Question

John Moore, a 22-year-old patient weighing in at 150 pounds, arrived at the emergency department (ED) after being thrown from his horse and passing out for a few minutes; later he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. His respirations were very shallow, and his lips and nail beds turned blue. The patient lost control of his bladder and bowel. The patient bit his tongue and was bleeding from his mouth. The radiology department called and was now ready for the patient. List the correct order of actions that should be taken by the nurse. Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure, and the specific nursing care for each stage. The ED physician orders the following: Valium (diazepam) 10 mg every 10 to 15 minutes prn for seizures (maximum dose of 30 mg). Once seizures stop, administer Dilantin (phenytoin) 10 mg/kg IVPB. ECG monitoring continuously, VS, GCS, neuro checks every 30 minutes. Explain what meds the nurse should provide, in what order, and how they should be administered.

Answer 1

Answer : A seizure can be defined as abnormal ,uncontrolled electrical activity in the brain cells

• The patient experienced with tonic -clinic seizues or grand mal seizures .
• Seizures often has three distinct phases : aura ,ictus and postictal state  .
• The first phase involves alterations in smell, taste and visual perception ,hearing and emotional state .this is known as aura ,which is actually a small partial seizure that is often followed by larger event .
• The seizue is known as ictus .there are two major types of seizure : partial and generalized .what happens to the person during the seizure depends on where in the brain the disruption of neural activity occurs .
• Following a seizure ,the person enters into the postictal state .drowsiness and confusion are commonly experienced during this phase .the postictal state is the period in which the brain recovers from the insult it has experienced .

Specific nursing care :

• Patient safety is one of the main consideration during seizure activity .it is important to remembered that DRSABCD
• D- danger ,R -response ,S- send For help ,A - airway , B- breathing ,C - circulation , D - defibrillation .
• Nurse should must stay with the patient Whs call For help .
• It is important to note the time that the seizures started and its characteristics .
• Protection should be given to patient head .
• Do not restrict the movement of patient , it may cause musculo skeletal damage ,clear any risk area from patient .
• Attempts can be made to turn the patient in to recovery position .
• Check For patent airway .
• Provide mouth gag to prevent tongue bite .
• Monitor vital signs .
• Administer anti convulsive medications as prescribed by doctor .

Doctor orders :

If the patient is having convulsions ,We should check the vital signs first and provide  valium to decrease the jerky movements of the body and then We should provide phenotoin bolus and after check For GCS and neuro checks and lastly should take ECG .

The drug valium  should be given IV slowly  10-15 minutes

Phenytoin should be given bolus first and then add in drip For maintenance .