Seizure Precautions for Pediatric
Bedside Nurses

Over the course of their careers, many inpatient pediatric nurses will care for a patient with seizures or who is at risk for seizures. Although often anxiety-provoking, the fear can be diminished by thinking critically about each child’s seizure. The nursing management of pediatric seizures, for which patient safety is the priority, should be driven by the clinical presentation of the child’s event. This article will present an algorithm to assist bedside nurses in safely caring for children with a variety of seizure types. The algorithm can be used as a road map to assist staff nurses in safely and appropriately stocking patients’ bedsides with emergency equipment as needed for children with seizures. However, to understand the clinical symptoms of a seizure, it is important to first review basic pathophysiology and seizure classification.

What Is a Seizure?

Seizures are a common neurologic disorder of childhood, and many pediatric nurses will care for children with epilepsy during their careers. The term “seizure precautions” is used frequently in nursing practice; however, its definition varies among institutions. Childhood epilepsy has many phenotypes, and while some children require airway clearance and ventilatory support in the event of a seizure, many will not. The bedside equipment for a child with seizures should reflect the patient’s symptoms. To that end, an algorithm based on seizure classification and current practice in seizure precautions is presented to aid bedside nurses in safely caring for children with seizures. The algorithm may also be used to assist in educating parents about the safest way to care for their child at home, without sending contradictory messages about different needs for equipment in the hospital and in the home.

Special Circumstance: Medication Taper

Children who have intractable partial epilepsy, about 30% of children with seizure disorders (Nadkarni et al., 2005), often undergo evaluation with long-term video EEG monitoring. In many cases, this is performed if surgical ablation of an epileptic focus is being considered (Major & Thiele, 2007). The pre-surgical evaluation often requires multiple hospitalizations with a goal to identify a discrete and operable seizure focus. The sole means for obtaining this information is by observing the child’s seizure; therefore, the medical staff may decide to quickly (over several) taper the child’s anti-epileptic drugs in the controlled hospital environment to provoke a seizure. By comparison, neurologists caring for patients who have been seizure-free for at least two years (Sirven, Sperling, & Wingerchuk, 2003) and who wish to wean these patients off anti-epileptic medication in the hopes that they may no longer require medications, are recommended to do so over an average of three months (Ranganathan & Ramaratnam, 2006). Seizure safety in either of these populations is paramount; however, those children who undergo surgical evaluation due to persistent breakthrough seizures on anti-epileptic medication are already at an increased risk for seizures, which only increases further upon admission to the hospital given their rapid medication taper. Findings from a study of children presence and young adults without primary generalized epilepsy showed a fourfold increase in frequency of generalized tonic-clonic seizures between patients whose medication was tapered over four days compared to those whose medication was tapered over 10 days (Malow, Lynch, Blaxton, & Mikati, 1994). Although there is no concrete recommendation regarding length of time to wean medication in the hospital, this study highlights the unpredictability of the seizure type that a child may experience during the taper. Therefore, it is prudent for the bedside nurse to pad the child’s side rails and stock all emergency supplies at that patient’s bedside (Gilbert, Counsell, Guin, & Snively, 2000).

From Symptoms to Supplies

Often, nurses interpret the phrase “seizure precautions” to mean that the child requires full resuscitation equipment (such as bag valve mask, suction, cardiorespiratory monitor) at his or her beside, no matter the type of seizures experienced. Alternatively, the bedside supplies chosen might reflect the symptoms experienced and the circumstances under which the child was admitted to the hospital. As will be described, a seizure-focused algorithm can be used to determine bedside needs, with a likely cost-containment advantage (see Figure 1). By following the algorithm, if a child has staring spells lasting five seconds and is not being weaned off anti-epileptic medications, there is no need for a bag and mask at that child’s bedside because there is no risk of respiratory compromise. However, if the child has a complex-partial seizure involving staring spells, which secondarily generalizes to a tonic-clonic seizure, it is crucial to have appropriate supplies at the bedside in the event of cyanosis and/or aspiration of secretions (Pullen, 2003). If the child has minimal motor involvement with his or her seizures and no respiratory compromise, there is again no need to have a bag and mask on hand at the bedside. However, if the child has seizures with extremity jerking and there is a potential for injury by hitting the bedrails, it would be prudent to apply seizure pads to the railings (Pullen, 2003). Regardless of the seizure classification, if a child experiences pooling of secretions, oxygen desaturation, or extensive motor involvement (such as rhythmic jerking), there should be necessary safety precautions in place at the bedside (bag and mask, suction, and seizure pads on the bed rails). Furthermore, if limited information is available regarding seizure classification, the bedside nurse must be prepared for any and all seizure types.

Figure 1.Bedside Seizure Safety
Does your patient have ahistory of seizures? |

YES | | NO |

What are the clinical symptoms of the event? | | Maintain routine safety precautions (bedrails up) |

Symptoms with neitherrespiratory compromise normotor involvement (staringspells, eyelid fluttering) | | Motor symptoms withoutrespiratory compromise(myoclonic jerks) | | • ANY symptom accompaniedby respiratory compromise(tonic-clonic movements)• Motor symptoms accompaniedby LOC (atonic seizures) |

Is your patient on amedication wean orcompletely off seizuremedication? |

NO | | YES | SUPPLIES*Bag, valve mask (if clinically indictated)Suction (canister and catheter)Cardiorespiratory monitor Pulse ox Seizure pads (if clinically indicated) | Maintain routine*Bedside RN needs to assess not only that equipment is in place, but also that it functions properly at each shift change. safety precautions(bedrails up) |
Nursing Impact

Aside from the benefits that the algorithm has for children and their families, there is an additional benefit to staff nurses. A constant balancing act occurs between the care bedside nurses provide to their patients and the time spent in that endeavor. Frequently, nurses spend large amounts of time at the beginning of their shift collecting supplies for each patient, some of which are unnecessary. Alternatively, situations may arise in which a particular piece of equipment is needed emergently but is not at the bedside. Both of these scenarios cause anxiety and stress, and neither is efficient for the nurse nor ideal for the patient. Consulting the bedside algorithm when the child is admitted to the unit allows the nurse to anticipate what supplies that child might require during the hospitalization and to prepare for the admission in a calm, non-emergent way. This saves time for the nurse and minimizes the risk of being unprepared for emergency situations. Additionally, the bedside nurse should perform a test of the equipment to ensure that all supplies are properly functioning when they are placed at the patient’s bedside. This test should also be repeated at each shift change, when another nurse assumes care of the child.

REFFERENCE: http://www.pediatricnursing.net/ce/2012/article36191194.pd

Seizure Precautions for Pediatric
Bedside Nurses

SUBMITTED BY:
Rosemarie Languido
Mafe Mana-ay
RN HEALS 2