Case study - Epilepsy: Nursing

Nurse Karla works on an inpatient neurology unit and is caring for Nisha, a 24-year-old female with a history of generalized onset tonic-clonic seizures. After settling Nisha in her room, Nurse Karla goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Nisha’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. 

First, Nurse Karla recognizes important cues. As she reviews the electronic health record, or EHR, Karla notes Nisha is on seizure precautions and has an order for lorazepam IV push for seizures, per protocol. As she enters Nisha’s room, she finds Nisha lying supine on her bed. 

Nisha: I don’t feel right. I feel like I’m going to have a seizure. 

Nurse Karla: Okay Nisha, I’ll stay with you. 

Then, Nisha’s body begins cycling through periods of intermittent jerking movements and muscle tightening. Her breathing is sporadic, and she alternates between rapid breathing and apnea. Her pupils are dilated, she's intermittently biting her cheek, and doesn’t respond to verbal cues. 

Nurse Karla calls for help while noting the time the seizure activity began. Then, she protects Nisha from injury by ensuring there are no objects in Nisha’s bed that could hurt her during the seizure.  

Next, Nurse Karla analyzes these cues. Nurse Karla realizes that during tonic-clonic seizures, the airway can become obstructed, and she recognizes Nisha needs effective airway management.