Accurate documentation of a patient’s seizure activity directly impacts patient care and outcomes. Recording the event is necessary primarily to provide diagnostic clarity for the healthcare team. Detailed records help physicians and neurologists classify the seizure type and determine the underlying cause. This documentation also guides treatment decisions, such as adjusting anti-seizure medications or identifying potential seizure triggers. Furthermore, objective documentation provides a complete legal record of the event and the nursing interventions performed.
Documenting the Antecedent and Initial Phase
The documentation process begins immediately with the observation of any changes that precede the active seizure, known as the prodromal phase or an aura. The prodrome may involve subtle mood or behavioral changes, such as irritability, anxiety, or fatigue, which can occur hours or even days before the seizure. An aura is a distinct warning sign that occurs just before the seizure begins and is considered part of the seizure itself, often involving sensory changes like a strange taste, smell, visual disturbance, or a sense of déjà vu. It is important to note whether the patient reports any such precursor and to document the specific nature of that sensation.
The nurse must also document the setting and the patient’s activity at the moment the event was first observed. This initial record includes the patient’s position (standing, sitting, or lying down) and the exact location. Recording the precise start time establishes the seizure’s duration, which is essential for clinical management. If the patient sustained any injury, such as a fall or striking an object, this must be noted immediately.
Detailed Observation During the Ictal Phase
The ictal phase is the period of active seizure activity, and its documentation requires objective detail using standardized terminology. The first priority is to record the start and stop times of the seizure to establish the duration. This time measurement is significant, as seizures lasting longer than five minutes may be classified as status epilepticus, requiring immediate intervention.
A precise description of the motor activity must be documented, specifying whether the movements are generalized, affecting both sides of the body, or focal, beginning in one limb or one side. Terms like tonic, which describes sustained stiffening of the muscles, and clonic, which refers to rhythmic jerking movements, should be used. Further descriptions must include the specific body parts involved, noting if the movements were symmetric or asymmetric, and whether they progressed or spread from one area to another.
Documentation must also capture any associated autonomic changes or automatisms observed during the event. Autonomic changes include skin color changes (cyanosis or pallor), incontinence, and excessive sweating (diaphoresis). Automatisms are non-purposeful, repetitive behaviors, such as lip-smacking, clapping, or repeated swallowing, commonly seen in focal seizures with impaired awareness. Finally, the nurse must describe the patient’s level of consciousness during the event, noting if the patient was unresponsive, confused, or if awareness was preserved.
Post-Seizure Assessment and Follow-up Documentation
The post-ictal phase begins when the seizure activity ceases and continues until the patient returns to their baseline neurological status. Documentation must describe the patient’s post-ictal state, which often involves symptoms like confusion, drowsiness, headache, or fatigue. The duration of this altered state of consciousness should be timed and recorded, as a lengthy recovery period can suggest a more severe seizure.
Immediately following the event, the nurse must perform and document a full assessment, including a set of vital signs and a neurological examination. This assessment should focus on any new neurological deficits, such as muscle weakness (Todd paralysis), pupillary changes, or difficulty with speech, and the assessment must continue until the patient is stable. All interventions performed during or after the seizure, such as the administration of supplemental oxygen or the provision of anti-seizure medication, must be documented with the time, dose, and route.
The final step involves communicating with the healthcare provider. The nurse must record the time and method of notifying the physician or other licensed independent practitioner of the seizure event. Any new orders received, such as stat laboratory work or changes to the medication regimen, must also be documented, completing the record of the seizure and the patient’s response to care.