Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 5 Nervous System^255



  • Risk for fall

  • Anxiety


NURSING INTERVENTION



  • Monitor patient during the seizure for breathing, skin color (cyanosis)—
    patient may have diminished oxygenation during seizure.

  • May need supplemental oxygen post-seizure.

  • Keep oxygen equipment and suction equipment and emergency airway man-
    agement equipment at bedside (intubation may be performed by anesthesi-
    ologist, nurse anesthetist, or respiratory therapist).

  • Monitor duration of seizure and progression of symptoms.

  • Monitor for incontinence of bladder or bowel.

  • Monitor for status epilepticus—prolonged seizures or repeated seizures,
    considered a medical emergency.

  • Position patient to decrease risk of injury:

    • remove objects that may injure patient.

    • turn patient on side to reduce risk of aspiration.

    • do not insert anything in patient’s mouth during seizure.



  • Assess the patient post-seizure.

  • Explain to the patient:

    • Medication use, side effects, and interactions.

    • Importance of taking medications on time, not skipping doses.

    • Importance of checking with prescriber before taking any new medica-
      tions or over-the-counter (OTC) medications or supplements.

    • Have lab tests for drug level of antiepileptic drugs checked as directed.




Crucial Diagnostic Tests


X-ray


An x-ray of the skull or spine is done to determine the presence of fracture, dis-
location, calcification into soft tissue areas, degree of curvature (normal antero-
posterior curve of areas of the spine, versus lateral curvature of scoliosis).

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