1. Charting
1.1. Seizure began at (time/location). Lasted (time). Observed the following: (movements), (behaviors), describe LOC, incontinence, post seizure vitals, state if airway remained patent, any injuries that may have occurred, describe LOC post seizure. State patient's description of sensations or aura.
2. Precautions
2.1. -IV access -Bed close to nursing station -Pad side rails/keep them up -Keep bed in lowest position -Ensure suction and oxygen set up (simple face mask)
3. Immediate Interventions
3.1. If patient on floor
3.1.1. -Assist lowering to floor -Cushion head
3.1.1.1. Return to bed once safe/appropriate
3.2. -Call for help -Remove any potential obvious harm -Check airway and pulse -Apply oxygen 10L via facemask -Loosen tight clothing
3.2.1. Second on scene
3.2.1.1. -Notifies MD -Prepares medication if/once ordered
3.2.1.1.1. Loading dose of Dilantin 1G IV followed by 300mg daily
3.2.2. Further Interventions
3.2.2.1. -Talk to patient, call them by name -Check their orientation -Test motor power -Note: speech, eye deviation, duration of event, any behaviors (like lip smacking), or incontinence
3.2.2.1.1. If doesn't stop (after 3min or 2 back to back GTC without recovery), even after benzodiazepines, call code 66
3.2.2.2. After seizure
3.2.2.2.1. -Monitor the following q15 minutes until return to pre-seizure level of consciousness (LOC): airway, resps, SpO2, pulse, GCS, LOC -Place patient in recovery position -Suction if needed. Consider oral airway if needed
3.2.2.2.2. Patient to remain 1:1 until responds verbally AND follows commands