A rapid response team is called to an inpatient unit for a client who is experiencing a generalized tonic-clonic seizure. The seizure activity has been continuous for 12 minutes without the client regaining consciousness. Upon arrival, the nurse notes circumoral cyanosis and audible gurgling respirations. Arrange the following emergent interventions in the priority sequence they must be executed.
- 1Turn the client onto a lateral decubitus position and protect the head from trauma.
- 2Apply high-flow supplemental oxygen via a non-rebreather mask.
- 3Verify the patency of the client's existing intravenous catheter.
- 4Administer the prescribed rapid-acting intravenous lorazepam.
- 5Initiate a prescribed intravenous loading dose of fosphenytoin.
Answer
The correct sequence prioritizes immediate airway clearance and safety (lateral position), followed by oxygenation, establishing access, stopping the active seizure with a rapid-acting agent, and finally preventing recurrence with a long-acting agent.
The correct sequence follows the fundamental principles of resuscitation: Airway, Breathing, Circulation, and then targeted pharmacological therapy. In status epilepticus, the physical airway is compromised by patient position and secretions, making lateral positioning the first action. Once the airway is open, providing oxygen treats the immense cerebral metabolic demand and cyanosis. Next, circulation and access must be verified to safely administer medications. The immediate pharmacological goal is to break the seizure using a rapid-acting benzodiazepine. Finally, a long-acting antiepileptic drug is given to provide sustained seizure prophylaxis.
Step-by-Step Solution
Key Concept
Prioritization in Status Epilepticus Management