QLexNursing

✅ Guide the client to the bed from the floor – Indicated

💠 Safety is the top priority: During a seizure, the nurse’s main goal is to prevent physical injury. Gently guiding the client to a flat surface or the bed ensures that they do not fall and sustain head or musculoskeletal trauma.

💠 Avoid forceful restraint: Holding the client down or restricting their movements can cause fractures or dislocations due to the strength of involuntary muscle contractions. Instead, allow the seizure to occur while ensuring safety.

💠 Environmental safety control: Move nearby furniture, sharp objects, or medical equipment away from the client’s immediate area. This minimizes the risk of hitting or cutting themselves during seizure activity.

💠 Clinical significance: Safe positioning and environmental control reduce secondary injuries and allow for effective observation of the seizure’s characteristics and duration.

✅ Place a pad under the client’s head if the client is on the floor – Indicated

💠 Head protection: Cushioning the head prevents traumatic injury from repetitive banging or impact with hard surfaces. A folded blanket, towel, or pillow can effectively absorb shock.

💠 Maintains alignment: Keeping the neck in a neutral position supports proper airway alignment and reduces cervical strain.

💠 Comfort and safety: The soft padding minimizes bruising or scalp lacerations, especially in clients with fragile skin or post-infectious weakness.

💠 Clinical goal: To protect the brain and soft tissues from injury while maintaining airway patency and overall physical stability during convulsive movements.

❌ Place a tongue blade in the client’s mouth – Contraindicated

💠 Airway obstruction hazard: Placing objects, including tongue blades or fingers, in the mouth can obstruct airflow or cause aspiration if dislodged.

💠 Oral injury risk: Inserting any object can break teeth or injure soft tissues such as the tongue, lips, or gums, causing bleeding and further complications.

💠 Evidence-based guidance: Modern seizure management guidelines discourage inserting anything in the mouth; the tongue rarely causes airway obstruction.

💠 Nursing principle: Focus on airway positioning (turning the head to the side) and suctioning after the seizure if secretions or vomitus are present instead of inserting items.

✅ Turn the client to one side or tilt the head forward – Indicated

💠 Prevents aspiration: Turning the client laterally allows saliva, mucus, or vomit to drain from the mouth instead of entering the airway.

💠 Supports airway patency: This position prevents the tongue from falling backward and blocking airflow, improving spontaneous ventilation.

💠 Enhances oxygenation: A side or forward-tilted position optimizes breathing mechanics and reduces the risk of hypoxia.

💠 Promotes postictal recovery: Once the seizure stops, the same position helps the client recover consciousness safely while maintaining airway clearance and oxygen saturation.

✅ Note the time and duration of the seizure – Indicated

💠 Clinical documentation: Accurate timing is essential to determine whether the seizure is isolated or prolonged (status epilepticus, lasting over 5 minutes).

💠 Treatment planning: Knowing the seizure’s duration helps the provider decide on interventions like benzodiazepine administration or changes to anticonvulsant therapy.

💠 Observation details: Record physical manifestations such as limb movement, eye deviation, incontinence, or cyanosis, which aid in diagnosis and care evaluation.

💠 Safety follow-up: After the seizure, note postictal behavior (confusion, fatigue, headache) and provide reassurance while maintaining monitoring for recurrent events.