SEIZURE DISORDERS

OVERVIEW
Epilepsy Group of disorders characterized by excessive excitability of neurons in the CNS [cerebral cortex or gray matter
Seizure Brief episode of abnormal electrical activity [epileptic event] Paroyxmal uncontrolled electrical discharge in brain that interrupts normal function. Convulsion Applies only to abnormal motor movement phenomena. i.e. jerking movements during a tonic-clonic [grand mal] attack

SEIZURE DISORDERS
Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons.

ETIOLOGY
Most common: 1st 6 months life: High fevers [febrile seizures], severe birth injury, congenital defects involving the central nervous system (CNS), infections, and inborn errors of metabolism B/2 2& 20 yrs: primary causative factors are birth injury, infection, trauma, and genetic factors 20 & 30 y: primary causative factors are birth injury, infection, trauma, and genetic factors >50y:cerebrovascular lesions (stroke) and metastatic brain tumors

CLASSIFICATION OF SEIZURES
Partial seizures: begin in one part of the brain
Simple partial: consciousness remains intact Complex partial: impairment of consciousness

Generalized seizures: involve the whole brain Underlying cause: electrical disturbance [dysrhythmias] in nerve cells in one area of brain= uncontrolled electrical discharges
Characteristic seizure is a manifestation of this excess neuronal discharge

ICS
Partial Seizures (seizures beginning locally)
Simple Partial Seizures (with elementary symptoms, generally without impairment of consciousness) With motor symptoms With special sensory or somatosensory symptoms With autonomic symptoms Compound forms

ICS
Complex Partial Seizures (with complex symptoms ,generally with impairment of consciousness)
With impairment of consciousness only With cognitive symptoms With affective symptoms With psychosensory symptoms With psychomotor symptoms (automatisms) Compound forms

ICS
Partial Seizures Secondarily Generalized Generalized Seizures (convulsive or nonconvulsive, bilaterally symmetric, without local onset)
Tonicclonic seizures Tonic seizures Clonic seizures Absence (petit mal) seizures Atonic seizures Myoclonic seizures (bilaterally massive epileptic) Unclassied seizures

TYPES OF SEIZURES
Tonic-clonic [Grand mal seizure] Manifested as major convulsive activity characterized by tonic phase [muscle rigidity] followed by synchronous muscle jerks [clonic phase].

Febrile seizure- common in young child Occurs with very high fevers

PHASES OF SEIZURES
Prodromal phase Signs or activity that precede a seizure
Aural phase Sensory warning Ictal phase Occurs w/full seizure

Postictal phase Period of recovery after seizures

SPECIFIC CAUSES OF SEIZURES

Cerebrovascular disease Hypoxemia Fever (childhood) Head injury Hypertension Central nervous system infections Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal Allergies

NURSING MANAGEMENT: DURING A SEIZURE

Observation and documentation of patient signs and symptoms before, during, and after seizure Nursing actions during seizure for patient safety and protection After seizure care to prevent complications

BEFORE & DURING A SEIZURE

The circumstances before the seizure (visual, auditory or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation
The occurrence of an aura (a premonitory or warning sensation), which can be visual, auditory, or olfactory The rst thing the patient does in the seizurewhere the movements or the stiffness begins, conjugate gaze position, and the position of the head at the beginning of the seizure.
This information gives clues to the location of the seizure origin in the brain.

In recording, it is important to state whether the beginning of the seizure was observed.

BEFORE & DURING A SEIZURE

The type of movements in the part of the body involved
The areas of the body involved (turn back bedding to expose patient)

The size of both pupils and whether the eyes are open
Whether the eyes or head turned to one side

The presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing)

BEFORE & DURING SEIZURE

Incontinence of urine or stool
Duration of each phase of the seizure Unconsciousness, if present, and its duration Any obvious paralysis or weakness of arms or legs after the seizure Inability to speak after the seizure Movements at the end of the seizure Whether or not the patient sleeps afterward

Cognitive status (confused or not confused) after the seizure

BEFORE & DURING A SEIZURE

Nursing care is directed at Preventing injury and supporting the patient, not only physically but also psychologically

AFTER A SEIZURE
Nurses role: Document the events leading to and occurring during and after the seizure and Prevent complications (e.g. aspiration, injury) Risk for hypoxia, vomiting and pulmonary aspiration Place in side-lying position to ease drainage of oral secretions-Suction if needed Maintain patent airway & prevent aspiration SEIZURE PRECAUTIONS-padded side rails Resuscitative equipment/suction equipment, oral airway at bedside Bed in low position

SEIZURE CARE-*SEE NOTES AREA

SEIZURE CARE
Keep the patient on one side to prevent aspiration.
Make sure the airway is patent. There is usually a period of confusion after a grand mal seizure. A short apneic period may occur during or immediately after a generalized seizure .The patient, on awakening, should be reoriented to the environment. If the patient becomes agitated after a seizure (postictal),use persuasion and gentle restraint to assist him or her to stay calm.

THE EPILEPSIES
Group of syndromes characterized by unprovoked, recurring seizures Classified by specific patterns of clinical features: age of onset, family hx and type of seizure Types of epilepsies differentiated by how activity of seizure presents Can be primary [idiopathic] or secondary [cause is known & symptom of another cause-i.e. brain tumor Head injury is one of the main causes of epilepsy that canbe prevented.

PATHOPHYSIOLOGY
Messages from the body are carried by the neurons (nerve cells) of the brain by means of discharges of electrochemical energy that sweep along them. These impulses occur in bursts whenever a nerve cell has a task to perform.

CLINICAL MANIFESTATION
Range from simple staring episode [absence seizure] to prolonged convulsive movements w/loss of consciousness [tonic-clonic-grand mal]
Simple partial seizures, only a nger or hand may shake, or the mouth may jerk uncontrollably. The person may talk unintelligibly; may be dizzy; and may experience unusual or unpleasant sights, sounds, odors, or tastes, but without loss of consciousness Complex partial seizures
Remains motionless or moves automatically but inappropriate for time and place. Does not remember the episode when It is over.

Generalized seizures, previously referred to as grand mal seizures, involve both hemispheres of the brain, causing both sides of the body to react

ASSESSMENT/DIAGNOSTICS
Aimed at determining the type of seizure, frequency and severity and factors leading to seizure
Developmental hx

Questions regarding any type of head injury that may have affected brain
H&P

Neuro, biochemical, hematologic and serologic studies

MRI- to detect structural lesions EEG-furnishes diagnostic evidence

MEDICAL MANAGEMENT
Pharmacologic management Controls rather than cures seizures. Selected on the basis of the type of seizure being treated and the effectiveness and safety of the medications. Medication levels must be monitored to determine if drug levels are therapeutic or toxic or for adjustment of dose if needed

MEDICAL MANAGEMENT
Surgical
Indicated for patients whose epilepsy results from intracranial tumors, abscesses, cysts, or vascular anomalies.

NURSING PROCESS: PATIENT WITH EPILEPSY

Assessment Seizure hx Factors that may precipitate seizures; does the person have aura prior [can indicate where seizure originated. i.e. flashing lights [occipital lobe] Alcohol use Observation and assessment during and post

NSG DX
Based on the assessment data, the patients major nursing diagnoses may include the following: Risk for injury related to seizure activity Fear related to the possibility of seizures Ineffective individual coping related to stresses imposed by epilepsy Decient knowledge related to epilepsy and its control

COLLABORATIVE/POTENTIAL COMPLICATIONS

Status epilepticus Medication toxicity

PLANNING & GOALS

Major goals

prevention of injury control of seizures achievement of a satisfactory psychosocial adjustment, acquisition of knowledge and understanding about the condition, and absence of complications.

NSG INTERVENTIONS

Injury prevention: PRIORITY Reducing fear of seizures in pt. Help improve coping mechanisms Provide education: patient and family Manage for potential complications

INJURY PREVENTION: PRIORITY

Seizure precautions-pad side rails
Bed lowest position Side rails [top] up Fall precaution Oral airway taped to wall

REDUCING FEARS
Adhere to medication regimen
Emphasize medication compliance Periodic monitoring while on medication Identify factors that precipitate seizures encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimulants), exercise, and rest (sleep deprivation may lower the seizure threshold). Avoid excessive activity Additional dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients.

COPING MECHANISMS
Social, psychological, and behavioral problems that frequently accompany epilepsy can be more of a disability than the actual seizures. Epilepsy may be accompanied by feelings of stigmatization, alienation, depression, and uncertainty.
Counseling services for patient and family

PATIENT TEACHING: HOME CARE/COMMUNITY

Thorough oral hygiene after each meal, gum massage, daily ossing, and regular dental care are essential to prevent or control gingival hyperplasia in patients receiving phenytoin (Dilantin). Instruct to inform all health care providers of the medication being taken, because of the possibility of drug interactions. Teach medication compliance as prescribed and safety Reinforce medical follow-up and monitoring of drug levels Community referrals Epilepsy Foundation of America Medic alert bracelet Instruct regarding side effects Instruct to notify provider of any sudden changes

PATIENT TEACHING
The patient should never discontinue medications, even if there is no seizure activity.
Keep a medication and seizure chart, noting when medications are taken and any seizure activity Notify the patients physician if patient cannot take medications due to illness. Have anti-seizure medication serum levels checked regularly. When testing is prescribed, the patient should report to the laboratory for blood sampling before taking morning medication.

PATIENT TEACHING
Avoid seizure triggers, such as alcoholic beverages, electrical shocks, stress, caffeine, constipation, fever, hyperventilation, and hypoglycemia. Take showers rather than tub baths to avoid drowning if seizure occurs; never swim alone.
Exercise in moderation in a temperature-controlled environment to avoid excessive heat. Develop regular sleep patterns to minimize fatigue and insomnia.

EVALUATION
Expected Patient Outcomes a. Complies with treatment regimen and identies the hazards of stopping the medication b. Can identify appropriate care during seizure; care-givers can also do so
2.Indicates a decrease in fear 3.Displays effective individual coping 4.Exhibits knowledge and understanding of epilepsy a. Identies the side effects of medication

STATUS EPILEPITICUS
acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks Medical emergency Continuous clinical or electrical seizures (on EEG) lasting at least 30 minutes, even without impairment of consciousness. Factors that precipitate status epilepticus include withdrawal of anti-seizure medication, fever, and concurrent infection

MEDICAL MANAGEMENT
Airway & adequate oxygenation are established If the patient remains unconscious and unresponsive, a cuffed endotracheal tube is inserted. Iv diazepam (Valium), lorazepam (Ativan) IV: DRUG OF CHOICE TODAY,. DILANTIN LOADING: 1 GRAM-MUST BE ON CARDIAC MONITOR IV Access, blood work [serum glucose, electrolytes, phenytoin [Dilantin] levels Vital signs, neurologic and cardiac monitoring Needs ICU setting Prepare for intubation to rest patient

NSG
Ongoing assessment: respiratory, cardiac and neurologic Ongoing vital signs Document all seizure activity and observations Maintain patient safety at all times-seizure precautions Administer medication as indicated and monitor response Position patient if not contraindicated Suction and resuscitative equipment at bedside Monitor labs Emotional support for family