J. Iverson Riddle Developmental Center

Seizure Documentation

Accurate descriptions ofseizures are a valuable guidefor the medical staff inproviding appropriate medicaltreatment.

Seizure Observation tips:Describe observations in simple

terms.Describe only what is actually

seen.Describe events in the order in

which they happened. Note the time started and ended.

Observations before, during, and after a seizure are very important.

When observing a seizure ask yourself the following questions:

What was the person doing just before the seizure?

Did the person cry out or attract your attention in any way?

When observing a seizure ask yourself the following questions:

Does the person have frequent staring episodes?

Was the person confused or did they lose consciousness?

When observing a seizure ask yourself the following questions:

Did the person respond when spoken to or touched?

Did the person’s body become limp or stiff?

When observing a seizure ask yourself the following questions:

Did the person fall to the floor or did his head drop?

Did the person have jerking of the body? Mild or severe?

When observing a seizure ask yourself the following questions:

Was the jerking over the entire body or on one side or limb of body? Which side?

Did the person’s eyes change? (Blinking, staring, pupils enlarged)

When observing a seizure ask yourself the following questions:

Did the person lose control of bladder or bowel?

Did the person’s skin color change? (Pale, flushed, or bluish tint - Cyanosis)

When observing a seizure ask yourself the following questions:

Were there any unusual actions such as lip smacking, humming, picking at clothes, or wandering around in a disoriented manner?

When observing a seizure ask yourself the following questions:

How long did the symptoms occur?

After the episode, what was the person’s state of alertness? Confused, dazed, or sleepy? If so , how long?

When observing a seizure ask yourself the following questions:

If the person is able to respond, ask if there was any “warning” that the episode was beginning such as a strange feeling, sound or odor? (Aura)

Always report to the nurse immediately when the following occurs:

The person has a seizure for the first time.

The seizure is prolonged, severe, or different from usual seizures.

Always report to the nurse immediately when the following occurs:

The person has been injured.

The person has one seizure after another

The person does not start breathing after the seizure.

Documenting Seizures

Each seizure must be documented on the seizure checklist in the individual’s record.

An accident report must be completed of the person gets injured.

Documenting Seizures

A note should be made in thenurses notes: If anything unusual happens

during the seizure. If the person has an injury. If the person goes into a deep

sleep or is confused after the seizure.

Vagus Nerve Stimulator (VNS)

Some people who live at JIRDC have an implanted device called a Vagus Nerve Stimulator (VNS). It is important to document the number of times that magnet is used.

Seizure Record

Section 1 Date ex. 04/19/23 Time ex.01:32 AM Indicate a.m. or p.m. (do not use military time) Duration Specify # of min. and sec.

Seizure Record

Section 2Circle yes or no if the person was alert or responds to touch / voice

Seizure Record

Section 3 Check if the person was

confused / unaware or unconscious

Seizure Record

Section 4 (Muscle Tone) Check all that apply to each

seizure. - Limp

- Stiff - Falls to floor / ground - Head Drops

Seizure Record

Section 4 (Muscle Tone) If none of these descriptions

apply check the “No change” box

Seizure Record

Section 5 (Muscle Activity)

Check the best description of each seizure. - Mild Twitching- Severe Jerking

Seizure Record

Section 5 (Muscle Activity)

If neither of these descriptions apply check the “No change” box.

Seizure Record

Section 6 (Location / Area of Body) Check the best description of each seizure. - Entire Body- (R) Right Side - (L) Left Side

Seizure Record

Section 6 (Location / Area of Body) If neither of these descriptions apply check the “No change” box.

Seizure Record

Section 7 (Eyes) Check the best description of each seizure.

- Blank - Blinking - Enlarged pupils

Seizure Record

Section 7 (Eyes) If neither of these descriptions apply check the “No change” box.

Seizure Record

Section 8 (Other)Check all that apply to each seizure. - Loses Bladder Control - Pale / Sweating / Appeared

frightened- Cyanosis (Blue)

Seizure Record

Section 8 (Other)Check all that apply to each seizure. - Difficulty breathing- Lip smacking / Chewing- Unusual movement

Seizure Record

Section 9 (STATUS AFTER SEIZURE) Check the best description after each seizure. - Confused - Deep Sleep- Resumed previous activity immediately

Seizure Record

Section 10 (VNS MAGNET USED)

If the person has a VNS implant, indicate the number of times that the magnet is used.NOTE – If the person does not have a VNS mark as N/A.

Seizure Record

Section 11 (Recorded by - Signature /

Title)

Sign and indicate title (ex. TR I; HC; RT; etc.)

Seizure Record

Section 12 Medications Given (Nurse to complete) If the person needs medications, the nurse will record information in this area.

Seizure Record

Section 12 Medications Given (Nurse to complete) The name of the medication, date, time given and the nurses signature will be recorded in this section.

Practice Documenting a seizureWhile walking to the workshop with a groupat 10:00am, Tommy Brown suddenly falls tothe ground, and is unconscious. He does notrespond to touch and is not alert. His body isstiff, followed by severe jerking on the leftside. When checked, his pupils are very large(dilated). During the assessment, you note that he lost control of his bladder and has abluish color (cyanosis) around his mouth. Theseizure activity lasts for 5 minutes. Tommy sleeps deeply for 1 1/2 hours after returningto the cottage.