Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 17-3

Employing Seizure Precautions and

Seizure Management (Continued)

Comments

14. If the patient is in bed, remove the pillow and raise side
    rails.


15. Do not restrain patient. Guide movements, if necessary.
    Do not try to insert anything in the patient’s mouth or
    open jaws.


16. If possible, place patient on the side with the head flexed
    forward, head of bed elevated 30 degrees. Begin administra-
    tion of oxygen, based on facility policy. Clear airway using
    suction, as appropriate. (Refer to Skill 14-9, Suctioning the
    nasopharyngeal and oropharyngeal airways, Chapter 14,
    Oxygenation.)


17. Provide supervision throughout the seizure.


18. Establish/maintain intravenous access, as necessary.
    Administer medications, as appropriate, based on medical
    order and facility policy.


19. After the seizure, place the patient in a side-lying position.
    Clear airway using suction, as appropriate.


20. Monitor vital signs, oxygen saturation, and capillary
    glucose as appropriate.


21. Allow the patient to sleep after the seizure. On awakening,
    orient and reassure the patient.


22. Remove PPE, if used. Perform hand hygiene.

ExcellentSatisfactoryNeeds Practice