To: All consumers, caregivers, guardians, case managers

Re: Seizure Plan of Care Policy and Form

Enclosed is AbilitiesSeizure Policy, and Plan of Care Form. This form is a mandatory requirement for anyone who has a medical diagnosis of epilepsy in which they can have more than two (2) seizures within a day. Attached you will find Abilities updated “Policy and Procedures for Seizures (Epileptic Event),” and a “Physician Orders for Seizures.”

The physician must fill out the front part of the form completely, and check EITHER:

“CALL 9-1-1 IMMEDIATELY”

**OR**

“ONLY CALL 9-1-1 IF,”and sign the bottom.

**Please be advised that Danielle’s Law will supersede any doctor’s order in the event the seizure becomes a life-threatening event. **

Once the physician has completed the front page, you as the caregiver may sign the back. Once you return the signed physician’s order form, Abilities supervisor &/or nurse will obtain a verbal approvals (via phone) from the legal guardian & case manager/support broker. The verbal approval will be acceptable until it can be actually signed. Copies of the physician’s order will be available upon request.

All of Abilities employees involved with the care of your consumer during an epileptic event will then follow the physician’s orders.

This form should be given to the doctor at the time of your physical each year. It must be returned with the physical. If you have any questions, please feel free to contact your program supervisor.

Sincerely,

Heather Tucker, RN

Agency RN

PHYSICIAN ORDERS(for Seizures)

Individual Name: / Date:
Type of Seizures:
SEIZURE DESCRIPTION: Check all that may apply:
Remains Conscious / Bites tongue / Fidgets with objects
Unconscious / Becomes stiff / Suddenly drops objects
Stares / Blinks / Becomes limp / Falls to floor
Confused / Disoriented / Becomes Incontinent bladder bowel
Other:
Jerky Movements: / Body / Legs / Arms / Head
Color of the skin: / Normal / Pale / Flushed / Turns Blue
Typical behavior
after the seizure: / Confused or disorientated / Sleepy or sleeps / Headache / Other:
Length of Typical Seizure: / Usual Seizure Frequency:
Date of Last Seizure / Updates:

Seizure Precautions: Check all that apply:

takes medications / wears helmet / use arm chair
avoid machinery / uses oxygen / VNS
Other:

Plan of Care/ First aid for Seizures:

Abilities will follow the First Aid / 9-1-1 Protocol for Seizures and the physician orders described below.

This is done in accordance with Danielle’s Law NJAC 10:42A.

CALL 9-1-1 IMMEDIATELY

**OR**

ONLY CALL 9-1-1 FOR ANY OF THE FOLLOWING:

  1. Has _____ or more seizures during program hours (7:30am-3:30pm)
  2. The consumer has not had a seizure at home or while in program for over 1 year.
  3. The seizure lasts longer than 5 minutes.
  4. The person has consecutive (one right after the other without fully recovering) seizures
  5. The person experiences difficulty with breathing, shortness of breath, trouble swallowing, or is choking.
  6. Person does not start breathing within one minute.
  7. Person becomes blue, gray, or ashen in color.
  8. Person does not promptly regain consciousness after the seizure in their usual way.
  9. Person has an atypical seizure (one that is not typical of their usual seizure).
  10. Person has sustained a serious injury requiring medical attention.
  11. Person is a diabetic or is pregnant.

Swipe magnet _____time(s) over VNS Give ______as prescribed

Administer O2 ____/____ via ______

______

Physician Name (Print)Signature Phone # Date

Original in service recipient file.

Orig.: 9/05 med 002 pg 1

Rev: 12/07, 12/09, 1/14, 4/16

The team members below have reviewed and agree with the physician’s orders and the seizure plan of care for this individual: .

NAME (Print) / SIGNATURE / TITLE (circle) / DATE
Guardian or Consumer
Caregiver
Case Manager or Support Coordinator
Agency RN or LPN
Program Supervisor or Asst. Supervisor

**This form must be completed at least yearly or whenever there is a change in one’s seizure condition.**


FIRST AID FOR SEIZURES

  1. Follow Physician’s Orders.
  2. Remain calm. You cannot stop a seizure once it is started.
  3. DO NOT restrain the person or force anything between the teeth.
  4. Administer seizure PRN if prescribed.
  5. Swipe magnet over Vagal Nerve Stimulator (if applicable), as directed by physician. DO NOT hold magnet on the VNS as this will shut off the device.
  6. Clear the area around the person to prevent injury from sharp or hard objects.
  7. Move the person only if a harmful object cannot be moved from the area and there is no other way to prevent serious injury.
  8. Place a pillow or soft object (jacket, sweatshirt, etc.) under the head to cushion.
  9. Loosen tight clothing (collar, shirt, tie, belt, etc.) and remove eyeglasses.
  10. Observe the person’s actions during the seizure.
  11. Time the seizure from very beginning to end. Complete a seizure report form after the seizure isover. Send copy of report to agency RN.
  12. After the convulsive seizure place the person on the side with head turned to the side so saliva can drain out and tongue will not close airway. This is also a safe recovery position.
  13. After seizure is over, make sure the person is breathing normally. If the person does not start breathing within one minute, call 911 and assess the need for rescue breathing or CPR.
  14. Check for any injuries and provide first aid as indicated.
  15. Assist person with cleanup if there was incontinence.
  16. Reassure the person that he/she is all right.
  17. Allow the person to rest/sleep in a quiet place until transported home or until fully oriented.
  18. DO NOT offer food or drink until the person is fully awake.
  19. Notify the caregiver of the seizure, complete seizure report (form #001), copy to all necessary parties.

ABILITIES OF NORTHWEST JERSEY, INC.

POLICY AND PROCEDURE FOR SEIZURES (EPILEPTIC EVENT)

GENERAL INFORMATION

  1. All Abilities employees, including drivers, will be trained in seizures upon hire. Types of seizures, First Aid and care of the person having a seizure, and VNS procedures will be covered.
  2. Staff will sign off that they have received the training.
  3. It is the responsibility of the caregiver to provide Abilities with a Seizure Plan of Care form pertaining to their seizures.
  4. It is the responsibility of the Program Supervisors to notify their employees of which consumers have a seizure disorder. This information is updated and provided upon admission, on an annual basis, or as needed, to the Supervisors. Specific seizure information is provided by the consumer’s caregiver’s and/or their physician.
  5. Staff will follow the Plan of Care on file. Danielle’s law supersedes any/all doctor’s orders in the event of a life-threatening situation.
  6. There are two (2) Seizure Plan of Care (SPOC) forms.

1. GeneralSeizure Plan of Care is required for any of the following:

  1. Has a known seizure disorder.
  2. Does NOT normally have more than two (2) seizures in one (1) day.
  3. Takes anti-seizure medications.

2. Physician’sSeizure Plan of Care (SPOC) is required for anyone who is known to have more than two (2) seizures in one day.

  1. Both the General and Physician’s seizure forms must be updated annually, preferably at the time of the consumer’s annual physical, or when there is any change in the consumer’s seizure status.
  2. PRN seizure medications must accompany a physician’s script and detail when the medication should be given at the time of the seizure event. The script will be valid for one year.
  3. All PRN seizure medications and/or VNS magnets must be easily accessible to staff. PRN medications will be in a lock box at all times. Supervisors and or Agency RN will educate the employees on the use of the PRN medications, when to give, side effects, etc.

911 WILL BE CALLED FOR THE FOLLOWING:

  1. The person’s seizure is or becomes life-threatening (Danielle’s Law)
  2. Has multiple (more than two) seizures within the day.
  3. The person experiences difficulty with breathing, shortness of breath, trouble swallowing, or is choking.
  4. Person does not start breathing within one minute.
  5. Person becomes blue, gray, or ashen in color.
  6. Person does not promptly regain consciousness after the seizure in their usual way (per Seizure Plan of Care).
  7. The seizure lasts longer than5 minutes.
  8. Person has an atypical seizure (one that is not typical of their usual seizure as described on the Seizure Plan of Care).
  9. Person has sustained a serious injury requiring medical attention.
  10. Person is a diabetic or is pregnant.
  1. 9-1-1 will automatically be called if the General, or Physician’s Plan of Care is incomplete, or has expired at the time of the seizure.
  1. There is no documentation of the consumer having a history of seizures, or has not had a seizure at home or while in program for over 1 year (per Seizure Plan of Care)

Orig.: 9/05 med 002 pg 1

Rev: 12/07, 12/09, 1/14, 4/16