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A 10-year-old male is admitted to the acute-care facility after having a tonic-clonic seizure. What would be the priority nursing action immediately after the seizure?

Explanation

• Tonic-clonic (also called grand mal) seizures are characterized by stiffening of the arms and/or legs, a loss of consciousness, and then rhythmic jerking of the extremities lasting 2 to 5 minutes. Excessive salivation may present as frothing at the mouth. The pulse rate and blood pressure increase and may take time to return to normal. Breathing is impaired during the seizure, and the patient is often incontinent of urine or feces during the episode. The patient is often very lethargic and confused for hours afterwards.

• Monitor oxygen saturation and respiratory rate and depth while the patient rests or sleeps. Some patients may start to have another seizure while in the recovery phase. Their breathing may become very shallow, or they may become apneic during the sleep phase. 

• Providing a calm, restful environment is not the highest priority.

• Monitoring vital signs should be done, but a full set is not necessary every 15 minutes. A full neuro exam is not required every 15 minutes, especially when the child needs to rest, but an evaluation of consciousness should be done every 15 minutes by calling his name and/or touching his shoulder.

• Maintaining a patent airway with the child lying on his side is the intervention used during the active seizure.

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