Seizure Precaution Implementation And Management Policy . - CentraCare
10/3/2019Seizure PrecautionImplementation andManagement Policy andProcedureChandra Brower, BSN, RNMary Larson, DNP, APRN, FNP‐C1Learning ObjectivesSelf-report a greaterunderstanding ofevidence-based practiceas a result of thislearning activityTo educate and shareinformation with nursesand other healthcareproviders focused onevidence-basedpractice.21
10/3/2019Seizure TypesGeneralized Produced by electrical impulses from bothhemispheres of the brainFocal Produced (at least initially) by electrical impulsesin a relatively small part on one side of the brain3Main variants of generalized seizuresTonic-clonic (Grand Mal)AbsenceMyoclonic42
10/3/2019Tonic‐Clonic SeizureMost common and dramatic, and most well knownPatient loses consciousnessGeneralized body stiffening (called the "tonic" phase ofthe seizure) for 30 to 60 seconds followed by violentjerking (the "clonic" phase) for 30 to 60 secondsTongue biting and urinary incontinence5Absence SeizureShort loss of consciousness (just a few seconds) with few or no symptomsMost often a childTypically interrupts an activity and stares blanklyBegin and end abruptlyUsually not aware that they are having a seizure“Losing time“Eye flutter or blinking is common63
10/3/2019Myoclonic SeizureSporadic jerksUsually on both sides of the bodyMay result in dropping or involuntarily throwing objectsPeople may have myoclonus that is not due to seizureactivity-myoclonic simply describes the movement72 Types of Focal Onset SeizuresFocal OnsetSeizureFocal Aware simple complexFocal Impaired Awareness complex partial seizure84
10/3/2019Focal Aware SeizurePatients retain awarenessJerking, muscle rigidity, spasms, headturningUnusual sensations affecting either thevision, hearing, smell, taste, or touchMemory or emotional disturbances9Focal Impaired AwarenessPatient loses awarenessPatients seem to be "out of touch," "out of it," or "staringinto space“Automatisms consist of involuntary but coordinatedmovements that tend to be purposeless and repetitiveAutomatisms such as lip smacking, chewing, fidgeting,walking and other repetitive, involuntary butcoordinated movements105
10/3/2019Combined Generalized and FocalClonicTonicAtonic11Clonic SeizuresRepetitive, rhythmic jerks that involveboth sides of the body at the same time126
10/3/2019Tonic SeizureStiffening ofthe musclesShortdurationUsually occurduring sleep13Atonic SeizuresSudden and general loss of muscletone, particularly in the arms andlegs, which often results in a fallFalls may result in head injuries147
10/3/2019Status Epilepticus Both focal and generalized seizures can lead to acondition known as status epilepticus. Two or more epileptic seizures following oneanother without recovery between them. May be convulsive: seizure activity is noticeable. May be non‐convulsive: seizure activity is notnoticeable.15Patient Care During & Post Seizure Make sure the camera is not obstructed. Turn on the lights. Speak loudly and perform your assessment clearly andaccurately. Part of the EEG includes a video monitor Monitor is not just important to “see” the seizure Not to “spy” on our staff at all see our nursing assessment of the patient during and following the seizureBEST PRACTICE to care for our patients The VOA (video observation assistant) camera is not the same as the EEG camera LPNs & RNs: STAY WITH your patient and complete the assessments as noted below. Stay out of the way of the EEG camera during eventThe RN will need to be aware of what is going on (obviously) the LPN is able to complete these assessments Nursing assistants: STAY WITH the patient while you phone your RN or LPN The video camera in the room records both the seizure event AND nursing staff’s response and assessment to theseizure. Important to the physicians reading the EEG to interpret the EEG recording Determine the patient’s neurologic state following the seizure168
10/3/2019Purpose The purpose of this quality improvement project was to ensurethat the hospital staff within the St. Cloud Hospital wereknowledgeable on how to provide the appropriate and expectedseizure precaution measures for adult inpatients at risk forseizures and seizure related injuries.17Statistics Approximately 70% of seizures have no known cause. The frequent causes for the remaining 30% include: Brain tumor and/or stroke Head Trauma Poisoning or substance abuse Infection Maternal injury, infection, or systemic illness thataffects the developing brain of the fetus duringpregnancy. (Epilepsy Foundation Minnesota, n.d.).189
10/3/2019Why was this a problem?No standardized seizureprecaution procedure ormanagement policy existedat the St. Cloud Hospital.Even though seizureprecautions could beordered in the patient’selectronic medical record bya healthcare provider, therewas no standardized orofficial seizure precautionspolicy.The Neuroscience and SpineUnit had its own unitspecific guidelines for thoseinpatients placed in seizureprecautions; however, noother unit in the hospitalhad these guidelines.19Interprofessional Team – Task ForceDoctor ofNursingPractice(DNP) studentRegisteredNurseNeurologistCoordinatorCore ChargeNurseEducator2010
10/3/2019ShareholdersA clinical valueanalysis specialistThe Neuroscienceand Spine/NeuroProgressive CareUnit (NPCU)directorThe MedicalProgressive Unit(MPCU) directorThe Medical Unit 2directorThe Medical Unit2/MPCU educator.21Committee Approvals RequiredThe ProductValue AnalysisCommittee (PVAC)The EducationCouncil committeeThe AdministrativePatientCare Council(APCC) committeeThe Clinical PatientCare Committee(CPCC),The NursingResearch ReviewBoard (NRRB)The InstitutionalReview Board (IRB)at the College of St.Scholastica.2211
10/3/2019SettingThis quality improvement project took place at the St. Cloud Hospital.The St. Cloud hospital serves patients who are admitted with various diagnoses; includingthose patients with seizure disorders or who are at a high risk for having a seizure due to theirdiagnosis.This quality improvement project chose to compare the Neuroscience and Spine Unit/NeuroProgressive Care Unit (NPCU) to the Medical 2 Unit/Medical Progressive Care Unit (MPCU)because it was felt that the hospital staff in both of these areas had comparable knowledge andwere both equally as likely to care for patients at risk of seizure activity.23PopulationInclusion CriteriaAdult, aged 18 years of age andolder, inpatient population atthe St. Cloud Hospital who had ahistory of active seizures (withinthe last three months), were at ahigh risk for having a seizure, orwere actively seizing.Exclusion CriteriaNo vulnerable adults, pediatric(aged 17 years of age andyounger) inpatients, oroutpatients.2412
10/3/2019Goals Establish and implement a standardized seizureprecaution policy based on evidence‐based practice andbest practice recommendations. Ensure that all adult inpatients with a seizure precautionorder had all of the appropriate supplies at their bedsidein the event that a seizure occurred during theirhospitalization.25Objectives Create a seizure precaution policy based on the bestevidence‐based practice Educate the hospital staff of the new seizure precautionspolicy. Evaluate learning with a pre‐ and post‐ survey. Obtain approval from necessary committees to ensureproper seizure precaution supplies were ordered prior to theimplementation. Evaluate the hospital staff’s understanding of supplies with apre‐ and post‐ checklist.2613
10/3/2019Sample Sizefor pre‐ andpost‐surveyAll 170 registered nurses on theNeuroscience and Spine Unit,NPCU, Medical 2 Unit, and MPCUwere encouraged to participate inthe pre- and post-survey.27Seizure Precaution PolicyOriginal: 12/15 Minor Review:Full Review:Replaces:Responsible Person: Coordinator, Neuroscience Support ServicesApproving Committee: Clinical Patient Care CommitteeCategory: Patient CareCross Reference: EEG Monitoring, Continuous; Transport to/from Procedures, IntrahospitalType: Procedure PURPOSETo provide seizure precautions for adult patients. POLICYSeizure precautions will be implemented in the event of a seizure, a seizure history (within last 3 months), and/or a high risk of seizures. DEFINITIONS Aura: A warning of an approaching seizure. Epilepsy: Recurrent, unprovoked seizures caused by biochemical, anatomical, and physiological changes. Postictal Phase: The interval immediately following the seizure. Seizure: A clinical presentation of the central nervous system characterized by abnormal cerebral electrical discharges. Status Epilepticus: Recurrent seizures without complete recovery of consciousness between attacks or virtually continuous seizure activity for more than 30 minutes, with or without impairedconsciousness. STANDARD OF PRACTICEPatient care staff will be knowledgeable about seizure precaution measures. OUTCOME STANDARDPatients can expect a safe environment in the event of a seizure. PROCEDURE Set-up suction head with canister and tubing. Have Yaunker suction available in room next to suction head. Set-up oxygen with flow meter and green adapter. Have non-rebreather mask available in room next to oxygen set-up. Ensure that the patient has an IV access. Apply seizure pads to upper side rails. Inspect environment for potential safety hazards and remove from surroundings (examples: sharp objects, hot drinks, breakable items, etc.). Consideration will be given for performing procedures at the bedside whenever possible. REFERENCESNational Guidelines/National Standards/RegulatoryAmerican Association of Neuroscience Nurses. (2009). Care of the patient with seizures (2nd ed.): AANN clinical practice guidelines series. From ss, C. (2004). Seizures regaining control. RN, 67(12), 44-50.Schrub, E. & Caple, C. (2014). Seizure precautions for adults: Initiating and maintaining. CINAHL Nursing Guide.Disclaimer: The policies and procedures posted on CentraNet are for internal use only. They may not be copied by independent companies or organizations that have access toCentraNet, as this large Central Minnesota Hospital cannot guarantee the relevance of these documents to external entities2814
10/3/2019Seizure PadsApply seizure pads tothe upper side rails ofthe patient’s bed.IV AccessSeizure Precautions PolicyGo-live date: February 2nd, 2016Ensure that patienthas a functional IVaccess.Oxygen set-up Suction set-up The purpose is to provide seizureprecautions to adult patients. Implement seizure precautions on apatient in the event of a seizure, aseizure history (within the last 3months), or if at high risk of seizures. In the event of a seizure, do not try tohold the person down or restrainthem. Do not insert any objects in thepatient's mouth. Inspect and remove potential safetyhazards from the patient’ssurroundings. Consider performing procedures atthe bedside whenever possible. Current seizure pads are in theprocess of being updated with bedspecific models. Look for this changein the upcoming months.References:American Association of Neuroscience Nurses. (2009). Care of the patient with seizures (2nded.): AANN clinical practice guidelines series. Retrieved fromwww.aann.org/pdf/cpg/aannseizures.pdfCross, C. (2004). Seizures regaining control. RN, 67(12), 44-50.Set-up oxygen flowmeter with greenadapter. Have nonrebreather maskavailable in room andnext to oxygen set-up.Posey. (n.d.). 5725 posey seizure side rail pads. Retrieved adsHave suction headwith canister andtubing set-up andready. Yaunkerneeds to be availablenext to suction head.Schrub, E. & Caple, C. (2014). Seizure precautions for adults: Initiating and maintaining.CINAHL Nursing Guide.Mary Larson, RNDNP StudentThe College of Saint ScholasticaJanuary 201629Pre‐ and Post‐Survey DataQuestion 4. Following a seizure, I would implement seizure precautions.Pre-SurveyFollowing a seizure, I would implement seizure precautions.Post-SurveyFollowing a seizure, I would implement seizure %20.0%0.05410.0%0.0%00.0%YesNoYesNo The post-survey showed an improvement in the overall understanding of seizures 100% of the registered nurses selected that they would implement seizure precautions and notify aprovider following a seizure.3015
10/3/2019Pre‐ and Post‐Survey DataQuestion 7. Seizure precautions include which of the following? Select all that apply.Post- SurveySeizure precautions include which of the following? Select all that apply.Pre-SurveySeizure precautions include which of the following? Select allthat apply.120.0%80.0%120.0%0.986100.0%0.75 40.0%1100.0% 0.9048 0.85780.0%0.750.0710.0710.191There was an overall improvement in correct responses for seizure precautions seen on the post-survey. However, there is still room forimprovement due to not all of the correct responses are at 100%.31Pre‐ and Post‐ Implementation ChecklistTable 2. Percentage of rooms that were correctly equipped with suppliesTable 2.Percentage of rooms that were correctly equipped with supplies pre- versus post- seizure precaution policy implementationOxygen*SuctionIV AccessSeizure PostMedical Unit 00%100%100%50%100%100%100%Neuroscience and 100%97%100%100%100%Note. Neuroscience and Spine Unit/NPCU had a unit standard pre-implementation to have seizure pads, IV access, oxygen and suction set-up in room, whereas MedicalUnit 2 /MPCU did not have a unit standard.*On the pre-evaluation, any type of oxygen present in room was counted as correct, however during the post-evaluation only a non-rebreather mask was consideredcorrect.3216
10/3/2019Ethical Considerations The population for this quality improvement project did not include vulnerable adults or pediatric, aged17 years of age and younger, inpatients seen at this Central Minnesota hospital. There were no proposed risks to the participants of this quality improvement project. No identifiable patient data was collected when conducting the pre‐ and post‐ implementation checklist;the only information recorded was the seizure precaution supplies at the patient’s bedside and what unitthey were on. There was also no proposed risks to the hospital staff who completed the pre‐ and post‐survey due to noidentifiable data was collected. The only information gathered about the registered nurses was whichhospital unit they currently worked on and how long they had been a registered nurse.33DiscussionThere was a noted difference in the observedoutcomes and the anticipated outcomes as noted bya decreased percentage of oxygen present in thepost-evaluation checklist audit.This quality improvement project created astandardized seizure precaution policy which wasaimed at improving safe patient care by having thenecessary supplies available at the patient’s bedside;while also increasing nursing staff knowledge.3417
10/3/2019DiscussionLike many other studies and quality improvement projects, thiswill continue to be an ongoing process which will involveconstant monitoring and evaluation.This policy is currently up for a full review.The post-survey showed an improvement in the correctlyselected necessary supplies to be placed at the bedside,however additional unnecessary items were also selected.35ConclusionBy creating a standardized seizure precaution policy andevaluation tools, the St. Cloud Hospital increased the staff’sknowledge about seizures, what supplies and actions are necessarywhen a seizure precaution order was placed in the patient’selectronic medical record.The expectation was that by standardizing the seizure precautionpolicies and procedures, an improvement in patient safetyoutcomes would be seen.This quality improvement project did not focus on the datacollection regarding patient outcomes and safety due to theinaccuracy of reported or underreported seizure related injuries.However, additional research was needed to see if bystandardizing seizure precautions and providing hospital staffknowledge, patient safety outcomes improve.3618
10/3/2019MagnetStory37Questions?3819
10/3/2019References American Association of Neuroscience Nurses. (2009). Care of the patient with seizures (2nd ed.): AANN clinical practice guidelines series.Retrieved from www.aann.org/pdf/cpg/aannseizures.pdf Centers for Disease Control and Prevention. (2015). Chronic disease prevention and health promotion: Targeting epilepsy. Retrieved blications/AAG/epilepsy.htm Cross, C. (2004). Seizures regaining control. RN, 67(12), 44‐50. Cullen, L., Hanrahan, K., Tucker, S., Rempel, G., & Jordan, K. (2012). Evidence‐based practice building blocks: Comprehensive strategies, tools,and tips. Iowa City, IA: Nursing Research and Evidence‐Based Practice Office, Department of Nursing Services and Patient Care, University ofIowa Hospitals and Clinics. Epilepsy Foundation Minnesota. (n.d.). What is epilepsy. Retrieved from t‐epilepsy/ Kralj‐Hans, I., Goldstein, L. H., Noble, A. J., Landau, S., Magill, N., McCrone, P., . Ridsdale, L. (2014). Self‐management education for adults withpoorly controlled epilepsy (SMILE (UK): A randomized trial protocol. BioMed Central Neurology, 14(69). doi:10.1186/1471‐2377‐14‐69 Labiner, D. M., Bagic, A. I., Herman, S. T., Fountain, N. B., Walczak, T. S., & Gumnit R. J. (2010). Essential services, personnel, and facilities inspecialized epilepsy centers – Revised 2010 guidelines. Epilepsia, 51(11), 2322‐2333.39References Pallin, D. J., Goldstein, J. N., Moussally, J. S., Pelletier, A. J., Green, A. R., & Camargo, C. A. (2008). Seizure visits in US emergency departments:Epidemiology and potential disparities in care. Journal of Emergency Medicine, 1(2), 97‐105. doi: 10.1007/s12245‐008‐0024‐4 Perkins, A. M. & Buchhalter, J. R. (2006). Optimizing care in the pediatric epilepsy monitoring unit. Journal of Neuroscience Nursing, 38(6), 416‐421. Sanders, P. T., Cysyk, B. J., & Bare, M. A. (1996). Safety in long‐term EEG/video monitoring. Journal of Neuroscience Nursing, 28(5), 305‐313. Sauro, K. M., Macrodimitris, S., Krassman, C., Wiebe, S., Pillay, N., Federico, P., . Jette, N. (2014). Quality indicators in an epilepsy monitoringunit. Epilepsy & Behavior, 33, 7‐11. Schrub, E. & Caple, C. (2014). Seizure precautions for adults: Initiating and maintaining. CINAHL Nursing Guide. Shafer. P. O., Buelow, J. M., Noe, K., Shinnar, R., Dewar, S., Levisohn, P. M., & Barkley, G. L. (2012). A consensus‐based approach to patientsafety in epilepsy monitoring units: Recommended for preferred practices. Epilepsy & Behavior, 25, 449‐456. Spanaki, M. V., McCloskey, C., Remedio, V., Budzyn, D., Guanio, J., Monroe, T., Schultz, L. (2012). Developing a culture of safety in the epilepsymonitoring unit: A retrospective study of safety outcomes. Epilepsy & Behavior, 25, 185‐188.4020
patient in the event of a seizure, a seizure history (within the last 3 months), or if at high risk of seizures. In the event of a seizure, do not try to hold the person down or restrain them. Do not insert any objects in the patient's mouth. Inspect and remove potential safety hazards from the patient's surroundings.
Guidelines for Seizure Management Seizure management (Revision 2010) Rectal diazepam administration (Revision 2010) Vagal nerve stimulation (Revision 2010) Seizure Management Overview A seizure is an event in which there is a temporary change in behavior resulting from a
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STC-6 PRECAUTION [WITHOUT 4WAS] PRECAUTIONS PRECAUTION PRECAUTIONS Precaution for Supplemental Restraint System (SRS) "AIR BAG" and "SEAT BELT PRE-TENSIONER" INFOID:0000000006046074 The Supplemental Restraint System su
TORCH 04 10 Mo/F URI, 15DA Seizure, stuporous 80/28 WNL ND Spastic quadriplegia 05 5 Mo/M URI, 14DA Seizure, drowsy 36/35 WNL ND Recovered . 14 DA Stuporous to drowsy 66/21 WNL ND Drowsy to alert, increased DTR 10 28 Mo/M URI, 10DA Seizure, lethargic, 38/103 WNL Negative for HSV Alert, eye deviation . (arrows). C, D. Follow-up MR images .
Motivation for Revision Some seizure types, for example tonic seizures or epileptic spasms, can have either a focal or generalized onset. Lack of knowledge about the onset makes a seizure unclassifiable and difficult to discuss with the 1981 system. Retrospective seizure descriptions often do not specify a level of consci
Febrile seizure Most common 6 mo to 5 years Most children have temp 39 C (102.2 F) at the time of their seizure And tolerate high temp later with no sz Controlled studies: fever lowering does not protect in future fevers 1 in 25 children will have one 1 in 100 of the 1 in 25 who has FS will develop epilepsy after the seizure: 4 in
2019 FACS New Zealand 5 Anti-seizure medications in New Zealand Anti-seizure medications were primarily designed for use in seizure treatment, but they have also been
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