Policy Manual sample

MDT Home Health Care Agency, Inc. 108 SEIZURE PRECAUTIONS PURPOSE: Seizure precautions are used to prevent injury to a patient who experiences a seizure and to aid in diagnosis by observing and recording seizure activity. RESPONSIBLE PERSONNEL: RN, LPN, HHA SPECIAL CONSIDERATIONS: Patients and caregivers should be included in planning appropriate intervention during the seizure. The nurse should assess the patient's or caregiver's knowledge of appropriate interventions so that an appropriate teaching plan can be developed. An assessment of the living conditions for potential safety hazards and appropriate suggestions for their correction is important. If the patient will not use a bed with siderails, the family should be instructed to make the bed as low as possible, to move one side against the wall and to remove sharp edges and objects from the immediate area. If the patient is bedbound, the siderails should be up at all times. The caregiver should be instructed to observe and document any potential precipitating factors, to note the point of origin and the progression, the type of movement and which body areas were involved, the presence of incontinence, breathing patterns, the duration, and conditions which occurred after the seizure (i.e., unconsciousness, weakness, confusion). If the nurse observes the seizure, this information should be recorded in the patient's clinical record and reported to the physician. PROCEDURE: 1. Clear the patient's environment of hard or sharp objects. 2. Lower patient to the floor if he or she is in a standing or sitting position. 3. Place pillow under patient's head. 4. Do not force anything between patient's teeth. 5. Protect patient's head. 6. Push away furniture the patient may strike. 7. Loosen restrictive clothing, but do not interfere with patient's movements. 8. Wipe vomitus or excess saliva from mouth to maintain open airway. 9. Observe patient for: • length of seizure • states of seizures • repeated seizures • post seizure mental status 10. When patient awakens from seizure, speak with reassuring voice. Tell them where they are and what has happened. 11. If the patient does not awaken from one seizure before another begins, call 911 and activate EMS system. 12. Assist patient with comfort measures. DOCUMENTATION: Document all findings in patient's clinical record and document any interventions that were initiated. Document all teaching and the response of the caregiver to that teaching. If further action is indicated, document follow-up/notification of Clinical Supervisor and/or physician.