Seizure Nursing Guide 2026
⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.
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Seizure classification, active seizure management, status epilepticus treatment ladder, anti-seizure medication administration, postictal care, and NCLEX essentials.
1. Seizure Classification
Focal (Partial) Seizures — one brain area
| Type | Description |
|---|
| Focal aware (simple partial) | Patient is awake and aware; may have motor jerking, sensory phenomena, autonomic changes, or psychic symptoms (déjà vu, fear) |
| Focal impaired awareness (complex partial) | Impaired consciousness; automatisms (lip smacking, hand rubbing, picking at clothes); confusion after |
| Focal to bilateral tonic-clonic (secondary generalization) | Starts focal, spreads to both hemispheres; full convulsion follows focal onset |
Generalized Seizures — both hemispheres
| Type | Description | EEG |
|---|
| Absence (petit mal) | Brief staring spells, 5–30 seconds; no postictal period; child resumes activity immediately | 3 Hz spike-and-wave |
| Tonic-clonic (grand mal) | Classic convulsion — tonic (stiffening) then clonic (jerking) phase; postictal confusion/fatigue | Polyspike + wave |
| Tonic | Sudden sustained muscle stiffening; fall risk | Low-voltage fast activity |
| Clonic | Rhythmic jerking without preceding tonic phase | Polyspike + wave |
| Atonic (drop attacks) | Sudden loss of muscle tone; fall; brief LOC | Generalized polyspike + slow wave |
| Myoclonic | Brief shock-like jerks, usually arms; morning predominance (juvenile myoclonic epilepsy) | Polyspike + wave |
2. During a Seizure: Nursing Priorities
DURING a seizure — what you DO:
- Stay with the patient — note exact time seizure began
- Protect from injury: lower to floor if possible, clear surrounding objects, pad side rails
- Turn patient to SIDE (lateral position) to prevent aspiration of secretions
- Loosen clothing around neck and chest
- Suction if needed (after active jerking stops — airway may be compromised)
- Apply oxygen via face mask (NRB or simple mask)
- Do NOT restrain limbs (increases injury risk; does not stop seizure)
- Do NOT put anything in the mouth (NEVER — can break teeth, cause oral injury, bite healthcare worker)
- Note seizure characteristics: type of movement, where it started, eye deviation, incontinence, duration
- Time it — call provider if >5 minutes (status epilepticus threshold)
Airway position during seizure: Lateral (recovery) position prevents aspiration. HOB should be flat or 15° during convulsive phase; after jerking stops, position laterally and suction orally if needed.
3. Postictal Phase Assessment
The period after seizure activity ends. Can last minutes to hours.
- Todd's paralysis: focal weakness or paralysis on the side where seizure started — resolves within minutes to hours (important: can mimic stroke)
- Confusion, disorientation, fatigue, headache, amnesia of event
- Oral injury (tongue biting — lateral tongue biting is characteristic of tonic-clonic; midline bite suggests psychogenic non-epileptic event)
- Incontinence (bowel or bladder)
- Muscle soreness (from sustained contraction)
Post-Seizure Nursing Assessment
- Vitals + SpO2 (assess for hypoxia)
- GCS and neuro assessment (compare to baseline)
- Fingerstick glucose (hypoglycemia causes seizures AND follows seizures)
- Any injuries: head, tongue, extremities
- IV access — obtain if not present
- Labs if first seizure or prolonged: CBC, BMP (electrolytes, glucose, renal), AED levels if on therapy, tox screen, LFTs, pregnancy test in women of childbearing age
- Reorient patient — speak calmly; tell them they had a seizure
4. Status Epilepticus (SE)
Seizure lasting ≥5 minutes OR two or more seizures without return to baseline between them. A medical emergency — mortality increases with each minute of ongoing SE. Brain injury begins around 30 minutes.
Status Epilepticus Treatment Ladder
Stage 1: 0–5 minutes (Stabilization)
- ABCs: airway, oxygen, IV access, cardiac monitor, ECG
- Fingerstick glucose immediately → give thiamine 100 mg IV THEN D50W if glucose <60 mg/dL
- Labs: BMP, CBC, AED levels, tox screen, calcium, magnesium
Stage 2: 5–20 minutes (Initial Benzodiazepine Therapy)
- IV access available: Lorazepam (Ativan) 0.1 mg/kg IV (max 4 mg); repeat once in 5 min if still seizing
- No IV access: Midazolam (Versed) 10 mg IM (most effective for pre-hospital) OR diazepam 20 mg PR (rectal)
- Buccal or intranasal midazolam also effective if no IV
Stage 3: 20–40 minutes (Second-Line Anti-Seizure Medications)
If benzos fail × 2 doses:
- Levetiracetam (Keppra) 60 mg/kg IV (max 4,500 mg) over 10 min — currently preferred first-line second agent at many centers; well-tolerated
- Fosphenytoin (Cerebyx) 20 mg PE/kg IV at 150 mg PE/min — hypotension and bradycardia risk; cardiac monitoring required
- Valproate sodium 40 mg/kg IV at 6 mg/kg/min — avoid in pregnancy and liver disease
- Any of the above can be used; efficacy is similar
Stage 4: 40–60 minutes (Refractory Status Epilepticus)
- ICU admission required
- Continuous EEG monitoring
- Intubation and ventilation
- Anesthetic infusions: propofol, midazolam, or ketamine infusion; pentobarbital for super-refractory
- Target: burst-suppression pattern on EEG
Phenytoin (Dilantin) vs Fosphenytoin: Phenytoin cannot be given faster than 50 mg/min IV; causes severe tissue necrosis if extravasated (give in NS only, not dextrose); cardiac toxicity if too fast. Fosphenytoin is the prodrug — can be given faster and IM; dose expressed as "phenytoin equivalents (PE)." Most hospitals use fosphenytoin IV now.
5. Key Anti-Seizure Medications
| Drug | Route | Key Nursing Points |
|---|
| Levetiracetam (Keppra) | IV, PO | Minimal drug interactions; monitor for behavioral side effects (aggression, irritability); renal dose adjustment |
| Phenytoin (Dilantin) | IV, PO | MAX 50 mg/min IV; NS only (precipitates in dextrose); extravasation → purple glove syndrome/tissue necrosis; therapeutic level 10–20 mcg/mL; gingival hyperplasia, hirsutism (long-term); many drug interactions |
| Fosphenytoin (Cerebyx) | IV, IM | Max 150 mg PE/min IV; dosed in phenytoin equivalents (PE); cardiac monitoring required; paresthesias during infusion (transient) |
| Valproate (Depakote) | IV, PO | Monitor LFTs and CBC (hepatotoxicity, thrombocytopenia); teratogenic (neural tube defects) — contraindicated in pregnancy; check ammonia level if altered mental status |
| Phenobarbital | IV, PO | Sedation, respiratory depression — have intubation equipment ready; MAX infusion 60 mg/min IV; controlled substance |
| Carbamazepine (Tegretol) | PO | Hyponatremia (SIADH); monitor CBC (aplastic anemia rare); many CYP drug interactions; therapeutic level 4–12 mcg/mL |
| Lorazepam (Ativan) | IV, IM | First-line for acute SE; 4-hr half-life (shorter than diazepam); respiratory depression — have bag-valve mask available |
6. Seizure Precautions
Seizure precautions — standard nursing safety measures for at-risk patients:
- Padded side rails (up at all times)
- Bed in lowest position
- Suction and oxygen at bedside, ready to use
- IV access maintained (for medication administration)
- Call light within reach; patient not left alone in shower or bath
- Oral airway at bedside (do NOT place during active seizure — place after)
- Driving restriction: educate patient — most states require seizure-free period (typically 3–6 months) before driving
- Avoid triggers: sleep deprivation, alcohol, missed medications, fever, photosensitive epilepsy — avoid flashing lights
7. Seizure Triggers (AEIOU TIPS)
AEIOU TIPS mnemonic (seizure + altered mental status causes):
A = Alcohol/Acidosis | E = Epilepsy/Electrolytes (hyponatremia, hypoglycemia, hypocalcemia, hypomagnesemia) | I = Insulin/Intracranial (trauma, tumor, meningitis) | O = Overdose (cocaine, TCAs, INH, tramadol) | U = Uremia | T = Trauma/Temperature | I = Infection/Ischemia | P = Psychiatric/Poisoning | S = Structural/Stroke
8. Special Situations
Febrile Seizures (Pediatric)
Most common seizure type in children 6 months–5 years. Triggered by rapid rise in temperature. Simple febrile seizure: <15 min, generalized, occurs once in 24 hr — good prognosis, no increased risk of epilepsy. Complex febrile seizure: >15 min, focal, recurs in 24 hr — requires further workup. Treat fever; benzodiazepine if prolonged.
Eclampsia (Pregnancy)
Seizure in a patient with preeclampsia (hypertension + proteinuria in pregnancy). Treatment: IV magnesium sulfate (loading dose 4–6 g over 15–20 min, then 1–2 g/hr maintenance). Monitor for magnesium toxicity: loss of DTRs (first sign), respiratory depression, cardiac arrest. Antidote: calcium gluconate 1 g IV. Delivery is definitive treatment.
Alcohol Withdrawal Seizures
Typically occur 24–48 hours after last drink. Treat with benzodiazepines (CIWA-guided). Phenytoin is NOT effective for alcohol withdrawal seizures. Administer thiamine before dextrose (Wernicke's prevention).
NCLEX High-Yield Seizure Points
- During seizure: never restrain limbs, never put anything in mouth, turn to SIDE, protect from injury
- Status epilepticus = seizure ≥5 minutes or no return to baseline between seizures
- First-line SE treatment: lorazepam 0.1 mg/kg IV (or IM midazolam if no IV)
- Give thiamine before dextrose in undifferentiated altered mental status/seizure (prevents Wernicke's)
- Phenytoin: MAX 50 mg/min; NS only (no dextrose); monitor ECG; therapeutic 10–20 mcg/mL
- Phenytoin extravasation → purple glove syndrome (severe tissue necrosis)
- Eclampsia seizure treatment: magnesium sulfate (NOT phenytoin)
- Magnesium toxicity: loss of DTRs first, then respiratory depression; antidote: calcium gluconate
- Postictal Todd's paralysis: focal weakness after seizure — can mimic stroke; resolves spontaneously
- Valproate contraindicated in pregnancy (teratogenic — neural tube defects)
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