SEIZURE PRECAUTION

This precaution include all nursing interventions to protect the client from traumatic injury,side-lying position for adequate ventilation and drainage of secretion,providing privacy, and providing support following seizure.It is recommended that objects no be placed in a client's mouth to avoid injury to the oral cavity.It has been founded that significant injury to the mouth is rare during a seizure,even the most violent ones(Ellis,1993).Injury may occur from forcing an object into the mouth and from teeth biting down on a hard object. Even soft object may come apart and be aspirated .It is important that the nurse observe the client carefully before,during and after the seizure so that the episode can be documented accurately.

RESOURCES FROM CLINICAL SKILLS AND TECHNIQUES BOOK FROM MOSBY, 5TH EDITIONS (2002), PERRY&POTTER.

5P'S OF NEUROVASCULAR ASSESSMENT

Pain

• Determine amount and severity of pain if present.Ask client for descriptions;avoid coaching client with words to describe pain
• Ratioanale-manipulation and reduction may produce dull,aching pain as a result of pressure on nerve endings.Clients vary in perception and tolerence of pain.

Pallor

• Observe color of tissues distal of cast
• Rationale-pink indicates arterial pressure is normal,whitish color signifies decreased arterial supply, and bluish color signifies venous stasis.

Pulselessness

• When possible palpate distal pulse of casted extremity;note presence and strength of pulse.assess capillary refill by pressing on toenail or fingernail if cast is on extremity,releasing and noting pinking of nail;nail should pink up in 3 seconds or less.
• Rationale-weak and absent pulse may indicate decreased circulation.Blanching on pressure with subsequent capillary refill is indicative of arterial perfusion.Capillary refill is too sluggish if refill takes more than 3 seconds.It takes 2 seconds to say capillary refill is slowly and 4 seconds to repeat it once(Beare and Myers,1998).

Paresthesia

• Assess for numbness,tingling, or abnormal sensations.
• Rationale-may indicate nerve damage and/or development of compartment syndrome

Paraplegia

• Assess for motion
• Rationale-may indicate nerve damage and/or development of compartment syndrome

Resource from Clinical Nursing Skills and Techniques book, fifth edition (2002) by Mosby

NURSING ARTICLES