🏠 Study Hub 🖼️ Infographics
Nursing Field Notes / Neuro · Seizure Disorders · Med-Surg

Seizures

Safety during · precautions before · drugs after

NG-226 NEURO · SEIZURES ADHD-friendly visual edition

A seizure is a sudden, uncontrolled burst of electrical activity in the brain. Most stop on their own in under two minutes — so almost nothing you are tested on is about stopping it. It is about keeping the airway open and the patient uninjured while it runs, and knowing the exact minute it stops being a seizure and becomes status epilepticus.

📄 Simple Nursing original — opens in Drive →

🔄 SIDE-LYING firstTurn them on their side, pad the head, time it, and stay. Airway is the whole priority.
❌ The three NEVERSNever put anything in the mouth · never restrain · never leave them alone.
⏱️ 5 minutes = STATUSOne seizure ≥ 5 min, or repeats without waking in between. Airway → then a benzodiazepine to stop it.
💊 Never stop them abruptlySuddenly stopping an antiseizure drug is a classic cause of status epilepticus.

TYPES & PHASES

STEP 1 · CLASSIFY

Two questions sort every seizure: how much of the brain is involved, and what stage are we watching right now.

🧠 Generalized vs focal — how much brain is involved

GENERALIZED vs FOCAL — how much of the brain is involved?Brain seen from ABOVE · front of the head at the TOP · orange shading = abnormal electrical activityGENERALIZEDBOTH hemispheres from the startFRONTBACKch1ch2ch3ch4 FOCALONE area of ONE hemisphereFRONTBACKch1ch2ch3ch4 Consciousness is LOST from the startTonic–clonic · absence · myoclonic · atonicMay stay AWARE, or awareness is impairedSymptoms match the lobe · can spread
🧠 GENERALized = the whole GENERAL area. FOCAL = one FOCUS. If consciousness is lost from the very start, think generalized.

🌍 The generalized types

  • Tonic–clonic (“grand mal”) — stiffen then jerk, loss of consciousness. The one everyone pictures.
  • Absence (“petit mal”) — brief blank staring, often in children; mistaken for daydreaming or inattention.
  • Myoclonic — sudden brief jerks of a limb or the whole body.
  • Atonic (“drop attack”) — all tone lost, the patient falls. Helmets are a real intervention.
  • Tonic or clonic alone — stiffening only, or jerking only.
🧠 Absence seizures look like a child ignoring you. A teacher’s report of “stares off, then carries on mid-sentence” is the classic stem.

📍 The focal types

  • Focal AWARE (old name: simple partial) — patient stays awake and can remember it. Symptoms match the lobe: jerking of one hand, a strange smell, tingling.
  • Focal with IMPAIRED AWARENESS (old: complex partial) — altered awareness, staring, and automatisms: lip smacking, picking at clothes, fumbling.
  • Focal to bilateral tonic–clonic — starts in one place and spreads to the whole brain.
🧠 Automatisms = the body on autopilot. Lip smacking and clothes picking during a staring spell is focal, not absence.

⏱️ The phases — prodrome → aura → tonic → clonic → postictal

THE PHASES OF A TONIC–CLONIC SEIZURE — left to right in timeFront view of the patient at each stage · the bar under each panel is its typical duration1 · PRODROME“I feel off”hours – daysMood change, irritability,headache. The patient mayjust say “I feel off.”2 · AURA“I smell oranges”secondsA warning sensation — asmell, a taste, a risingfeeling, déjà vu, a visualchange.3 · TONICRIGID · extended10–20 secBody goes RIGID andextended. Air forced pastthe cords = a cry.Cyanosis. Jaw clenched.4 · CLONICJERKING30–60 secRhythmic JERKING of alllimbs. Frothing, tonguebiting, incontinence.5 · POSTICTALzzzdeep sleep · confusedmin – hoursDeep sleep, confusion,headache, muscle soreness.No memory of the event.
🧠 “PATCH-P”: Prodrome, Aura, Tonic, Clonic, then Postictal. The whole convulsion is usually under two minutes; the postictal phase is the long part.

⭐ The AURA is a warning, not a symptom to fix

An aura is an unusual sensation immediately before the seizure — a smell, a taste, a rising feeling in the stomach, a flash of light, déjà vu.

Classic stem: the client says “I smell oranges and there aren’t any on my tray.” The best response is “Have you experienced this sensation before?” — you are establishing whether this is their usual aura, because if it is, a seizure is about to happen and you have seconds to make them safe.

🧠 An aura is a free warning. Teach patients that when they feel theirs, they should sit or lie down immediately.

🧨 What triggers seizures

  • Missed or abruptly stopped antiseizure medication — the number one cause
  • Fever (febrile seizures in young children)
  • Head injury, stroke, brain tumor, meningitis
  • Metabolic: hypoglycemia, hyponatremia, hypocalcemia, hypoxia
  • Alcohol or benzodiazepine withdrawal; stimulant overdose
  • Sleep deprivation, extreme stress, flashing lights in photosensitive epilepsy
  • Eclampsia in pregnancy
SEE ALSO NG-252 · Meningitis and NG-247 · Head Injury — both cause seizures and both are on your differential.
🧠 Check the glucose and the sodium. Two cheap labs explain a surprising number of first seizures.

🎭 Not every “seizure” is a seizure

Events that look like seizures but are not epileptic: syncope (brief jerks after fainting), psychogenic non-epileptic events, breath-holding spells in toddlers, migraine aura, and transient ischemic attacks.

Clues that point away from a true seizure include a gradual onset, eyes held tightly closed, side-to-side head shaking, very long duration with normal oxygen saturation, and no postictal confusion.

Treat the patient safely either way — the diagnosis is made on video EEG, not at the bedside.

🧠 No postictal phase is the biggest clue. A real tonic–clonic seizure leaves the patient wrecked afterwards.

⚠️ “Seizure” vs “epilepsy”

A seizure is a single event — anyone’s brain can have one under enough provocation.

Epilepsy is a chronic disorder of recurrent unprovoked seizures. A febrile seizure or a seizure from hypoglycemia is not epilepsy.

🧠 One provoked seizure ≠ epilepsy. Fix the provocation first.
🩺

DURING THE SEIZURE

STEP 2 · DO

This is the highest-yield section on the page. If you learn one thing here, learn the order — and the three nevers.

✅ The bedside picture

DURING THE SEIZURE — what you actually do, in orderBedside scene, side view · numbers 1–6 match the captions underneathSUCTIONOXYGENSTAY · TIME IT1234561Turn them to the SIDE — lets salivaand vomit drain out2Pillow / padding under the HEAD,nothing hard nearby3Side rails UP and padded · bed LOWand flat4Oxygen and SUCTION ready at thebedside5STAY with them · call for help ·TIME the seizure6Loosen tight clothing at the neckand chest
🧠 “SIDE · PAD · TIME · STAY.” Four words that answer most “what does the nurse do first” questions about an active seizure.

✅ Priority order at the bedside

1
AIRWAY — turn the patient onto their SIDE. Gravity drains saliva, blood and vomit away from the airway. This is the single most important action.
2
Protect the head — pillow, folded blanket, or your hands. Move furniture and hard objects away.
3
Call for help and STAY. Use the call bell rather than leaving the room.
4
TIME it. Note the exact start time — the treatment changes at 5 minutes.
5
Loosen restrictive clothing at the neck and chest.
6
Prepare for suction and oxygen; lower the bed and raise the padded rails if the patient is in bed.
7
Observe and remember the details — you are the only witness.
🧠 Airway beats everything. If “turn the client to the side” is an option during an active seizure, it is almost always the answer.

❌ THE THREE NEVERS

❌ THE THREE NEVERS — these are the wrong answers on every examEach panel shows the action struck through in red · the caption says whyNEVER put ANYTHING in themouthThey cannot “swallow their tongue.” Youwill break teeth, cause aspiration, or bebitten.NEVER restrain or hold themdownForcing a convulsing limb causes fracturesand dislocations. Guide, do not grip.NEVER leave them aloneStay. Use the call bell. You are theairway, the timer and the witness.

Never insert anything into the mouth · never restrain or hold down the limbs · never leave the patient alone.

People cannot swallow their tongue. Forcing an object between clenched teeth breaks teeth, damages the airway and gets you bitten. Holding a convulsing limb causes fractures and dislocations — guide movements away from hazards instead of gripping.

🧠 “Nothing in, nobody holds, nobody leaves.”

👀 What to observe — you are the witness

The chart is the diagnostic test. Record:

  • Time started and time stopped — exact, not “a few minutes”
  • What the patient was doing immediately before; any aura reported
  • Where it started and whether it spread (focal → generalized)
  • Which body parts moved, and whether movement was symmetrical
  • Eye deviation, pupil size, head turning
  • Color — cyanosis, apnea
  • Incontinence of urine or stool; tongue or cheek biting
  • Level of consciousness during and after; duration of the postictal phase
🧠 “Where it starts tells you where the lesion is.” That is why “which side jerked first” matters more than it sounds.

⭐ If the seizure happens out of bed

  • Ease them to the floor — do not try to lift or move them onto the bed
  • Something soft under the head; clear the area
  • Roll onto the side as soon as the jerking allows
  • Nothing under the head that could obstruct breathing — a thin pillow or folded clothing, not a bulky cushion
  • Stay, time it, and get help
🧠 Down, soft, side, stay. Same four moves, wherever they are.
🚨

STATUS EPILEPTICUS

STEP 3 · EMERGENCY

A seizure that will not stop is a medical emergency — the brain is burning oxygen it cannot replace.

🚨 The definition and the escalation ladder

🚨 STATUS EPILEPTICUS — the seizure that will not stopLeft: the definition on a clock face · Right: the escalation ladder, read top to bottom5 MINIT IS STATUS EPILEPTICUS IF:one seizure lasting 5 minutes or more, ORrepeated seizures over ~30 minutes withoutreturning to baseline in between.0 minAIRWAY · OXYGEN · positionSide-lying, suction ready, high-flow O₂, pulse oximetry.0 minIV ACCESS · CHECK GLUCOSEHypoglycemia mimics and prolongs seizures. Draw labs.5 minBENZODIAZEPINE — stop the seizureIV lorazepam (Ativan) or diazepam (Valium); rectal or IM route if no IV.10–20 minSECOND-LINE antiseizure drugA loading dose of a longer-acting drug — fosphenytoin, levetiracetam or valproate.> 20–40 minREFRACTORY → ICUContinuous anesthetic infusion, intubation, continuous EEG.Airway and breathing first — then the #1 priority is to STOP THE SEIZURE.
🧠 “Five and it’s alive.” Five minutes of continuous seizure and it will not stop on its own — it needs a drug.

💊 The #1 drug: a benzodiazepine

After the airway and breathing are secured, the priority is to STOP the seizure. The first-line agents are benzodiazepines:

  • Lorazepam (brand: Ativan) — IV
  • Diazepam (brand: Valium) — IV or rectal gel when there is no IV access
  • Midazolam — intramuscular or intranasal when there is no IV access

Watch for the side effects: respiratory depression, hypotension and sedation. Have a bag-valve mask and monitoring in place before you push.

💊 Benzos BREAK the seizure but they also SLOW the breathing. Never give one without the airway equipment at the bedside.

⚠️ Why it is dangerous

  • Hypoxia — the patient is not ventilating effectively while convulsing
  • Hyperthermia from sustained muscle activity
  • Lactic acidosis, rhabdomyolysis and acute kidney injury
  • Aspiration
  • Permanent neuronal injury — neurons die from the metabolic demand
  • Fractures and dislocations from the convulsion itself
🧠 The brain is running a sprint it cannot stop. Every extra minute costs neurons.

🧪 Look for the cause while you treat

  • Blood glucose — checked immediately; hypoglycemia both mimics and prolongs seizures
  • Electrolytes — sodium, calcium, magnesium
  • Antiseizure drug levels — a subtherapeutic phenytoin level often explains the whole event
  • Toxicology, alcohol withdrawal history
  • Oxygen saturation and capnography
  • CT head once stable if the cause is unclear
🧠 “Did they take their medication?” is the most productive question in the room.

⭐ The most common cause of status is an abrupt medication stop

Never stop an antiseizure medication abruptly — not for a procedure, not because the patient feels better, not because they ran out.

Doses are tapered over weeks under a provider’s direction. Teach patients to:

  • Refill before running out and never skip doses
  • Carry a medical alert ID
  • Tell every prescriber and dentist what they take
  • Call the provider rather than stopping if side effects appear
🧠 “Stopping suddenly is how a controlled epileptic ends up intubated.” Say it exactly like that and you will never miss the question.
🛏️

AFTER THE SEIZURE & PRECAUTIONS

STEP 4 · RECOVER

The postictal patient is confused, exhausted and at risk. And the padding should have been up long before any of this.

✅ Postictal care

1
Keep them side-lying and suction as needed — secretions are the airway risk now.
2
Assess LOC, neuro status and vital signs; check oxygen saturation and give oxygen as needed.
3
Check for injuries — head, tongue, shoulders, hips; check for incontinence and provide hygiene privately.
4
Reorient calmly and repeatedly. They will not remember the seizure and may be frightened or combative.
5
Let them sleep. Deep postictal sleep is normal — keep the rails up and the bed low.
6
Document everything and notify the provider.
🧠 Postictal confusion is expected. Postictal FOCAL WEAKNESS is not — a lasting one-sided weakness (Todd’s paralysis) needs reporting.

😴 What the postictal phase looks like

  • Deep sleep, difficult to rouse — minutes to hours
  • Confusion and disorientation, sometimes agitation
  • Headache and generalized muscle soreness
  • No memory of the event at all
  • Possible temporary weakness on one side

Document this phase by name: “documented as the postictal phase.”

🧠 “Post-ictal” = after the ictus (the seizure itself). Ictal = during, interictal = between.

📝 How to document it

Write it so someone who was not there can classify the seizure:

“At 1412 client reported an odd smell, then had tonic–clonic activity beginning in the right arm and spreading to all four limbs (focal onset, becoming bilateral). Eyes deviated left. Cyanosis noted. Turned to left side, airway maintained, O₂ 2 L nasal cannula applied, side rails padded and up. Activity stopped at 1413:40 (100 seconds). Incontinent of urine. Postictal, deeply asleep, rousable to voice at 1425, oriented to person only. Vital signs …. Provider notified.”

🧠 Onset · spread · duration · airway · postictal. Five elements and the note writes itself.

🛏️ Seizure precautions — set up BEFORE anything happens

SEIZURE PRECAUTIONS — what the room looks like BEFORE anything happensSide view of the prepared bed space · set this up on admission, not when the seizure startsSUCTIONOXYGENSide rails UP and PADDEDIV access maintainedBed in the LOWEST positionSuction + oxygen set up and testedCall bell within reachFloor kept clearALSO:no oral temperatures · supervise showers · nothing hot or glass at the bedside · know where the rescue benzodiazepine is.Padding and rails do not stop a seizure — they stop the injury. Set them up the moment seizure risk is identified.
🧠 “Low bed, up rails, suction & O₂, clear floor.” If a stem asks what you set up for a new admission with a seizure history, that is the list.

⚠️ Everyday safety teaching

  • Showers, not baths — a seizure in a bath is a drowning risk
  • Never swim alone; supervision at all times in water
  • No driving until the legally required seizure-free interval is met — and clearance comes from the provider, not the nurse
  • Avoid working at heights, with open flame, or with dangerous machinery
  • Avoid known triggers: sleep deprivation, alcohol, flashing lights if photosensitive
  • Medical alert bracelet at all times
  • Teach family what to do — and what never to do — during a seizure
🧠 Water and heights are the two killers. The seizure itself rarely is.

👨‍👩‍👧 Teach the family — and when to call 911

  • Stay calm, time it, protect the head, turn them on their side
  • Nothing in the mouth, no restraints, do not leave them
  • Move furniture away; take glasses off; loosen anything tight at the neck
  • Stay with them until they are fully awake and oriented

Call emergency services if: the seizure lasts > 5 minutes · a second seizure follows without recovery · the patient does not wake up · breathing is difficult · it happened in water · they are injured, pregnant, or diabetic · it is their first seizure.

🧠 Five minutes, second seizure, doesn’t wake up, in water, first ever. Any one of those = call.

🤰 Pregnancy and antiseizure drugs

Several antiseizure medications are teratogenicvalproic acid in particular carries a high risk of neural tube defects and is generally avoided in people who could become pregnant. Carbamazepine also carries risk.

Teach that a pregnancy must be planned with the prescriber, that folic acid supplementation is routinely recommended, and that the medication is never stopped without medical advice — an uncontrolled seizure is dangerous for both mother and fetus.

💊 “Val is bad for the belly.” Valproate + pregnancy is the classic exam pairing.

✅ When drugs are not enough

  • Ketogenic diet — high fat, very low carbohydrate; used mainly in refractory pediatric epilepsy and requires dietitian supervision
  • Vagus nerve stimulator — an implanted device; the patient can swipe a magnet over it when an aura starts
  • Responsive neurostimulation / deep brain stimulation
  • Epilepsy surgery — resection of a well-localized focus after video EEG mapping
🧠 Refractory = two appropriate drugs failed. That is the point at which these options get considered.

🧊 A note on febrile seizures

Common in children roughly 6 months – 5 years, triggered by a rapid rise in temperature. Most are brief, generalized and do not cause brain damage.

Teach parents: control fever with antipyretics as directed, keep the child safe and side-lying during the event, and do not use ice baths or alcohol rubs — rapid cooling causes shivering, which raises the temperature again.

🧠 Reassure, don’t over-treat. Most children with febrile seizures never develop epilepsy.
💊

DRUGS & DIAGNOSTICS

STEP 5 · TREAT

Know the names, the one big monitoring point for each, and the rule that applies to every single one of them.

🚨 The rule that applies to every antiseizure drug

Never stop an antiseizure medication abruptly.

Abrupt withdrawal precipitates status epilepticus. Doses are tapered slowly. This is true of all of them, and it is the most commonly tested single fact about the class.

💊 One rule, every drug. If an answer option says “stop the medication,” it is wrong unless a provider ordered a taper.

💊 The drugs by name

DrugThe thing you monitor / teach
Phenytoin (Dilantin)Therapeutic level commonly cited as 10–20 mcg/mL (a typical adult range that varies by lab); hold and report above 20. Gingival hyperplasia — meticulous oral care and dental visits. Nystagmus is an early toxicity sign. IV: mix with normal saline only (precipitates in dextrose) and infuse slowly.
FosphenytoinA prodrug of phenytoin used IV/IM in emergencies; fewer infusion-site problems, still monitor cardiac rhythm and blood pressure.
Levetiracetam (Keppra)Well tolerated; watch for mood and behavior changes — irritability, agitation, depression. Driving permission comes from the provider.
Carbamazepine (Tegretol)Blood dyscrasias (agranulocytosis, aplastic anemia), Stevens–Johnson syndrome, hyponatremia, many interactions. Report sore throat, fever, bruising or rash.
Valproic acid / divalproexHepatotoxicity and pancreatitis; thrombocytopenia; teratogenic — neural tube defects. Monitor LFTs, ammonia, platelets.
LamotrigineSerious rash / Stevens–Johnson syndrome — titrate slowly and report any rash immediately.
PhenobarbitalSedation, respiratory depression, dependence; strong enzyme inducer.
Lorazepam · diazepam · midazolamRescue drugs for an active seizure or status. Respiratory depression, hypotension, sedation.
DEEP DIVE Carbamazepine and valproic acid have a whole comparison page: NG-241 · Carbamazepine vs Valproic Acid.
💊 PHENytoin = PHEN-cy gums. Levetiracetam = “Keppra makes you kranky.” Valproate = “Val hurts the liVer.” Lamotrigine = “Lamo-RASH-gine.”

🧪 Phenytoin level — the number you must recognize

PHENYTOIN LEVEL — the number you must recognizeSerum concentration scale (micrograms per mL) · left = too little, right = toxic · commonly cited range — varies by labSUB-THERAPEUTICseizures not controlledTHERAPEUTIC10–20 mcg/mLTOXIChold the dose · notify051015202530serum phenytoin (mcg/mL)Level 22 mcg/mL →HOLD the dose and notify the providerEARLY SIGNS OF TOXICITY• NYSTAGMUS — often the first thing you see• Ataxia, slurred speech, unsteady gait• Drowsiness, confusion, double visionLONG-TERM / GIVING IT• GINGIVAL HYPERPLASIA — meticulous oral care• IV: mix with SALINE, never dextrose; give slowly• Hirsutism, rash; many drug interactions

A reported level of 22 mcg/mL means hold the dose and notify the provider. Do not give it and document later.

10–20 mcg/mL is the commonly cited therapeutic range for total serum phenytoin; it is a typical adult reference range and varies by laboratory (and free/unbound levels use a different range) — always check the range reported with your patient’s result.

🧠 10 to 20 is fine. Over 20 you’re done.

📈 EEG and imaging

EEG — reading the electrical activity of the “EGG head”Left: electrode placement, side view · Right: what the trace shows and how you prep the patientrecordersticky scalp electrodesTHE TRACEspike-and-wave burstnormal backgroundPREPARING THE PATIENTWASH the hair before and after — gel and oils stop electrodes stickingNO caffeine or stimulants for 12–24 h (tea, coffee, cola, energy drinks)😴SLEEP DEPRIVATION is often requested — it makes abnormal activity show🍽️EAT beforehand — the patient is NOT kept NPO; low glucose alters it💊Antiseizure medication may be held — only on a provider’s order
🧠 EEG = the EGG head (Electrical activity of the brain). ECG = C for Cardiac. Two letters apart, two completely different tests.

🖼️ The other diagnostics

  • CT head — first-line after a new seizure to exclude bleed, tumor or trauma
  • MRI — better for structural lesions and mesial temporal sclerosis
  • Blood glucose, electrolytes, calcium, magnesium
  • Antiseizure drug levels and a toxicology screen
  • Lumbar puncture if infection is suspected
🧠 A first seizure in an adult always earns imaging. The seizure is a symptom, not the diagnosis.

🎯 NCLEX traps on this topic

The stem says…The answer is…
“Client is actively seizing — first action?”Turn the client to the side (airway)
“Which action does the nurse take during a seizure?”Protect the head / clear the area — never insert anything, never restrain
“I smell oranges and there aren’t any on my tray”“Have you experienced this sensation before?” — that is an aura
“Deep sleep and confusion after the event — documented as?”The postictal phase
“Seizure has lasted 6 minutes”Status epilepticus — airway, then IV/rectal benzodiazepine
“Phenytoin level is 22 mcg/mLHold the dose and notify the provider
“Preparing for an EEG — which instruction?”No caffeine for 12–24 h · wash the hair · eat beforehand (not NPO)
“Client on levetiracetam asks about driving”Driving permission must come from the provider
“Client feels better and wants to stop the medication”Never stop abruptly — it causes status epilepticus
“Safe bathing for a client with epilepsy?”Take showers rather than baths
🧠 Side · protect · time · never stop the drug. That covers most of the exam’s seizure questions.
🔄 DURING = airwaySide-lying · pad the head · time it · stay. Suction and oxygen ready. Loosen tight clothing.
❌ Three NEVERSNothing in the mouth · no restraints · never leave them. These are always the wrong-answer distractors.
⏱️ 5 min = STATUSAirway and breathing first, then the #1 priority is to STOP the seizure — IV or rectal benzodiazepine (lorazepam, diazepam).
💊 Never stop abruptlyPhenytoin therapeutic 10–20, hold above 20; gum care. Keppra = mood changes + provider clears driving.