The most immediate concern when it comes to grand mal epileptic seizures is to prevent traumatic injury and/or choking. Because of the uncontrolled violent movements of the entire body, aside from the danger of choking, victims have incurred all types of fractures and internal bleeding with damage to vital organs. Thus the only way to prevent injury is to be with the patient when the seizure begins and have ready all of the required equipment. Of course in an in-patient setting this is not always the case and not always possible, so the failure to prevent injury and/or choking is not always the result of negligence.

Therefore, we shall explore the standards of care regarding seizure precautions, which require a risk assessment, care plan and nursing intervention. First of all, the assessment of risk that the patient will have a seizure during the hospitalization requires a history and observation of certain risk factors:

1. New diagnosis of seizure disorder;

2. Frequent seizure activity;

3. Any seizure activity during the past year;

4. History of head trauma including surgery within the past three years;

5. Treatment with medications that lower the seizure threshold (antidepressants and anti-psychotics)

6. Withdrawal of anti-epileptic medication for evaluation of a seizure disorder and re-adjustment of medication regimen;

7. Any seizure activity within the past 12 months.

Second, there must be a care plan to set up the environment to prevent injury, maintain continuous observation to know when a seizure is starting and be able to get to the patient within a few seconds of onset. Thus, when seizure precautions are warranted by any of the above risk factors the care plan must include the following:

1. Make certain that the patient has the following equipment:

a. Nasal cannula and tubing;

b. Oxygen flow meter;

c. Suction gauge;

d. Suction canister;

e. Suction tubing to connect to canister;

2. Assign patient to room in close proximity to the nurses station;

3. Maintain continuous observation via video monitor;

4. Maintain assembled suction equipment in room;

5. Maintain assembled oxygen equipment at bedside;

6. Pad side rails of bed;

7. Keep bed in low position with all side rails up at all times;

8. Keep unnecessary equipment out of patients room;

9. Instruct patient not to get out of bed without assistance;

10. Assure that call bell is always within patients reach. Make sure that the family knows where it is and how to use it;

11. Avoid use of restraints;

12. Obtain one-to-one sitter if patient is unable to follow instructions to maintain safety;

13. Check vital signs every fifteen minutes and maintain airway patency during the post ichtal phase (period of time immediately following the seizure, during which the patient remains comatose or stuperous).

Finally, it is imperative that the nurses focus on observation and response. Being at risk of having a grand mal seizure while unattended is extremely dangerous because of the potential for catastrophic injury and/or choking. When this risk is identified or should be identified, the nurses owe a duty to know whenever there is an onset of a seizure and be in attendance during the clonic (wild uncontrolled movements and clamping of the jaw) and post ichtal phases.

On the other hand, in some cases, the nurse may have a defensible argument, but then the burden of proof shifts to the defense to show either that there were no discoverable risk factors or that the injury occurred despite the fact that everything possible was done and the nurse was unable to prevent it.