Seizure pts 101

  1. fyi for new er nurses: ive worked er for two yrs - my biggest pet peeve is when nurses/techs/whoever, let seizure pts ambulate to the bathroom, down the hall, to the phone, wherever. does it not make sense that pts coming to the er for seizure activity should not be allowed to get out of the bed until they have been treated? pts will argue that they are fine..dont let them persuade you. we had one man go to the bathroom after his second load dose of dilantin (he had just gotten it) - he shut the door and locked it. 30min later, the nurse notices he never came out. security had to come unlock the door. he obviously seized and fell hitting his head on the sink. he never recovered. i dont let seizures pts get out of bed until at least 30 min after their second load dose - even then, they shouldnt be sent off alone.
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  2. 20 Comments

  3. by   cursenurse
    i have been in the er for about three weeks now, and it seems to be the practice to let the seizure patients ambulate freely(in fact i had one just last night). what practical suggestions could you provide to keep these patients safe and at the same time keep the nurse from having to babysit them(as if i have the time)?
  4. by   bellehill
    This is a problem on the floor too. A new admission in with seizures asking to go down and smoke. I can't tie them in bed but I can insist a family member be with them (after explaining the risks).
  5. by   traumaRUs
    We encourage use of the urinal/bedpan until completely past the post-ictal period. Dilantin IV bolus usually makes pts pretty sleepy also and we discourage ambulation during this time also.
  6. by   Medic946RN
    I always kinda thought this was basic stuff, but maybe because I was medic for year and years, but the two pt's you never let walk to the bathroom are seizure patients and cardiac patients. You can avoid a lot of codes that way.
  7. by   kelnich
    How can you tell if a patient is faking? Is it pretty obvious?
    I am a student nurse and I work on a med/surg floor as a nurse extern and I had a patient seize on me. This was my first experience with seizures.
    The patient had tonic, clonic movements then stopped and went into decerebrate posturing <?> then back to tonic-clonic.
    I read through her chart and it said she had a history of seizure vs. pseudoseizure. The RN I was precepting under said that most likely she is faking it because she wasn't foaming at the mouth and she didn't have urine loss. Do you have urine loss with all seizures? Not only that, like 10 mins after the seizure the pt wants to eat and she said if the pt is hungry it is most likely not a real seizure.
    Just curious, because this patient does an awesome job of faking it if she was.
    Although I do want to add, that even *I* know not to let the patient ambulate. She wanted to go to the bathroom and I was like "nope, bedpan" so she's like can you bring me one of those things I can sit on by the bed and I was still like "nope." This unfortunate lady was 350+ pounds. If she were to seize on the comode or toilet, there is not a soul who could pick her up.
    Sorry to jump on this thread but it seems to relate.
  8. by   traumaRUs
    Codes in the bathroom - even BIG bathrooms are pretty icky!
  9. by   Spidey's mom
    Quote from kelnich
    How can you tell if a patient is faking? Is it pretty obvious?
    I am a student nurse and I work on a med/surg floor as a nurse extern and I had a patient seize on me. This was my first experience with seizures.
    The patient had tonic, clonic movements then stopped and went into decerebrate posturing <?> then back to tonic-clonic.
    I read through her chart and it said she had a history of seizure vs. pseudoseizure. The RN I was precepting under said that most likely she is faking it because she wasn't foaming at the mouth and she didn't have urine loss. Do you have urine loss with all seizures? Not only that, like 10 mins after the seizure the pt wants to eat and she said if the pt is hungry it is most likely not a real seizure.
    Just curious, because this patient does an awesome job of faking it if she was.
    Although I do want to add, that even *I* know not to let the patient ambulate. She wanted to go to the bathroom and I was like "nope, bedpan" so she's like can you bring me one of those things I can sit on by the bed and I was still like "nope." This unfortunate lady was 350+ pounds. If she were to seize on the comode or toilet, there is not a soul who could pick her up.
    Sorry to jump on this thread but it seems to relate.
    Pseudoseizure is not "faking". It has a psychological aspect to it - please do some further study on it.

    Just because someone doesn't "foam at the mouth" or become incontinent doesn't mean they didn't have a seizure. Seizures manifest themselves in many ways. I've had two generalized seizures and didn't urinate on myself because I HAD JUST GONE TO THE BATHROOM.

    Please don't assume folks are "faking".

    steph
  10. by   Dplear
    I work on a pedi neuro unit and we often see people hungry after seziures. Not everyone has the same type of seziure activity. I have only seen a few people urinate in themselves afterwards or during and I have NEVER seen "foaming" at the mouth. Yes, sometimes they drool a bit but that is all. As for Psuedoseziures, one of the ways we tell when someone is psuedoseizing is to hold their arm up over thier head....then let it drop towards thier face. Sounds cruel but in a real seziure they do not have control of their muscle and will hit their face. In a psuedoseizure they will either let thier arm miss their face or turn their head. It is a natural instinct to protect your face and they do it without realizing they are doing it.

    Dave
    Last edit by Dplear on Aug 15, '04
  11. by   CEN35
    How do you know if a seizure pt is faking it? OR even a pt who is allegedly passed out?

    Well we have had a few come through ours over the years. They are looking for ativan, valium or something.

    Hold their arm above their face while they are lying supine, and let go of it. You will will be able to tell by the way their arm falls, if they are controlling it. If they are really "out" from whatever, (i.e. drug overdose, ETOH, SZ, or anything else), their arm will fall on their face, or over their body. Most who are faking it, it will fall to their side or above their head.

    True story: It's somewhere else in this section (although two or three uears old)

    A patient came in with ????????? (Don't remember that part) C/O seizure. Checked the guy out, and was acting unresponsive. The arm ALWAYS fell to his right side witht the "Drop test" as we called it. So we left the room. The doc came in and examined the pt, and left the room. The doc said just let him hang out in there for a while.

    In the meantime we got a new patient in the room next to him (seperated by a curtain), who was a trauma patient. I don't remember what was wrong with him, but we had to sedate him and give him some pain releif.

    So here's how it went:

    Doc: Give him some morphine, eh 4mg IV.

    Fake SZ pt (yelling): Morphine? Where's my morphine? I want morphine too!!!!

    Me: But he's in a lot of pain sir.

    Fake SZ pt: I'm in a lot of f*cking pain you want to hear me moan?

    Doc: Give him some versed too, say 2mg IV.

    Again from the next room over Fake SZ pt: Vesred? Holy crap he's gettinig versed? I need versed, alot of it, I just had a seizure.

    This went on for about 10 minutes while the alleged SZ pt listened to what the other pt was getting, and then telling us what he wanted. Finally after about 10 minutes, the fake SZ pt got mad, pulled out his IV and said "I'm leaving this place, I'm not getting any of the godd stuff!"

    later..........
  12. by   nursemike
    Quote from kelnich
    How can you tell if a patient is faking? Is it pretty obvious?
    I am a student nurse and I work on a med/surg floor as a nurse extern and I had a patient seize on me. This was my first experience with seizures.
    The patient had tonic, clonic movements then stopped and went into decerebrate posturing <?> then back to tonic-clonic.
    I read through her chart and it said she had a history of seizure vs. pseudoseizure. The RN I was precepting under said that most likely she is faking it because she wasn't foaming at the mouth and she didn't have urine loss. Do you have urine loss with all seizures? Not only that, like 10 mins after the seizure the pt wants to eat and she said if the pt is hungry it is most likely not a real seizure.
    Just curious, because this patient does an awesome job of faking it if she was.
    Although I do want to add, that even *I* know not to let the patient ambulate. She wanted to go to the bathroom and I was like "nope, bedpan" so she's like can you bring me one of those things I can sit on by the bed and I was still like "nope." This unfortunate lady was 350+ pounds. If she were to seize on the comode or toilet, there is not a soul who could pick her up.
    Sorry to jump on this thread but it seems to relate.
    An EEG during the seizure activity is fairly diagnostic, but seizures are funny critters. In our Epilepsy Monitoring Unit, we use continuous EEG and videotape so the neurologists can study seizures and patterns of seizures. Patients are generally off antiepileptics for a week or more during stay, and we sometimes use sleep deprivation to try to provoke seizures. The goal is not only to rule out pseudoseizures (which may seem real enough to the person experiencing them) but in some cases to surgically treat localized lesions that can lead to seizures (difficult tongs birth is a classic example.)
    There are also blood tests and sometimes radio-isotope tests we do, and I pretty well know my way to the CT and MRI labs.
    Our EMU patients are usually ad-lib to ambulate on the unit, except immediately post-ictal. In a bit over a year, I don't know of anyone seizing in the hall. Brains are apparently a bit like cars--they do all sorts of strange things, but when you take them to the "mechanic" they start running perfectly. It's surprisingly hard to get someone to seize when you want them to. But as far as falls, these folks are at risk for falls on the street all the time, so falling in the hospital isn't really worse.
    We don't generally try to lift a tonic/clonic patient back into bed, unless they are pretty small and we have plenty of horse. Again, waking up on the floor isn't a new experience for most of them. Turn them to their side, if you can, but you usually can't.
    Despite what I was told in nsg school, we never, ever put anything in an epileptic's mouth during a seizure. I have yet to see a tongue bite, though I've heard it does happen.
    Sometimes a nurse may carefully do suction to protect the airway, but you really don't want to provoke the gag reflex.
    I have yet to see "foaming at the mouth"--sometimes there's a bit of spittle.
    We get a lot of absence seizures, too, which are really hard to diagnose at a glance--is he seizing, or watching t.v.? And a few localized seizures, where maybe just the arm is seizing. I don't know how many of those are pseudoseizures--some, but not all.
    The most amazing part of the EMU is how little drama there actually is.
  13. by   needsmore$
    Remember also to CYA with your charting-if patients are refusing bedpan/urinal-and demanding to amb to BR-make sure you document in your notes that pt and/or family was informed about safety concerns-ie: possibility of seizing while in BR/hallway, risk of injury, sedation, etc. Document patient and/or family responses using quotes. If you are certain that the patient should not get OOB then notify your physician and get retraint order if applicable. Again, remember JCAHO requirements for restraint use and appropriate documentation to CYA. This way, if something untoward occurs, at least you have hopefully covered yourself and your institution from a medical-legal problem ( not that patients like to sue hospitals for anything!!!) LOL

    Anne
  14. by   RN92
    I have found that some of our older seizure pts are very familiar with signs and symptoms of seizure activity. We have one lady who always pees on herself and drools at the mouth.
    I have used the hand drop method. Other ways of telling, are to use a yanker to suction the mouth. If the pt "purses" her lips or sucks on the yanker - chances are they are faking it. Another method...(may seem harsh,but it works)- get some saline in a syringe and squirt a small amount to the face. If they are faking, they will twinge. I hardly ever have to go that far - but some patients are very convincing. I had a pt once, tell me in advance that he felt a seizure coming on. I realize people have auras, but 20 to 30min pryor??? Please!! Also, on men - you can drop the arm/hand over their "private parts" -they NEVER hit it if they're faking it. Its really sad for the patients that arent faking it. And, we have a lot of patients that arent.

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