The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury
The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.)
a. Teach the family how to insert an oral airway during the seizure.
b. Assess the home for items that could harm the patient during a seizure.
c. Provide information on how to obtain a Medical Alert bracelet.
d. Teach the patient to communicate to the caregiver plans for bathing.
e. Discuss with family steps to take if the seizure does not discontinue.
f. Demonstrate how to restrain the patient in the event of a seizure.
ANS: B, C, D, E
Assessment of the home for safety, providing information on Medical Alert bracelets, teaching the patient to communicate before bathing, and discussing steps to take with status epilepticus are important interventions for the patient who is having seizures. Inserting an airway may harm the patient by forcing the object into the mouth or by biting down on a hard object. Never restrain a patient who is having a seizure, but protect the patient from hitting his body on objects around him to prevent traumatic injury.
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