I am a new nurse working in LTC. Today one of my pts had a seizure. I was called to the pt's room by CNA. She stated that pt had jerking movements. I didn't notice any on my arrival. Pt was profusely sweating and non-verbal. This is what I did:
-listened lung sounds,
- listened heart
-checked blood glucose level, even though pt wasn't diabetic
_pt had Hx of seizure disorder and was on Dilantin 300mg HS. So I called MD and received the order to drow the blood tomorrow for Dilantin level
-documented in nursing notes the pt's situation, assessments and my interventions
I am wondering if I missed anything in my assessment? Do I need to check for PERLA? Neuro assessment? What exactly do I need to assess? When I came to the pt's room, he was non-verbal.
What shoud I pay attention next time in similar situation?