The client sustains a minor leg abrasion and stops breathing for a few seconds during a grand mal seizure. Which is the best nursing documentation after the client's seizure?
1. Type of muscle contractions
2. Size and description of abrasion
3. Length of client's apneic episode
4. Description of the seizure in detail
4
4. Describing the seizure in detail is the best documentation after a seizure because it is the most comprehensive item listed and includes the type of muscle contractions observed during the seizure, the description of injuries, how the injuries occurred, and the description of any breathing abnormalities.
1. The nurse includes documentation about the type of muscle contraction experienced by the client during the seizure to communicate important information about the seizure to the rest of the health care team. The information helps to classify and plan suitable treatment for the seizures.
2. The nurse includes documentation about the abrasion to establish baseline data and to record the event.
3. The nurse documents client data about oxygenation and ventilation during the seizure because breathing is a vital function. Although the nurse can have trouble measuring the length of client apnea during the seizure especially if more than 1 apneic period occurs, the nurse includes client data about respiratory characteristics, patterns, oxygen saturation, and supplemental oxygen.
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