Med-Surg Study Guide Latest Update Winter 2021/2022

• 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 • 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 ▪ 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 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