ATI Guide MedSurg

During Protect the client’s privacy and the client from injury (move furniture away, hold head in lap if on the floor). Position the client to provide a patent airway. (Remember aspiration, turn head to side) Be prep ...

During Protect the client’s privacy and the client from injury (move furniture away, hold head in lap if on the floor). Position the client to provide a patent airway. (Remember aspiration, turn head to side) Be prepared to suction oral secretions. Turn the client to the side to decrease the risk of aspiration. Loosen restrictive clothing. Do not attempt to restrain the client. Do not attempt to open the jaw or insert airway during seizure activity (can damage teeth, lips, and tongue). Do not use padded tongue blades. Document onset and duration of seizure and findings (level of consciousness, apnea, cyanosis, motor activity, incontinence) prior to, during, and following the seizure Post Seizure This is the postictal phase of the seizure episode. Maintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. Check vital signs. Assess for injuries. Perform neurological checks. Allow the client to rest if necessary. Reorient and calm the client, who might be agitated or confused. Determine if client experienced an aura, which can indicate the origin of seizure in the brain. Try to determine possible trigger (e.g., fatigue). (Precautions transmission): Tuberculosis Appropriate interventions  Prevent infection transmission.  Wear a N95 HEPA filter or powered air purifying respirator when caring for clients who are hospitalized with TB. (23.2)  Place the client in a negative-airflow room, and implement airborne precautions.  Use barrier protection when the risk of hand or clothing contamination exists.  Have the client wear a surgical mask if transportation to another department is necessary. The client should be transported using the shortest and least busy route.  Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided plastic bags or no-touch receptacles.  Airborne precautions are not needed in the home setting because family members have already been exposed. Exposed family members should be tested for TB