seizure

If 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.

Thank you, Mattmrn2013, for your reply. I have difficulty documenting situations like that one. Could you give me an example of charting. For example, '' Called to pt room at 1200....... and so on....''

Thank you!:)

I 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.

Sorry, 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"

Great! Thanks for explanation!