A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first?

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This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. (Option B) Stopping the status epilepticus is a priority over determining its cause through a neurologic assessment. Quickly obtaining the oxygen saturation level and managing the airway are priority assessments. (Option C) Blood draw is needed for laboratory studies but is not a priority over stopping the seizure. (Option D) A VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped. Educational objective: Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.

A Client with a Ventriculoperitoneal Shunt Has a Dazed Appearance