Continuing Nursing Education

Objectives and posttest can be found on page 195.

Seizure Precautions for Pediatric

Bedside Nurses
Ellen Thomen Clore

ver the course of their

careers, many inpatient
pediatric nurses will care for
a patient with seizures or
who is at risk for seizures. Although
often anxiety-provoking, the fear can
be diminished by thinking critically
about each childs seizure. The nursing management of pediatric seizures,
for which patient safety is the priority, should be driven by the clinical
presentation of the childs event. This
article will present an algorithm to
assist bedside nurses in safely caring
for children with a variety of seizure
types. The algorithm can be used as a
road map to assist staff nurses in safely and appropriately stocking patients bedsides with emergency
equipment as needed for children
with seizures. However, to understand
the clinical symptoms of a seizure, it
is important to first review basic
pathophysiology and seizure classification.

What Is a Seizure?
A seizure is a paroxysmal electrical
discharge of neurons in the brain that
results in a change in function or
behavior (Blumstein & Friedman,
2007). The area of cortical involvement and the subsequent temporary
changes in cerebral function caused
by this abnormal discharge contribute
to the clinical manifestation of the
event (Fagley, 2007). The clinical presentation of that abnormal neuronal
discharge varies from twitching lasting two to three seconds to generalized tonic-clonic movements (a brief
period of rigidity followed by rhyth-

Ellen Thomen Clore, MSN, RN, is a Pediatric

Nurse Practitioner, Childrens National
Medical Center, Washington, D.C.
Statement of Disclosure: The author reported no actual or potential conflict of interest in
relation to this continuing nursing education
article.

Seizures are a common neurologic disorder of childhood, and many pediatric

nurses will care for children with epilepsy during their careers. The term seizure
precautions is used frequently in nursing practice; however, its definition varies
among institutions. Childhood epilepsy has many phenotypes, and while some
children require airway clearance and ventilatory support in the event of a
seizure, many will not. The bedside equipment for a child with seizures should
reflect the patients symptoms. To that end, an algorithm based on seizure classification and current practice in seizure precautions is presented to aid bedside
nurses in safely caring for children with seizures. The algorithm may also be used
to assist in educating parents about the safest way to care for their child at home,
without sending contradictory messages about different needs for equipment in
the hospital and in the home.

mic convulsions) that can continue

for hours if untreated (Yamamoto,
Olaes, & Lopez, 2004). Some individuals may have associated symptoms,
such as cyanosis, while others may
have very few clinical symptoms that
a seizure is occurring.
Approximately 10% of the population will have at least one seizure in
their lifetime (Marks & Garcia, 1998).
Of this group, 1% to 3% will be diagnosed
with
epilepsy
(Hauser,
Annegers, & Kurland, 1993), which is
defined as recurrent, spontaneous,
unprovoked seizures. Each year 30,000
children will be diagnosed with
epilepsy (Blumstein & Friedman,
2007), and 30% of those children will
suffer from seizures that are refractory
to medical management, a condition
known as intractable seizures
(Nadkarni, LaJoie, & Devinsky, 2005).
The bedside nurse should obtain a
detailed description of the seizure,
including duration, frequency, and
symptoms (Marthaler, 2004). As in the
adult population, seizures that present
in childhood are classified by electrographic findings and clinical presentation with a constellation of symptoms
noted in each seizure type.

Seizure Classification
Simple Partial Seizures
Simple partial seizures are defined
as abnormal neuronal discharges

PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

occurring in only one hemisphere of

the brain (partial) in which consciousness is preserved (simple). These
episodes usually last a few seconds but
can last longer, and are often referred
to by the individual as an aura that
portends a second seizure type.
Depending on the part of the brain
afflicted by the excessive firing, the
symptoms of the aura are varied and
may include paresthesias, hallucinations, dysphagia, sweating, flushing,
or motor disturbances, such as jerking
(Yamamoto et al., 2004). Since the
individual is conscious during the
seizure, and the clinical symptoms of
the seizure are usually very brief, there
are fewer safety risks to address.
However, it is important for the bedside nurse to know if the patients simple partial seizure usually precedes a
complex-partial or generalized seizure
because these seizure types put the
patient at an increased safety risk.

Complex Partial Seizures

A complex-partial seizure is defined
as a seizure originating from one
hemisphere of the brain with impairment of consciousness (Yamamoto et
al., 2004). Most commonly, these
seizures originate in the temporal
lobe, so common clinical manifestations can be as subtle as automatisms
(purposeless, repetitive motions, such
as picking motions of the hands) or as
obvious as bizarre behaviors (such as
undressing in public) (Gambrell &
191

Seizure Precautions for Pediatric Bedside Nurses

Flynn, 2004). During complex partial
seizures, the individual may appear to
be fully awake, but will not respond
to commands and will have amnesia
for the event. There is a risk of injury
to the patient and nurse if the patient
becomes combative during an attempt to restrain. Thus, a thorough
history of the typical details of the
seizure is crucial to the safe delivery of
care. Complex partial seizures most
commonly last two to three minutes
but can extend up to 15 to 30 minutes
(Yamamoto et al., 2004), and may secondarily generalize to both hemispheres of the brain.

Generalized Seizures
A generalized seizure is one in
which the neuronal discharge occurs
in both hemispheres of the brain and
may involve a depressed level of consciousness (Blumstein & Friedman,
2007). There are two main categories
of generalized seizures: nonconvulsive and convulsive.
Nonconvulsive. Absence seizures
are characterized by brief periods of
altered consciousness with subtle
motor activity, such as eyelid fluttering, staring, or lip smacking
(Yamamoto et al., 2004). One study
found these episodes to last an average of 9.4 seconds (Sadleir, Farrell,
Smith, Connolly, & Scheffer, 2006);
once the seizure is over, the individual returns to the previous activity.
These episodes are often mistaken for
daydreaming because of their short
length, and these individuals are frequently admitted to the hospital for
overnight video EEG monitoring to
diagnose the event.
These events, epileptic or not, usually have no history of respiratory
compromise or significant motor
involvement, and as such, these
patients are at low risk of injury during their seizures. However, the risk of
injury does not disappear if the onset
of seizure activity coincides with
other activities, such as driving or eating.
Myoclonic seizures usually manifest as sudden, brief head drops and
arm flexion, and may occur hundreds
of times per day (Blumstein &
Friedman, 2007). However, each
episode may last only one or two seconds and does not involve respiratory
compromise. Conversely, atonic
seizures involve a sudden loss of tone
and consciousness (Yamamoto et al.,
2004), and although the seizures last
only for a few seconds without respiratory compromise, these individuals
are at extremely high risk for falls and
injury because of the clinical presen192

tation of their seizure (Yamamoto et

al., 2004).
Convulsive. The most common
type of generalized seizure is the
tonic-clonic seizure. This event is
characterized by a loss of consciousness, a brief period of muscle rigidity
(tonic phase) followed by rhythmic
jerking of all the patients extremities
(clonic phase) (Yamamoto et al.,
2004). Respirations may be irregular,
there may be oxygen desaturation,
and there is frequently a pooling of
secretions in the oropharynx, which
puts the individual at risk for aspiration.
Other types of convulsive generalized seizures include clonic seizures
involving rhythmic jerking of extremities without a preceding tonic phase,
and tonic seizures involving full body
rigidity (Yamamoto et al., 2004). Both
types involve a loss of consciousness
as well as the possibility for respiratory compromise.

Special Circumstance:
Medication Taper
Children who have intractable partial epilepsy, about 30% of children
with seizure disorders (Nadkarni et al.,
2005), often undergo evaluation with
long-term video EEG monitoring. In
many cases, this is performed if surgical ablation of an epileptic focus is
being considered (Major & Thiele,
2007). The pre-surgical evaluation
process often requires multiple hospitalizations with a goal to identify a
discrete and operable seizure focus.
The sole means for obtaining this
information is by observing the
childs seizure; therefore, the medical
staff may decide to quickly (over several days) taper the childs anti-epileptic drugs in the controlled hospital
environment to provoke a seizure. By
comparison, neurologists caring for
patients who have been seizure-free
for at least two years (Sirven, Sperling,
& Wingerchuk, 2003) and who wish
to wean these patients off anti-epileptic medication in the hopes that they
may no longer require medications,
are recommended to do so over an
average
of
three
months
(Ranganathan & Ramaratnam, 2006).
Seizure safety in either of these populations is paramount; however, those
children who undergo surgical evaluation due to persistent breakthrough
seizures on anti-epileptic medication
are already at an increased risk for
seizures, which only increases further
upon admission to the hospital given
their rapid medication taper.
Findings from a study of children

and young adults without primary

generalized epilepsy showed a fourfold increase in frequency of generalized tonic-clonic seizures between
patients whose medication was
tapered over four days compared to
those whose medication was tapered
over 10 days (Malow, Lynch, Blaxton,
& Mikati, 1994). Although there is no
concrete recommendation regarding
length of time to wean medication in
the hospital, this study highlights the
unpredictability of the seizure type
that a child may experience during
the taper. Therefore, it is prudent for
the bedside nurse to pad the childs
side rails and stock all emergency supplies at that patients bedside (Gilbert,
Counsell, Guin, & Snively, 2000).

From Symptoms to
Supplies
Often, nurses interpret the phrase
seizure precautions to mean that
the child requires full resuscitation
equipment (such as bag valve mask,
suction, cardiorespiratory monitor) at
his or her beside, no matter the type
of seizures experienced. Alternatively,
the bedside supplies chosen might
reflect the symptoms experienced and
the circumstances under which the
child was admitted to the hospital. As
will be described, a seizure-focused
algorithm can be used to determine
bedside needs, with a likely cost-containment advantage (see Figure 1).
By following the algorithm, if a
child has staring spells lasting five seconds and is not being weaned off
anti-epileptic medications, there is no
need for a bag and mask at that childs
bedside because there is no risk of respiratory compromise. However, if the
child has a complex-partial seizure
involving staring spells, which secondarily generalizes to a tonic-clonic
seizure, it is crucial to have appropriate supplies at the bedside in the
event of cyanosis and/or aspiration of
secretions (Pullen, 2003).
If the child has minimal motor
involvement with his or her seizures
and no respiratory compromise, there
is again no need to have a bag and
mask on hand at the bedside.
However, if the child has seizures with
extremity jerking and there is a
potential for injury by hitting the
bedrails, it would be prudent to apply
seizure pads to the railings (Pullen,
2003).
Regardless of the seizure classification, if a child experiences pooling of
secretions, oxygen desaturation, or
extensive motor involvement (such as
rhythmic jerking), there should be

PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

Figure 1.
Bedside Seizure Safety
Does your patient have a
history of seizures?
YES
NO
What are the
clinical symptoms
of the event?

Symptoms with neither

respiratory compromise nor
motor involvement (staring
spells, eyelid fluttering)

Motor symptoms without

respiratory compromise
(myoclonic jerks)

Is your patient on a
medication wean or
completely off seizure
medication?
NO

YES

Maintain routine
safety precautions
(bedrails up)

Maintain routine
safety precautions
(bedrails up)
ANY symptom accompanied
by respiratory compromise
(tonic-clonic movements)
Motor symptoms accompanied
by LOC (atonic seizures)

SUPPLIES*
Bag, valve mask (if clinically indictated)
Suction (canister and catheter)
Cardiorespiratory monitor
Pulse ox
Seizure pads (if clinically indicated)

*Bedside RN needs to assess not only that

equipment is in place, but also that it functions
properly at each shift change.

necessary safety precautions in place

at the bedside (bag and mask, suction,
and seizure pads on the bed rails).
Furthermore, if limited information is
available regarding seizure classification, the bedside nurse must be prepared for any and all seizure types.

Patient/Family Education
A discussion of pediatric seizure
precautions and bedside safety would
be incomplete without addressing
methods to improve patient/family
education surrounding the issue.
Pediatric epilepsy is a frightening
diagnosis for families, and the childs
safety at home is the parents primary
concern. The message given to parents as they observe their childs nursing care in the hospital should be
consistent with what is prescribed at
home. It is contradictory to require a
bag and mask and suction equipment

at the hospital bedside if the family

will not be provided with these supplies upon discharge. The bedside
safety algorithm will eliminate this
contradiction because it provides
nurses with a tool to appropriately
and safely care for their children without using unnecessary supplies. By
thinking critically about each child
and the phenotype of each specific
seizure, nurses can simultaneously
care for and educate children and
their families about seizure safety.
Additional educational topics for
children and families about seizure
safety at home may include CPR
and/or the administration of rescue
medication (such as rectal diazepam
or buccal midazolam). These can be
helpful tools for the family prior to
discharge because they empower parents to take their child home safely
without unnecessary equipment.

PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

Nursing Impact
Aside from the benefits that the
algorithm has for children and their
families, there is an additional benefit
to staff nurses. A constant balancing
act occurs between the care bedside
nurses provide to their patients and
the time spent in that endeavor.
Frequently, nurses spend large
amounts of time at the beginning of
their shift collecting supplies for each
patient, some of which are unnecessary. Alternatively, situations may
arise in which a particular piece of
equipment is needed emergently but
is not at the bedside. Both of these
scenarios cause anxiety and stress,
and neither is efficient for the nurse
nor ideal for the patient. Consulting
the bedside algorithm when the child
is admitted to the unit allows the
nurse to anticipate what supplies that
child might require during the hospitalization and to prepare for the
193

Seizure Precautions for Pediatric Bedside Nurses

admission in a calm, non-emergent
way. This saves time for the nurse and
minimizes the risk of being unprepared for emergency situations.
Additionally, the bedside nurse
should perform a test of the equipment to ensure that all supplies are
properly functioning when they are
placed at the patients bedside. This
test should also be repeated at each
shift change, when another nurse
assumes care of the child.

Cost-Effectiveness
A final advantage to this algorithm
is that it increases cost-effectiveness of
appropriate seizure precautions. The
priority for all health care providers is
patient safety, and by using the bedside safety algorithm, it is possible to
provide the safest care as well as eliminate the unnecessary use of resources. To reinforce the economic
scope of the issue, some institutions
require that every patient admitted
with seizures, as well as those patients
admitted to rule out a diagnosis of
epileptic seizures, have a bag and
mask at the bedside. In an example
taken from one pediatric institution,
an average of 1000 patients/year are
admitted to the video EEG monitoring unit (non-ICU), all requiring a bag
and mask as a part of standard admission protocol. Although many chil-

dren will require the oxygen and/or

ventilatory support provided by a bag
and mask (and it is important that it
be readily available in those situations), there are also children who
will not. A patient with childhood
absence epilepsy, for example, will
not have respiratory compromise
with seizures, and therefore, to place a
bag and mask at that childs bedside is
an unnecessary use of hospital
resources. Implementing the bedside
seizure safety algorithm will empower
nurses to think critically about their
patients seizure activity, while at the
same time, reduce hospital costs.
Throughout health care, the aim
has been to make significant changes
in the approach to clinical practice,
with a focus on improving patient
safety. Nursing education is vital to
providing excellent and safe care, and
it is crucial to effect change in the
inpatient hospital setting.
Bedside nurses are responsible for
the safety of their patients. Ensuring
that the correct supplies are easily
accessible in the event of an emergency is part of that responsibility.
Seizure precautions are an important
aspect of patient safety; however, they
should not be employed indiscriminately because each patient with
seizures displays different symptoms.
The algorithm presented can act as a
road map for staff nurses to help them

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think critically about their patients

seizures, and by so doing, stock the
appropriate supplies at the bedside.
This thought process combines critical thinking about complex medical
scenarios with the compassion and
empathy for children and families for
which nurses strive. By providing
excellent care at the bedside, nurses
ultimately empower families to feel
comfortable caring for their child at
home, while simultaneously conserving resources.
References
Blumstein, M.D., & Friedman, M.J. (2007).
Childhood seizures. Emergency Clinics
of North America, 25(4), 1061-1086.
Fagley, M.U. (2007). Taking charge of seizure
activity. Nursing, 37(9), 42-47.
Gambrell, M., & Flynn, N. (2004). Seizures
101. Nursing, 34(8), 36-41.
Gilbert, M., Counsell, C., Guin, P., & Snively,
C. (2000). Seizure surgery. Critical Care
Extra, 100(9), 24AA-24BB, 24DD-25.
Hauser, W.A., Annegers, J.F., & Leonard, T.K.
(1993). Incidence of epilepsy and
unprovoked seizures in Rochester,
Minnesota: 1935-1984. Epilepsia, 34(3),
453-468.
Major, P., & Thiele, E. (2007). Seizures in children: Laboratory diagnosis and management. Pediatrics in Review, 28, 405414.
Malow, B.A., Lynch, B., Blaxton, T.A., &
Mikati, M. (1994). Relationship of
Carbamazepine reduction rate to
seizure frequency during inpatient
telemetry. Epilepsia, 35(6), 1160-1164.
Marks, W.J., & Garcia, P. (1998).
Management of seizures and epilepsy.
American Family Physician, 57(7),
1589-1600.
Marthaler, M.T. (2004). Seizures revisited.
Nursing Management, 35(4), 71-74.
Nadkarni, S., LaJoie, J., & Devinsky, O.
(2005). Current treatments of epilepsy.
Neurology, 64(Suppl. 3), S2-S11.
Pullen, R.L. (2003). Protecting your patient
during a seizure. Nursing, 33(4), 78.
Ranganathan, L.N., & Ramaratnam, S.
(2006). Rapid versus slow withdrawal of
antiepileptic drugs. Cochrane Database
of Systematic Reviews, (1). DOI:
10.1002/14651858.CD005003.pub2.
Sadleir, L.G., Farrell, K., Smith, S., Connolly,
M.,
&
Scheffer,
I.E.
(2006).
Electroclinical features of absence
seizures in childhood absence epilepsy.
Neurology, 67, 413-418.
Sirven, J.I., Sperling, M., & Wingerchuk, D.M.
(2003). Early versus late antiepileptic
drug withdrawal for people with epilepsy
in remission. Cochrane Database of
Systematic Reviews, (1). DOI:
10.1002/14651858.CD001902.
Yamamoto, L., Olaes, E., & Lopez, A. (2004).
Challenges in seizure management:
Neurologic versus cardiac emergencies. Topics in Emergency Medicine,
26(3), 212-224.

Note: Reprinted with permission from Tim and Amy Potvin.

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