1 / 37

J. Iverson Riddle Developmental Center

J. Iverson Riddle Developmental Center. Seizure Documentation. Accurate descriptions of seizures are a valuable guide for the medical staff in providing appropriate medical treatment. Seizure Observation tips:. Describe observations in simple terms. Describe only what is actually seen.

akasma
Download Presentation

J. Iverson Riddle Developmental Center

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. J. Iverson Riddle Developmental Center Seizure Documentation

  2. Accurate descriptions of seizures are a valuable guide for the medical staff in providing appropriate medical treatment.

  3. Seizure Observation tips: • Describe observations in simple terms. • Describe only what is actually seen. • Describe events in the order in which they happened. • Note the time started and ended.

  4. Observations before, during, and after a seizure are very important.

  5. When observing a seizure ask yourself the following questions: • What was the person doing just before the seizure? • Did the person cry out or attract your attention in any way?

  6. When observing a seizure ask yourself the following questions: • Does the person have frequent staring episodes? • Was the person confused or did they lose consciousness?

  7. When observing a seizure ask yourself the following questions: • Did the person respond when spoken to or touched? • Did the person’s body become limp or stiff?

  8. When observing a seizure ask yourself the following questions: • Did the person fall to the floor or did his head drop? • Did the person have jerking of the body? Mild or severe?

  9. When observing a seizure ask yourself the following questions: • Was the jerking over the entire body or on one side or limb of body? Which side? • Did the person’s eyes change? (Blinking, staring, pupils enlarged)

  10. When observing a seizure ask yourself the following questions: • Did the person lose control of bladder or bowel? • Did the person’s skin color change? (Pale, flushed, or bluish tint - Cyanosis)

  11. When observing a seizure ask yourself the following questions: • Were there any unusual actions such as lip smacking, humming, picking at clothes, or wandering around in a disoriented manner?

  12. When observing a seizure ask yourself the following questions: • How long did the symptoms occur? • After the episode, what was the person’s state of alertness? Confused, dazed, or sleepy? If so , how long?

  13. When observing a seizure ask yourself the following questions: • If the person is able to respond, ask if there was any “warning” that the episode was beginning such as a strange feeling, sound or odor? (Aura)

  14. Always report to the nurse immediately when the following occurs: • The person has a seizure for the first time. • The seizure is prolonged, severe, or different from usual seizures.

  15. Always report to the nurse immediately when the following occurs: • The person has been injured. • The person has one seizure after another • The person does not start breathing after the seizure.

  16. Documenting Seizures • Each seizure must be documented on the seizure checklist in the individual’s record. • An accident report must be completed of the person gets injured.

  17. Documenting Seizures A note should be made in the nurses notes: • If anything unusual happens during the seizure. • If the person has an injury. • If the person goes into a deep sleep or is confused after the seizure.

  18. Vagus Nerve Stimulator(VNS) • Some people who live at JIRDC have an implanted device called a Vagus Nerve Stimulator(VNS). It is important to document the number of times that magnet is used.

  19. Seizure Record • Section 1 Date ex. 8/10/2014 Time ex.9:39 AM Indicate a.m. or p.m. (do not use military time) Duration Specify # of min. and sec.

  20. Seizure Record • Section 2 Circle yes or no if the person was alert or responds to touch / voice

  21. Seizure Record • Section 3 Check if the person was confused / unaware or unconscious

  22. Seizure Record • Section 4 (Muscle Tone) Check all that apply to each seizure. - Limp - Stiff - Falls to floor / ground - Head Drops

  23. Seizure Record • Section 4 (Muscle Tone) If none of these descriptions apply check the “No change” box

  24. Seizure Record • Section 5 (Muscle Activity) Check the best description of each seizure. - Mild Twitching - Severe Jerking

  25. Seizure Record • Section 5 (Muscle Activity) If neither of these descriptions apply check the “No change” box.

  26. Seizure Record • Section 6 (Location / Area of Body) Check the best description of each seizure. - Entire Body - (R) Right Side - (L) Left Side

  27. Seizure Record • Section 6 (Location / Area of Body) If neither of these descriptions apply check the “No change” box.

  28. Seizure Record • Section 7 (Eyes) Check the best description of each seizure. - Blank - Blinking - Enlarged pupils

  29. Seizure Record • Section 7 (Eyes) If neither of these descriptions apply check the “No change” box.

  30. Seizure Record • Section 8 (Other) Check all that apply to each seizure. - Loses Bladder Control - Pale / Sweating / Appeared frightened - Cyanosis (Blue)

  31. Seizure Record • Section 8 (Other) Check all that apply to each seizure. - Difficulty breathing - Lip smacking / Chewing - Unusual movement

  32. Seizure Record • Section 9 (STATUS AFTER SEIZURE) Check the best description after each seizure. - Confused - Deep Sleep - Resumed previous activity immediately

  33. Seizure Record • Section 10 (VNS MAGNET USED) If the person has a VNS implant, indicate the number of times that the magnet is used. NOTE – If the person does not have a VNS mark as N/A.

  34. Seizure Record • Section 11 (Recorded by - Signature / Title) Sign and indicate title (ex. TR I; HC; RT; etc.)

  35. Seizure Record • Section 12 Medications Given (Nurse to complete) If the person needs medications, the nurse will record information in this area.

  36. Seizure Record • Section 12 Medications Given (Nurse to complete) The name of the medication, date, time given and the nurses signature will be recorded in this section.

  37. Practice Documenting a seizure While walking to the workshop with a group at 10:00am, Tommy Brown suddenly falls to the ground, and is unconscious. He does not respond to touch and is not alert. His body is stiff, followed by severe jerking on the left side. When checked, his pupils are very large (dilated). During the assessment, you note that he lost control of his bladder and has a bluish color (cyanosis) around his mouth. The seizure activity lasts for 5 minutes. Tommy sleeps deeply for 1 1/2 hours after returning to the cottage.

More Related