seizure disorders
TRANSCRIPT
SEIZURE DISORDERS
OVERVIEWEpilepsyGroup 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.
ConvulsionApplies 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 GeneralizedGeneralized Seizures (convulsive or nonconvulsive, bilaterally symmetric, without local onset) Tonic–clonic seizures Tonic seizures Clonic seizures Absence (petit mal) seizures Atonic seizures Myoclonic seizures (bilaterally massive epileptic) Unclassified 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 phaseSigns or activity that precede a seizure
Aural phaseSensory warning
Ictal phase Occurs w/full seizure
Postictal phasePeriod of recovery after seizures
SPECIFIC CAUSES OF SEIZURES
Cerebrovascular diseaseHypoxemiaFever (childhood)Head injuryHypertensionCentral nervous system infectionsMetabolic and toxic conditionsBrain tumorDrug and alcohol withdrawalAllergies
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 first thing the patient does in the seizure—where 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 durationAny 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
Nurse’s 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 finger 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 hxQuestions regarding any type of head injury that may have affected brain
H&PNeuro, biochemical, hematologic and serologic studies
MRI- to detect structural lesionsEEG-furnishes diagnostic evidence
MEDICAL MANAGEMENT
Pharmacologic managementControls 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
AssessmentSeizure hxFactors that may precipitate seizures; does the person have aura prior [can indicate where seizure originated. i.e. flashing lights [occipital lobe]
Alcohol useObservation and assessment during and post
NSG DX
Based on the assessment data, the patient’s 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 im-posed by epilepsy
•Deficient knowledge related to epilepsy and its control
COLLABORATIVE/POTENTIAL COMPLICATIONS
Status epilepticusMedication toxicity
PLANNING & GOALS
Major goalsprevention of injury control of seizuresachievement of a satisfactory psychosocial adjustment,
acquisition of knowledge and understanding about the condition, and absence of complications.
NSG INTERVENTIONS
Injury prevention: PRIORITYReducing fear of seizures in pt.Help improve coping mechanismsProvide education: patient and familyManage for potential complications
INJURY PREVENTION: PRIORITY
Seizure precautions-pad side railsBed lowest positionSide rails [top] upFall precautionOral airway taped to wall
REDUCING FEARS
Adhere to medication regimenEmphasize medication compliancePeriodic monitoring while on medication Identify factors that precipitate seizuresencouraged 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 activityAdditional 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 flossing, 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 patient’s 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 identifies the hazards of stopping the medicationb. Can identify appropriate care during seizure; care-givers can also do so
2.Indicates a decrease in fear3.Displays effective individual coping4.Exhibits knowledge and understanding of epilepsya. Identifies 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 emergencyContinuous 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 neurologicOngoing vital signsDocument all seizure activity and observationsMaintain patient safety at all times-seizure precautionsAdminister medication as indicated and monitor response
Position patient if not contraindicatedSuction and resuscitative equipment at bedsideMonitor labs Emotional support for family