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).