- 0Sep 27, '11 by username33Hello!
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?
- 7,280 Visits
- 1Sep 28, '11 by NCRNMDMIf the patient was non-verbal, and the CNA reported that he was seizing, he was probably postictal when you found him. Since he has a history of seizures, the seizure isn't particularly disturbing, but it needs to be investigated. I would've checked his pupils, done a neuro assessment, asked the CNA for the full story of how he was found and exactly what was happening, possibly checked BS, taken vital signs, and continued to monitor him. Of course, I would've notified the MD, and asked for orders. If I thought that the Dilantin level was going to be sub-therapeutic when it was drawn the next day, I might have asked the MD for orders for a PRN or stat med to give for the remainder of the day in case the patient began to seize again. After I had done all of that, I would've charted everything. I think you did the right things though. It sounds like you pretty much covered all your bases.
- 2Sep 28, '11 by NCRNMDMI would chart something like, "1200- Called to patient's room (room number one) by CNA Smith who reported that pt was having, "jerking movements" which she took to be a seizure. Upon arrival to pt room, I did not note any seizure activity, but did note that the patient was unresponsive to commands and sweating profusely. Assessed HR, breath sounds, and checked pts blood glucose, all of which were normal. Notified physician of situation, and received orders to draw a Dilantin level in AM. Pt has a history of seizures, and takes Dilantin 300 mg HS. M. Melton, RN" Only chart exactly what you know, exactly what was said, exactly what you did, and exactly what the patient said or looked like. Don't ever make assumptions, and don't ever write your opinion. In this instance, don't write that the patient was postictal because you don't know that for sure (even though it's very probable). Just be thorough, cover all your bases, and document all that you did, reported, observed, and said. Cover yourself and ensure that it's apparent that you gave quality care.
- 2Sep 29, '11 by NCRNMDMSorry, I didn't mean to say unresponsive to commands in my charting example. I meant to say, "pt was non-verbal and sweating profusely." I just caught my mistake. So the documentation should read, "1200- Called to patient's room (room number one) by CNA Smith who reported that pt was having, "jerking movements" which she took to be a seizure. Upon arrival to pt room, I did not note any seizure activity or jerking movements, but did note that the patient was non-verbal and sweating profusely. Assessed HR, breath sounds, and checked pts blood glucose, all of which were normal. Notified physician of situation, and received orders to draw a Dilantin level in AM. Pt has a history of seizures, and takes Dilantin 300 mg HS. M. Melton, RN"