Continuing Nursing Education
Objectives and posttest can be found on page 195.
Seizure Precautions for Pediatric
Bedside Nurses
O
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 nurs-
ing management of pediatric seizures,
for which patient safety is the priori-
ty, 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 safe-
ly and appropriately stocking pa-
tients 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 classifi-
cation.
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 involve-
ment 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 pres-
entation of that abnormal neuronal
discharge varies from twitching last-
ing two to three seconds to general-
ized 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 report-
ed no actual or potential conflict of interest in
relation to this continuing nursing education
article.
PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4
Ellen Thomen Clore
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 clas-
sification 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 occurring in only one hemisphere of
for hours if untreated (Yamamoto, the brain (partial) in which conscious-
Olaes, & Lopez, 2004). Some individu- ness is preserved (simple). These
als may have associated symptoms, episodes usually last a few seconds but
such as cyanosis, while others may can last longer, and are often referred
have very few clinical symptoms that to by the individual as an aura that
a seizure is occurring. portends a second seizure type.
Approximately 10% of the popula- Depending on the part of the brain
tion will have at least one seizure in afflicted by the excessive firing, the
their lifetime (Marks & Garcia, 1998). symptoms of the aura are varied and
Of this group, 1% to 3% will be diag- may include paresthesias, hallucina-
nosed with epilepsy (Hauser, tions, dysphagia, sweating, flushing,
Annegers, & Kurland, 1993), which is or motor disturbances, such as jerking
defined as recurrent, spontaneous, (Yamamoto et al., 2004). Since the
unprovoked seizures. Each year 30,000 individual is conscious during the
children will be diagnosed with seizure, and the clinical symptoms of
epilepsy (Blumstein & Friedman, the seizure are usually very brief, there
2007), and 30% of those children will are fewer safety risks to address.
suffer from seizures that are refractory However, it is important for the bed-
to medical management, a condition side nurse to know if the patients sim-
known as intractable seizures ple partial seizure usually precedes a
(Nadkarni, LaJoie, & Devinsky, 2005). complex-partial or generalized seizure
The bedside nurse should obtain a because these seizure types put the
detailed description of the seizure, patient at an increased safety risk.
including duration, frequency, and
symptoms (Marthaler, 2004). As in the Complex Partial Seizures
adult population, seizures that present A complex-partial seizure is defined
in childhood are classified by electro- as a seizure originating from one
graphic findings and clinical presenta- hemisphere of the brain with impair-
tion with a constellation of symptoms ment of consciousness (Yamamoto et
noted in each seizure type. al., 2004). Most commonly, these
seizures originate in the temporal
lobe, so common clinical manifesta-
Seizure Classification tions can be as subtle as automatisms
(purposeless, repetitive motions, such
Simple Partial Seizures as picking motions of the hands) or as
Simple partial seizures are defined obvious as bizarre behaviors (such as
as abnormal neuronal discharges 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 at-
tempt 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 sec-
ondarily generalize to both hemi-
spheres 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 con-
sciousness (Blumstein & Friedman,
2007). There are two main categories
of generalized seizures: nonconvul-
sive and convulsive.
Nonconvulsive. Absence seizures
are characterized by brief periods of
altered consciousness with subtle
motor activity, such as eyelid flutter-
ing, staring, or lip smacking
(Yamamoto et al., 2004). One study
found these episodes to last an aver-
age of 9.4 seconds (Sadleir, Farrell,
Smith, Connolly, & Scheffer, 2006);
once the seizure is over, the individ-
ual returns to the previous activity.
These episodes are often mistaken for
daydreaming because of their short
length, and these individuals are fre-
quently admitted to the hospital for
overnight video EEG monitoring to
diagnose the event.
These events, epileptic or not, usu-
ally have no history of respiratory
compromise or significant motor
involvement, and as such, these
patients are at low risk of injury dur-
ing their seizures. However, the risk of
injury does not disappear if the onset
of seizure activity coincides with
other activities, such as driving or eat-
ing.
Myoclonic seizures usually mani-
fest 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 sec-
onds 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 respi-
ratory compromise, these individuals
are at extremely high risk for falls and
injury because of the clinical presen-
192
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 conscious-
ness, 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 aspira-
tion.
Other types of convulsive general-
ized seizures include clonic seizures
involving rhythmic jerking of extrem-
ities 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 respirato-
ry compromise.
Special Circumstance:
Medication Taper
Children who have intractable par-
tial 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 surgi-
cal ablation of an epileptic focus is
being considered (Major & Thiele,
2007). The pre-surgical evaluation
process often requires multiple hospi-
talizations 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 sev-
eral days) taper the childs anti-epilep-
tic 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-epilep-
tic 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 popu-
lations is paramount; however, those
children who undergo surgical evalu-
ation 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
PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4
and young adults without primary
generalized epilepsy showed a four-
fold increase in frequency of general-
ized 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 sup-
plies 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-con-
tainment advantage (see Figure 1).
By following the algorithm, if a
child has staring spells lasting five sec-
onds 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 res-
piratory compromise. However, if the
child has a complex-partial seizure
involving staring spells, which sec-
ondarily generalizes to a tonic-clonic
seizure, it is crucial to have appropri-
ate 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 classifica-
tion, if a child experiences pooling of
secretions, oxygen desaturation, or
extensive motor involvement (such as
rhythmic jerking), there should be
 Figure 1.
Bedside Seizure Safety

Does your patient have a

history of seizures?

YES
NO

What are the

clinical symptoms Maintain routine
of the event? safety precautions
(bedrails up)

Symptoms with neither ANY symptom accompanied

Motor symptoms without
respiratory compromise nor by respiratory compromise
respiratory compromise
motor involvement (staring (tonic-clonic movements)
(myoclonic jerks)
spells, eyelid fluttering) Motor symptoms accompanied
by LOC (atonic seizures)

Is your patient on a
medication wean or
completely off seizure
medication?
NO YES SUPPLIES*
Bag, valve mask (if clinically indictated)
Suction (canister and catheter)
Cardiorespiratory monitor
Pulse ox
Maintain routine Seizure pads (if clinically indicated)
safety precautions
(bedrails up)
*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 classifica-
tion, the bedside nurse must be pre-
pared 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 par-
ents as they observe their childs nurs-
ing 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 sup-
plies 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 with-
out 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 par-
ents to take their child home safely
without unnecessary equipment.
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 unneces-
sary. 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 hospi-
talization and to prepare for the

PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4 193

Seizure Precautions for Pediatric Bedside Nurses

admission in a calm, non-emergent dren will require the oxygen and/or think critically about their patients
way. This saves time for the nurse and ventilatory support provided by a bag seizures, and by so doing, stock the
minimizes the risk of being unpre- and mask (and it is important that it appropriate supplies at the bedside.
pared for emergency situations. be readily available in those situa- This thought process combines criti-
Additionally, the bedside nurse tions), there are also children who cal thinking about complex medical
should perform a test of the equip- will not. A patient with childhood scenarios with the compassion and
ment to ensure that all supplies are absence epilepsy, for example, will empathy for children and families for
properly functioning when they are not have respiratory compromise which nurses strive. By providing
placed at the patients bedside. This with seizures, and therefore, to place a excellent care at the bedside, nurses
test should also be repeated at each bag and mask at that childs bedside is ultimately empower families to feel
shift change, when another nurse an unnecessary use of hospital comfortable caring for their child at
assumes care of the child. resources. Implementing the bedside home, while simultaneously conserv-
seizure safety algorithm will empower ing resources.
nurses to think critically about their
Cost-Effectiveness patients seizure activity, while at the
A final advantage to this algorithm same time, reduce hospital costs. References
is that it increases cost-effectiveness of Throughout health care, the aim Blumstein, M.D., & Friedman, M.J. (2007).
appropriate seizure precautions. The has been to make significant changes Childhood seizures. Emergency Clinics
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Fagley, M.U. (2007). Taking charge of seizure
patient safety, and by using the bed- with a focus on improving patient activity. Nursing, 37(9), 42-47.
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require that every patient admitted the safety of their patients. Ensuring Hauser, W.A., Annegers, J.F., & Leonard, T.K.
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Minnesota: 1935-1984. Epilepsia, 34(3),
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taken from one pediatric institution, aspect of patient safety; however, they dren: Laboratory diagnosis and man-
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ing unit (non-ICU), all requiring a bag seizures displays different symptoms. Malow, B.A., Lynch, B., Blaxton, T.A., &
and mask as a part of standard admis- The algorithm presented can act as a Mikati, M. (1994). Relationship of
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Marks, W.J., & Garcia, P. (1998).
On the Cover Ellie Shoal Potvin Management of seizures and epilepsy.
American Family Physician, 57(7),
1589-1600.
Ellie Shoal Potvin, a precious child known for Marthaler, M.T. (2004). Seizures revisited.
Specializing in being Kind, at only 6 years of age was diag- Nursing Management, 35(4), 71-74.
nosed on July 2, 2008, with a rare childhood cancer called Nadkarni, S., LaJoie, J., & Devinsky, O.
Stage 4 Rhabdomyosarcoma. To her parents shock, they (2005). Current treatments of epilepsy.
learned only 3% of children in the United States have this Neurology, 64(Suppl. 3), S2-S11.
type of rare pediatric cancer. Out of the 350 children total Pullen, R.L. (2003). Protecting your patient
diagnosed per year, only 175 children have a survival rate during a seizure. Nursing, 33(4), 78.
Ranganathan, L.N., & Ramaratnam, S.
past five years.
(2006). Rapid versus slow withdrawal of
Ellie fought a heroic battle for two years, having approx- antiepileptic drugs. Cochrane Database
imately 60 rounds of chemotherapy using over 10 different of Systematic Reviews, (1). DOI:
combinations of chemotherapy agents, and 30 days of radi- 10.1002/14651858.CD005003.pub2.
ation to her lungs and abdomen. On June 23, 2010, Ellie Sadleir, L.G., Farrell, K., Smith, S., Connolly,
earned her Angel wings. Ellies journey touched the hearts and souls of thousands M., & Scheffer, I.E. (2006).
of people through Caringbridge. In eight short years, Ellie taught the world how to Electroclinical features of absence
smile in the face of adversity and to find the blessing in each day. Her message was seizures in childhood absence epilepsy.
one of childlike faith and trust in Gods love and healing power. During the worst of Neurology, 67, 413-418.
Sirven, J.I., Sperling, M., & Wingerchuk, D.M.
times, Ellie found a way to smile and find the joy in life. Through the innocence of a
(2003). Early versus late antiepileptic
childs eyes, others found themselves Lifted Up to seek a higher purpose in life. drug withdrawal for people with epilepsy
Ellie symbolized the meaning of strength, love, hope, and courage. Ellies motto in remission. Cochrane Database of
was In It to Win It, and she played out that role until her last breath on earth. Ellies Systematic Reviews, (1). DOI:
mother, Amy Potvin, has decided to honor her daughters life by writing a book on 10.1002/14651858.CD001902.
Ellies courageous battle against cancer. The goal is to continue to spread Ellies Yamamoto, L., Olaes, E., & Lopez, A. (2004).
message of love, faith, and hope, as well as raise awareness of pediatric cancer. Challenges in seizure management:
To learn more about Ellie, Team Potvin, and the Lift Up Foundation, visit Neurologic versus cardiac emergen-
http://www.liftupellie.com/ cies. Topics in Emergency Medicine,
26(3), 212-224.
Note: Reprinted with permission from Tim and Amy Potvin.

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