A nurse is caring for a client who has a seizure disorder.

Exhibits

A nurse is caring for a client who has a seizure disorder. What following actions should the nurse take? (Select all that apply.)

Choice A: Time the duration of the seizure

Reason: Timing the duration of a seizure is crucial for several reasons. Firstly, it helps in determining the type of seizure and its severity. Seizures lasting more than 5 minutes are considered medical emergencies and may require immediate intervention to prevent complications such as status epilepticus, which is a prolonged seizure that can cause brain damage or death. By recording the start and end times, healthcare providers can assess the effectiveness of treatments and make necessary adjustments. Additionally, this information is vital for documenting the patient’s medical history and for future reference in managing the condition.

Choice B: Administer supplemental oxygen to the client

Reason: Administering supplemental oxygen is essential during a seizure, especially when the client’s oxygen saturation levels drop below the normal range of 95-100%. In the provided scenario, the client’s oxygen saturation is 86%, which is significantly low and indicates hypoxemia. Hypoxemia can lead to further complications, including brain damage due to insufficient oxygen supply. Providing supplemental oxygen helps maintain adequate oxygen levels in the blood, ensuring that vital organs, including the brain, receive enough oxygen to function properly. This intervention is critical in preventing hypoxic injuries and promoting recovery post-seizure.

Choice C: Place a tongue depressor in the client’s mouth

Reason: Placing a tongue depressor in the client’s mouth during a seizure is not recommended and can be dangerous. This outdated practice was once believed to prevent the client from biting their tongue, but it poses significant risks. The client could bite down on the depressor, causing dental injuries or even breaking the depressor, leading to choking hazards. Modern seizure management guidelines advise against placing any objects in the mouth during a seizure. Instead, the focus should be on ensuring the client’s safety by clearing the area of any harmful objects and positioning them safely.

Choice D: Turn the client to the side

Reason: Turning the client to the side, also known as the recovery position, is a critical intervention during a seizure. This position helps maintain an open airway and reduces the risk of aspiration, which can occur if the client vomits or has excessive saliva. Aspiration can lead to serious respiratory complications, including pneumonia. By positioning the client on their side, gravity helps drain fluids from the mouth, preventing them from entering the airway9. This simple yet effective measure is a standard practice in seizure management to ensure the client’s safety and comfort.

Choice E: Restrain the client

Reason: Restraining a client during a seizure is not recommended and can be harmful. Seizures involve involuntary muscle contractions, and attempting to restrain the client can lead to injuries such as fractures, muscle tears, or dislocations. Additionally, restraint can increase the client’s agitation and stress, potentially worsening the seizure. The appropriate approach is to ensure the client’s safety by removing nearby objects that could cause injury and allowing the seizure to run its course. Gentle guidance and support should be provided without applying force.