Identify nursing interventions that are appropriate for A.A. at this time

Question

What will be an ideal response?

Answer 1

• Reassure and gently reorient A.A.
• During the postictal phase of the seizure, assessment should include level of consciousness, motor
response to stimuli, and speech every 15 minutes for the first hour, then every 30 minutes for 2
hours.
• Assess respiratory status, including airway patency; effort, lung sounds; use of accessory muscles;
and color of skin, lips, and nail beds. Monitor ability to handle secretions and assess gag, cough,
and swallow reflexes. As effects of propofol (Diprivan) wear off, prepare for extubation and initiate
alternative oxygen therapy.
• Assess VS, peripheral pulses, and urinary output at least every hour to evaluate tissue perfusion.
• Provide a quiet, calm environment because sounds and stimuli can be confusing to the awakening
patient. Keep talk simple and to a minimum. Speak slowly and with pauses between sentences.
Repeating might be necessary. Use room light that is behind, not above, the patient to prevent
additional seizures and for patient comfort.
• Give A.A. nothing by mouth (NPO) until he is extubated and fully awake.
• Check his tongue, lips, and mouth for lacerations and assess skin for bruises, lacerations, or
shearing injuries.
• Monitor urine for red or cola color, which might signal rhabdomyolysis or myoglobinuria from
muscle damage.
• Monitor for weakness or paralysis, dysphasia, or visual disturbances.
• Pad the side rails on the bed, and keep the bed in low position.
• Check blood glucose and request serum laboratory tests as prescribed.
• Administer medications as prescribed.