Skill List > Care of a Patient During a Seizure
Clinical Alert
When the patient’s jaw is clenched nothing should be inserted into the mouth to try to prevent tongue biting. Inserting items may damage the mouth and teeth, provoke a possible gag reflex with vomit entering the airways, and a nurse inserting a finger into the mouth risks being bitten. If necessary insert an airway ONLY when the teeth have unclenched (after the tonic phase).

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Mosby Nursing Skills
Adapted by: Chris Brooker BSc MSc SRN SCM RNT 
Updated by: Chris Brooker BSc MSc SRN SCM RNT
Last updated: March 2018
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of caring for a patient during a seizure.

Introduction

The unpredictability of seizures profoundly affects people’s lives. Seizures (previously referred to as ‘fitting’) may be caused by epilepsy or other conditions that include alcohol withdrawal, raised intracranial pressure such as with a brain tumour or after head injury, high temperature (especially in children; see below), drug toxicity, and poisoning.

"Seizures are divided into groups depending on:

where they start in the brain (onset)
whether or not a person’s awareness is affected
whether or not seizures involve other symptoms, such as movement

Depending on where they start, seizures are described as being focal onset, generalised onset or unknown onset.” (Epilepsy Society - https://www.epilepsysociety.org.uk)

A partial seizure starts in a specific part of the brain. In a simple seizure, the patient does not lose consciousness, whereas in a partial complex seizure, the patient loses consciousness. Generalised seizures, of which there are several types, affect the whole brain and cause both nonconvulsive and convulsive seizures. Continuous seizure activity that lasts more than 30 min is status epilepticus, which is a medical emergency.

Each type of seizure has a unique combination of clinical features. In older children and adults a warning, or ‘aura’, involving taste, smell, sound, vision, etc. often occurs before a seizure, meaning that the person is aware that one is about to take place. It is very important to assess a patient carefully if you witness a seizure.

A generalised convulsive tonic-clonic seizure (previously known as a grand mal fit) lasts from 1 to 2 min. At the start of a seizure the patient may cry out. When the patient has a seizure the first phase (the tonic phase) is associated with rigidity of limbs and breath holding. This phase may be brief. In the second phase (clonic phase), there is rhythmical jerking of arms and legs. Characteristically the jerks are unilateral; initially close together and then decreasing in frequency. This phase is followed by a period of deep sleep, when the patient is usually unrousable and their body is limp.

During a seizure, take steps to keep the patient’s airway open; however, forcing something in the patient’s mouth may result in injury to the jaw, tongue, or teeth and may stimulate the gag reflex, causing vomit to enter the airways. Insert an airway ONLY when there is clear access for insertion.

Patient and family education

  • Explain the medication regimen to the patient and family.
  • Patients need to know that antiepileptic medications will help control epilepsy. Warn patients to take prescribed medications regularly. Patients should never stop medication suddenly because this will precipitate seizures.
  • The patient should wear a medical alert bracelet or carry an identification card noting presence of a seizure disorder and listing medications taken.
  • Teach family members about what to do when a seizure occurs. Ensure that the family understand that during a seizure, they must NOT try to force anything into the patient’s mouth as this may cause injury to the jaw, tongue, or teeth, and may stimulate the gag reflex, causing vomit to enter the airways.
  • Advise the patient to adhere to their doctor’s advice regarding alcohol intake because it is often incompatible with anticonvulsive medications.
  • Effective oral hygiene and frequent dental checks are necessary when the patient takes phenytoin long term because gingival hyperplasia (overgrowth of gum tissue) is a side effect (British National Formulary 2018).
  • Fatigue, stress, and illness can potentiate seizures. Therefore, patients need to eat a balanced diet at regular intervals, get enough sleep, and consult their GP promptly when ill.
  • A seizure usually imposes driving limitations. Patients must be informed that they must tell the DVLA if they've had any epileptic attacks, seizures, fits or blackouts and should be advised to stop driving in the meantime, otherwise their motor insurance will be invalid. The healthcare professional is responsible for telling the patient that informing the DVLA is their responsibility and this conversation must be documented in the medical records (Epilepsy and Driving - https://www.gov.uk/epilepsy-and-driving).
  • Assess the patient’s home for environmental hazards in light of the seizure condition.
  • Until the seizure condition is well controlled, make sure the patient does not have a bath or engage in activities such as swimming unless a knowledgeable person is present to supervise.
  • Refer the patient to a support group such as Epilepsy Action (see Additional resources) or a similar community resource for support groups.

Children and seizures

  • Teach family members what to observe for in seizures because many times they are present at the onset.
  • Some children with severe seizures should wear a helmet to protect their head when they fall. A child with tonic-clonic seizures should have bed rails padded and possibly suction and oxygen available at home to manage respiratory secretions for airway maintenance.
  • If children are too young to shower, advise family members to keep the water level low in the bath and not leave the child unattended.
  • Inform the staff at the child’s school regarding the seizures.
  • In children under 5 years, seizures are usually associated with a fever (high body temperature) and are known as febrile seizures (previously ‘convulsions’). If this occurs at home, summon an emergency ambulance; place pillows around the child to protect from injury; record the time of onset; remove clothing down to underwear; and tepid sponge the child starting at the forehead and working downwards. When the seizure is over, put the child in the recovery position and observe closely.

Older people and seizures

  • Older people often have symptoms that make it difficult to recognise a seizure disorder. Confusion lasting several days, receptive and expressive language problems, and unusual behaviours are often the result of a seizure.
  • Older people metabolise antiepileptic drugs more slowly; therefore, drugs accumulate, resulting in toxicity. Blood tests for drug levels may be necessary, according to the prescribing physician’s advice.
  • If patient has dentures, do not try to remove them during a seizure. If they loosen, tilt the head slightly forward and remove the dentures after the seizure.

Preparation and safety

  • If a patient is to be admitted with seizures, ensure that essential equipment is readily available. This includes:
    • oxygen and suction in working order
    • a selection of various sizes of artificial airways
    • charts for recording neurological status, vital signs, and seizure characteristics
    • bed rails should be in place and may be padded for additional safety
    • anticonvulsant medication, particularly in parenteral preparations.
  • Be aware of the patient’s seizure history and knowledge of precipitating factors (e.g., emotional stressors, concurrent illness, poor compliance with anticonvulsant medication, flashing lights). Note the frequency of past seizures, presence and type of aura (e.g., metallic taste), and body parts affected, if known. Use the family as a resource, if necessary.
  • Assess for any allergies to medicine or food (especially allergies to benzodiazepines).
  • Assess medication history and the patient’s adherence. Assess for any over-the-counter, herbal, or illegal drug use.

Procedure


  1. Protective clothing may be necessary if indicated by the patient’s condition.
    Rationale – To protect the nurse from potentially infected body fluids.
  2. Protect the patient from injury, but do not attempt to restrain their limbs. Loosen any restrictive clothing if possible.
    Rationale – Attempts to restrain limbs could cause injury. Assists expansion of the chest and abdomen during breathing.
  3. If the seizure occurs in a healthcare setting, draw the screens around the bed, stay with the patient, and call for assistance. If the seizure occurs in a public place, encourage bystanders to disperse to prevent the patient feeling crowded and possibly embarrassed.
    Rationale – This maintains the patient’s privacy and dignity.
  4. Use pillows as necessary to pad hard surfaces, and remove non-essential furniture and equipment. If the patient is in bed, remove pillows and raise bed rails. On rare occasions, such as near an open fire in the community, moving the patient from danger may be required. Consider your own safety.
    Rationale – To minimise the risk of injury to the patient and nurse. Removing pillows prevents the risk of suffocation.
  5. Observe the patient continuously, noting the following:
  6. The time the seizure started, and the duration of each phase of the seizure, including the recovery time (i.e., when the patient was able to resume normal activities).
    Rationale – This provides information about the type of seizure and causes, and informs medication choices.
  7. Limbs involved in the seizure.
    Rationale – This provides information about the type of seizure and causes, and informs medication choices.
  8. Whether movement is localised or general.
    Rationale – This provides information about the type of seizure and causes, and informs medication choices.
  9. Whether the jaw is clenched.
    Rationale – When the patient clenches their jaw they might bite their tongue; however, nothing should be inserted into the mouth to try to prevent this. Inserting items may damage the mouth and teeth, provoke a possible gag reflex with vomit entering the airways, and a nurse inserting a finger into the mouth risks being bitten. If necessary insert an airway only when their teeth have unclenched (after the tonic phase).
  10. Whether the patient is frothing at the mouth (saliva); suction may be needed when the seizure has finished.
    Rationale – Have suction equipment available in case it is needed to maintain an open airway.
  11. Whether the patient has been incontinent of urine or faeces.
    Rationale – This provides information about the type of seizure and causes, and informs medication choices. It alerts the nurse to provide hygiene care after the seizure.
  12. Breathing pattern – this will change. Patients are likely to hold their breath and may become cyanosed or just pale. Loud breathing sounds may indicate the end of the seizure. (The breathing reverts spontaneously and oxygen is not usually required.)
    Rationale – Have oxygen available in case it is needed to prevent hypoxia. Provides information that the seizure is over.
  13. During the period of deep sleep following the clonic phase, the patient should be left in the recovery position to maintain an airway and should not be disturbed, allowing the patient to recover in their own time. This period can last up to 30 min.
    Rationale – This allows the patient to recover naturally. Putting the patient in the recovery position allows the tongue to fall forwards away from the airway and secretions to drain from the mouth.
  14. The patient may be disorientated and should be calmly reassured explaining what has happened. Ensure patient comfort by offering a wash, change of clothing, etc., as necessary. Assist the patient to a comfortable position in bed with padded bed rails up, according to local policy. The bed should be at the lowest position with wheels braked. Place the call bell or intercom system within reach, and provide a quiet, nonstimulating environment.
    Rationale – Explanation and reassurance reduce the patient’s anxiety. Stay with the patient until they are fully recovered because some patients remain confused for a period or become violent. Provides for continued safety. Patients in the postictal state are often unable to verbalise their   needs and may try to get out of bed, which places them at heightened falls risk.
  15. Perform hand hygiene.
  16. All seizures must be documented and reported.

Note: If a seizure or seizures occur in rapid succession and last 30 min or longer this is called status epilepticus (Leach & Davenport 2014).This requires urgent medical intervention. If there is no previous history of seizures or a change in the pattern/length of seizures, the patient’s doctor should be informed.

Ongoing care, monitoring and support

  • After a seizure, conduct a head-to-toe assessment, including an inspection of the mouth and tongue for breaks in mucous membranes from bites and the presence of broken teeth.
    Rationale – Determines the presence of any traumatic injuries during the seizure.
  • When the patient is fully awake, ask them whether there was any warning aura prior to the seizure and whether it can be described (e.g., a smell or taste).
    Rationale – Provides information of an early warning of another seizure.
  • Provide for ongoing patient safety.
  • Monitor respiratory status for compromise (oxygen saturation, respiratory rate, depth of respiration, skin colour) after administration of benzodiazepines.
    Rationale – Drugs used during the seizure may depress respiration.
  • Inspect the patient’s environment for potential safety hazards (e.g., extra furniture). Request removal of safety hazards, if possible.
  • Place the patient’s bed or trolley at the lowest position, with the wheels braked and with padded bed rails up, according to local policy. Make sure that the call bell or intercom system is within reach, and provide a quiet, nonstimulating environment.
  • Assemble equipment at the bedside in anticipation of a further seizure including:
    • oral airways of the correct size
    • oxygen, face mask, or nasal cannula
    • suction with tubing and suction
    • pulse oximetry and blood pressure monitoring equipment
    • personal protective equipment as appropriate
    • equipment for intravenous access
      Rationale – Ensures that emergency equipment is accessible if another seizure occurs.
  • At an appropriate point (i.e. not immediately after a seizure) discuss with the patient any individual triggers that may induce a seizure such as:
    • lack of food and sleep
    • excessive heat
    • constipation
    • menstruation
    • alcohol
    • anxiety or stress. 
      Rationale – Assists the patient to avoid situations which may induce a seizure.

Documentation and reporting

  • Nurse’s observations before, during, and after the seizure; provide a detailed description of the type of seizure activity and sequence of events. Document in the patient’s nursing notes the following:
    • the time at which the seizure occurred
    • what the patient was doing at the time
    • any aura reported or cry heard prior to the seizure
    • any loss of consciousness
    • which parts of the body were affected and any sequence to this
    • any stiffening or jerky movements
    • urinary or faecal incontinence
    • duration of the seizure (ictal phase)
    • duration of the recovery period (postictal phase) 
    • the patient’s behaviour after the seizure.
  • Patient and family education (see above).
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