Medical Surgical Seizures #11

Question

During the ictal phase, which of these are important in the assessment of the client?

Answers

  1. Vital signs including oximeter readings.
    • Rationale:

      This answer is not correct because during the ictal phase (which is during the seizure) vital signs may not be obtainable due to muscular rigidity and movement. Usually vital signs are taken in the postictal stage.

  2. Movement of eyes, head, and muscle rigidity.
    • Rationale:

      This answer is correct because assessment of eye movement, head movement, and rigidity is important to document. Timing, type, and duration of movements may provide indication of where the foci in the brain are located. Disruptions in certain parts of the brain denotes the type of symptoms the client experiences during the seizure.

  3. Determining what type of aura occurred.
    • Rationale:

      This answer is not correct because in the ictal phase, the client is unable to communicate and will not be awake. The nurse can not determine type of auras or trigger activity prior to the seizure.

  4. Determining what the client was doing just prior to the seizure.
    • Rationale:

      This answer is not correct because the ictal phase is the middle of the seizure. Unless the nurse or another caregiver was in the room beforehand, this information cannot be known.

Overview

The ictal stage is the middle part of the seizure and the most intense. Symptoms include eye movement, head movement, falling, shaking of the whole body, loss of bowel or bladder control, grunting, body stiffness (muscle rigidity), and tongue smacking.

Explanation

Learning Outcomes

During a seizure, the ictal stage is the most intense part of the seizure with symptoms including eye movement, head movement, falling, shaking of the whole body, loss of bowel or bladder control, grunting, body stiffness (muscle rigidity), and tongue smacking. Data gathered during the ictal stage of a seizure is important because it can guide the diagnostician in the direction of brain involvement, which can lead to treatment options and differential diagnoses. Vital signs are always important; however, not possible during this phase. Aura is the first part of the seizure before the client loses consciousness. It is described like a warning signal. Determining what type of aura the client experienced will not be practicable during ictus, since the client will most likely be unable to communicate. Discovering the client’s activity prior to the seizure will likely be possible after the recovery phase of the seizure when the client is back to their baseline and not during the seizure.

Test Taking Tip

Video Rationale