Question

John Moore, a 22-year-old patient weighing in at 150 pounds, arrived at the emergency department (ED) after being thrown from his horse and passing out for a few minutes; later he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. His respirations were very shallow, and his lips and nail beds turned blue. The patient lost control of his bladder and bowel. The patient bit his tongue and was bleeding from his mouth. The radiology department called and was now ready for the patient. List the correct order of actions that should be taken by the nurse. Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure, and the specific nursing care for each stage. The ED physician orders the following: Valium (diazepam) 10 mg every 10 to 15 minutes prn for seizures (maximum dose of 30 mg). Once seizures stop, administer Dilantin (phenytoin) 10 mg/kg IVPB. ECG monitoring continuously, VS, GCS, neuro checks every 30 minutes. Explain what meds the nurse should provide, in what order, and how they should be administered.

Answer 1

Answer: Wanna play

Step-by-step explanation:

Answer 2

The nurse's immediate actions should be to protect the patient from injury during the seizure, followed by administering Valium (diazepam) as per the physician's orders. The patient is likely experiencing a generalized tonic-clonic seizure, characterized by three phases: the aura, ictal, and postictal phases. During the aura, the patient may have warning signs; the ictal phase involves the actual seizure, while the postictal phase follows with recovery. Nursing care involves ensuring safety during the seizure, providing emotional support, and monitoring vital signs. Following the seizure, Valium is administered, and once seizures cease, Dilantin is given. Continuous monitoring, neuro checks, and maintaining ECG monitoring are crucial.

Step-by-step explanation:

In response to the patient's generalized tonic-clonic seizure, the nurse's initial priority is to ensure patient safety, protecting from injury and maintaining an open airway. This includes moving any nearby objects that could cause harm. The patient is likely experiencing a tonic-clonic seizure due to the loss of consciousness, stiffening of the body, and violent muscle contractions.

The seizure has three phases:

Aura: May involve warning signs or sensations preceding the seizure.

Ictal Phase: The actual seizure, characterized by the epileptic cry, loss of consciousness, and muscle contractions.

Postictal Phase: Follows the seizure, during which the patient may be confused, fatigued, and exhibit shallow respirations.

Nursing care involves emotional support during the aura, ensuring safety during the ictal phase, and monitoring vital signs. Following the seizure, Valium (diazepam) is administered as per the physician's orders, and once seizures cease, Dilantin (phenytoin) is given. Continuous monitoring, including ECG, vital signs, and neuro checks, remains essential to detect any complications or changes in the patient's condition.