Seizures and Status Epilepticus: Safety First
What it is
A seizure is a sudden, uncontrolled electrical discharge of cerebral neurons that alters movement, sensation, behavior or consciousness; generalized seizures (tonic-clonic, absence) involve both hemispheres, while focal seizures begin in one area. Status epilepticus is a seizure lasting 5 minutes or longer, or repeated seizures without return to baseline between them. Continuous seizure activity raises cerebral oxygen and glucose demand while breathing is impaired, causing hypoxia, acidosis, hyperthermia and permanent brain injury, so care centers on the airway, injury prevention, timing and rapid benzodiazepine treatment.
What the NCLEX focuses on
- During a tonic-clonic seizure: stay with the client, turn the client to the side, protect the head, loosen tight clothing and time the seizure; never restrain or put anything in the mouth.
- Seizure precautions: bed in low position, padded side rails per policy, suction and oxygen ready at the bedside, IV access maintained.
- Status epilepticus: a benzodiazepine first (IV lorazepam; IM midazolam or rectal diazepam without IV access), then a second-line drug such as fosphenytoin, levetiracetam or valproate.
- Postictal phase: drowsiness and confusion are expected; keep the client side-lying, maintain the airway and suction secretions.
- Document the aura, onset, body parts involved, duration, incontinence and postictal state.
- Phenytoin: toxicity causes nystagmus, ataxia and slurred speech; long-term use causes gingival hyperplasia and reduces hormonal contraceptive effect; IV phenytoin is mixed only with 0.9% sodium chloride.
- Abruptly stopping antiseizure medication is a common cause of status epilepticus; absence seizures (brief blank staring) are mistaken for daydreaming.
Priority nursing actions
- Stay with the client, call for help and note the time the seizure began.
- Turn the client to the side, protect the head, move nearby objects and loosen tight clothing.
- At 5 minutes, or with a second seizure without recovery, activate the rapid response team and give the prescribed IV benzodiazepine.
- Give oxygen, suction oral secretions and check blood glucose.
- After the seizure, keep the client side-lying, monitor airway, vital signs and neurologic status, and document the event.
Numbers to know
| Value | Target or limit | Why it matters |
|---|---|---|
| Status epilepticus | Seizure of 5 minutes or longer, or repeated seizures without recovery | Emergency; brain injury risk rises with duration |
| Lorazepam IV (adult) | 0.1 mg/kg, maximum 4 mg per dose; repeated once if the seizure continues | First-line drug; monitor respirations and blood pressure |
| Phenytoin level | 10 to 20 mcg/mL (40 to 79 micromol/L) | Above 20: nystagmus, ataxia, slurred speech |
| IV phenytoin rate (adult) | No faster than 50 mg/min | Faster rates cause hypotension and dysrhythmias |
| Valproic acid level | 50 to 100 mcg/mL (347 to 693 micromol/L) | Monitor liver function and platelets |
Common exam traps
- Choosing to insert a padded tongue blade or oral airway into clenched teeth: wrong because it breaks teeth and injures the airway.
- Choosing to hold the arms and legs down: wrong because restraint causes musculoskeletal injury and does not stop the seizure.
- Choosing to leave the client to get the provider or the medication: wrong because the nurse stays, times the seizure and calls for help.
- Choosing to give water or the oral antiseizure dose right after the convulsion: wrong because a drowsy postictal client aspirates.
- Choosing to keep observing a tonic-clonic seizure past 5 minutes: wrong because this is status epilepticus and needs a benzodiazepine now.
What to teach
- Take antiseizure medication at the same times daily, never stop it abruptly, and wear medical identification.
- Avoid missed doses, sleep deprivation and alcohol; shower rather than bathe, swim only with a companion, and follow state driving laws.
- Phenytoin: brush, floss and see the dentist regularly, use a nonhormonal backup contraceptive, and report rash, unsteadiness or slurred speech.
- Family: call 911 for a seizure lasting longer than 5 minutes, a second seizure, breathing difficulty or an injury.
Client handout: Seizures: First Aid and Your Medicines (nurse guide and printable patient handout).
Try 2 NCLEX-style questions on this topic
From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.
A client’s tonic-clonic seizure has continued for 6 minutes despite positioning and protection. Which interpretation and action are correct?
- A. This is status epilepticus: call the rapid response team and prepare IV benzodiazepine per protocol
- B. Give the scheduled oral antiseizure medication as soon as the convulsions briefly pause so serum drug levels can be restored
- C. Continue timing and observation because generalized tonic-clonic seizures may normally last several minutes before emergency treatment is needed
- D. The seizure is probably ending and the remaining rhythmic movements represent postictal motor activity, so allow the client to recover without medication
The nurse admits a client with a history of tonic-clonic seizures. Which items belong in the room as seizure precautions? Select all that apply.
- A. Wrist restraints within reach for the next event
- B. Oxygen setup ready at the bedside
- C. Suction equipment set up and tested at the bedside
- D. Maintained IV access
- E. A padded tongue blade taped above the bed
- F. Padded side rails with the bed in low position
The correct answers, the reasoning for every option and 3,200+ more NCLEX questions are inside NCLEXPace. Create your account, then choose a plan to open them.
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- Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Chronic Neurologic Problems.
- Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61.
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