teeth clenched? Was there frothing? Did color change on face/lips? 3. Deviation of Eyes: Did eyes move laterally, upward, or downward? Was any nystagmus noted? What were the size and reaction of the pupils? 4. Was Individual incontinent of feces or urine? 5. Respiratory Pattern: Was there any apnea; dyspnea? Was there any irregular breathing, stertor, snoring, etc.? 6. Loss of consciousness: How soon could the Individual be aroused to point of response? Was Individual sleepy or confused during or after attack? What was duration of unconsciousness? POSTICTAL STATE: Find out what happened after the seizure: Was Individual able to move all extremities? Was any weakness noted? Did Individual have any complaint of discomfort or unusual sensation after episode? Did Individual have any changes or peculiarities of speech? Was Individual confused or combative? How long did confusion last? Did Individual have any other behavioral changes? Did Individual complain of a headache? Describe Individual s level of consciousness. Was he or she able to follow simple commands? Does the Individual recall anything that occurred during the seizure? How often has Individual had seizures? How long has it been since the last seizure? How long did this seizure last? -9-