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Med-Surg Study Guide
Seizures (6)
• Identify different types of Seizures
o Partial / Focal Seizures involves one hemisphere of the brain
▪ Complex Partial (Focal Motor Seizure)
• Impairment of awareness, associated with automatisms
such as
o Lip smacking
o Chewing at clothes
o Fidgeting and other involuntary but
coordinated movements
• Loss of consciousness or black out for several minutes
• Amnesia can occur immediately prior to and after
seizures.
▪ Simple Partial Sensory (Focal non-motor seizure)
• Unusual sensations affecting
o Vision
o Smell
o Taste
o Touch
o Hearing
• Consciousness maintained
▪ Simple Partial Psychological (Focal non-motor seizure)
• Memory or emotional disturbances
• Déjà vu
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• Consciousness maintained
▪ Simple Partial Motor (Focal motor seizure)
• Unilateral abnormal extremity movement
o Head turning spasms
o Generalized Seizures involves two hemispheres of the brain
▪ Grand Mal / Tonic-Clonic / Generalized
• Start by having an aura (seeing or hearing something
that is not there)
o First experience unconsciousness, muscle
stiffness followed by 1 -2 minutes of
rhythmic jerking of extremities.
▪ Biting of the tongue can occur
o Breathing can stop during tonic phase of irregular
during
colic phase.
▪ Absence
• Brief loss of consciousness
• Simple staring episode
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▪ Myoclonic
• Can be symmetrical or asymmetrical
• Brief jerking or stiffening of extremities
• Last seconds
▪ Clonic
• Repetitive jerking movements
• Muscle contracts then relaxes
• Lasts several minutes
▪ Tonic
• Increase in muscle tone
o Muscle stiffness and rigidity
• Loss of consciousness
• Last about 30 seconds to several minutes.
• Associated autonomic manifestations
o Arrhythmia
o Apnea
o Vomiting
o Incontinence
▪ Atonic /Akinetic
• Loss of muscle tone
• Frequently results in falling
• Postictal Phase
o After a seizure
o Fatigue and confusion
o Maintain side lying to prevent aspiration
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o Suction as needed
o Assess and monitor vital signs
o Allow rest
o Determine trigger
• Nursing interventions/actions associated with seizure documentation
o Glasgow coma scale is used
o Seizure Precautions
▪ Oxygen and suction apparatus available
▪ Privacy provided as soon as possible
▪ Side rails up and padded (can use blankets, towels, ect)
▪ Bed in lowest position
▪ Pillow under head
▪ Patient in side-lying position (immediately post seizure)
o Document the events leading to and occurring during and after seizure
o Nursing Care during a seizure
▪ Ease patient to the floor
▪ Protect head with a pad to prevent injury
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NURSING HESI MED SURG STUDY GUIDE
Med-Surg Study Guide
Seizures (6)
• Identify different types of Seizures
o Partial / Focal Seizures involves one hemisphere of the brain
▪ Complex Partial (Focal Motor Seizure)
• Impairment of awareness, associated with automatisms
such as
o Lip smacking
o Chewing at clothes
o Fidgeting and other involuntary but
coordinated movements
• Loss of consciousness or black out for several minutes
• Amnesia can occur immediately prior to and after
seizures.
▪ Simple Partial Sensory (Focal non-motor seizure)
• Unusual sensations affecting
o Vision
o Smell
o Taste
o Touch
o Hearing
• Consciousness maintained
▪ Simple Partial Psychological (Focal non-motor seizure)
• Memory or emotional disturbances
• Déjà vu
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• Consciousness maintained
▪ Simple Partial Motor (Focal motor seizure)
• Unilateral abnormal extremity movement
o Head turning spasms
o Generalized Seizures involves two hemispheres of the brain
▪ Grand Mal / Tonic-Clonic / Generalized
• Start by having an aura (seeing or hearing something
that is not there)
o First experience unconsciousness, muscle
stiffness followed by 1 -2 minutes of
rhythmic jerking of extremities.
▪ Biting of the tongue can occur
o Breathing can stop during tonic phase of irregular
during
colic phase.
▪ Absence
• Brief loss of consciousness
• Simple staring episode
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,LATEST UPDATE!!! CHAMBERLAIN COLLEGE OF
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▪ Myoclonic
• Can be symmetrical or asymmetrical
• Brief jerking or stiffening of extremities
• Last seconds
▪ Clonic
• Repetitive jerking movements
• Muscle contracts then relaxes
• Lasts several minutes
▪ Tonic
• Increase in muscle tone
o Muscle stiffness and rigidity
• Loss of consciousness
• Last about 30 seconds to several minutes.
• Associated autonomic manifestations
o Arrhythmia
o Apnea
o Vomiting
o Incontinence
▪ Atonic /Akinetic
• Loss of muscle tone
• Frequently results in falling
• Postictal Phase
o After a seizure
o Fatigue and confusion
o Maintain side lying to prevent aspiration
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, LATEST UPDATE!!! CHAMBERLAIN COLLEGE OF
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o Suction as needed
o Assess and monitor vital signs
o Allow rest
o Determine trigger
• Nursing interventions/actions associated with seizure documentation
o Glasgow coma scale is used
o Seizure Precautions
▪ Oxygen and suction apparatus available
▪ Privacy provided as soon as possible
▪ Side rails up and padded (can use blankets, towels, ect)
▪ Bed in lowest position
▪ Pillow under head
▪ Patient in side-lying position (immediately post seizure)
o Document the events leading to and occurring during and after seizure
o Nursing Care during a seizure
▪ Ease patient to the floor
▪ Protect head with a pad to prevent injury
LATEST UPDATE!!! CHAMBERLAIN COLLEGE OF
NURSING
4|Page HESI MED SURG STUDY GUIDE
