Physiological Adaptation Q 5
A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would not be included?
A. Notify the physician.
B. Restrain the patient's limbs.
C. Position the patient on his/her side with the head flexed forward.
D. Administer rectal diazepam.
Correct Answer: B. Restrain the patient’s limbs.
During a witnessed seizure, nursing actions should focus on securing the patient’s safety and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. Use and pad side rails with the bed in lowest position, or place the bed up against the wall and pad floor if rails are not available or appropriate.
Option A: The nurse should notify the physician in the event of a seizure so he could prescribe the correct medication. Ascertain knowledge of various stimuli that may precipitate seizure activity. Alcohol, various drugs, and other stimuli (loss of sleep, flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity.
Option C: A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back, blocking the airway. Turn head to side and suction airway as indicated. Insert plastic bite blocks only if the jaw is relaxed. Helps maintain airway patency and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Wooden tongue blades should not be used because they may splinter and break in the patient’s mouth.
Option D: Rectal diazepam may be a treatment ordered by the physician, who should be notified of the seizure. Diazepam may be used alone (or in combination with phenobarbital) to suppress status seizure activity. Diastat, a gel, may be administered rectally, even in the home setting, to reduce the frequency of seizures and need for additional medical care.