رجل عمره ٣٣ سنة في الجناح جاءته نوبة تشنج كبرى استمرت دقيقتين وتوقفت وحدها. بعدها صار نعساناً ومشوشاً ١٥ دقيقة، ثم بدأ يتحسن ويجاوب. التشبع ٩٦٪، والنبض ٩٨. ماذا يوثق الممرض؟

A 33-year-old man on the ward had a 2-minute tonic-clonic seizure that stopped on its own. Afterwards he was drowsy and confused for 15 minutes, then began improving and answering. SpO2 96%, HR 98. What does the nurse document?

1. Ongoing status epilepticus needing a second drug
2. Malingering by the client
3. A new stroke
4. The post-ictal phase and its duration

Answer: D) The post-ictal phase and its duration. A post-ictal phase of drowsiness, confusion and headache follows a generalised seizure. Document onset, type, duration, the post-ictal period and any transient weakness (Todd’s paresis), keeping the client on his side.