Competency Appraisal Group A EPILEPSY

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BSN 4A Competency Appraisal Group A EPILEPSY

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BSN 4A GROUP A
ABLUYAN, Daribel O. AGATEP, Guain Carlo AGBAYANI, Karenn Joice C. AGCANAS, Rose Ann APACIBLE, Rico Jason AQUINO, Cornelio III BELO, Princes Lalyn R. GADDUANG, Jose Bryan B.

EPILEPSY

is a brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness.

SEIZURE

occurs when a burst of electrical impulses in the brain escape their normal limits. They spread to neighboring areas and create an uncontrolled storm of electrical activity. The electrical impulses can be transmitted to the muscles, causing twitches or convulsions.

CAUSES:

There are around 180,000 new cases of epilepsy each year. About 30% occur in children. Children and elderly adults are the ones most often affected. There is a clear cause for epilepsy in only a minority of the cases. Typically, the known causes of seizure involve some injury to the brain. Some of the main causes of epilepsy include:  low oxygen during birth  head injuries that occur during birth or from

accidents during youth or adulthood  brain tumors  genetic conditions that result in brain injury, such as tuberous sclerosis  infections such as meningitis or encephalitis  stroke or any other type of damage to the brain  abnormal levels of substances such as sodium or blood sugar  In up to 70% of all case of epilepsy in adults and children, no cause can ever be discovered.

SYMPTOMS OF EPILEPSY
I. GENERALIZED SEIZURES: All areas of the brain (the cortex) are involved in a
generalized seizure. Sometimes these are referred to as grand mal seizures.

GENERALIZED SEIZURES (PRODUCED BY THE ENTIRE BRAIN)
1. "Grand Mal" or Generalized tonic-clonic
Absence 3. Myoclonic 4. Clonic

SYMPTOMS

Unconsciousness, convulsions, muscle rigidity
Brief loss of consciousness Sporadic (isolated), jerking movements Repetitive, jerking movements

5. Tonic
6. Atonic

Muscle stiffness, rigidity
Loss of muscle tone

SIX TYPES OF GENERALIZED SEIZURES


GRAND-MAL SEIZURE

is the most common and dramatic, and therefore the most well known. In this type of seizure, the patient loses consciousness and usually collapses. The loss of consciousness is followed by generalized body stiffening (called the "tonic" phase of the seizure) for 30 to 60 seconds, then by violent jerking (the "clonic" phase) for 30 to 60 seconds, after which the patient goes into a deep sleep (the "postictal" or after-seizure phase). During grand-mal seizures, injuries and accidents may occur, such as tongue biting and urinary incontinence.



ABSENCE SEIZURES

cause a short loss of consciousness (just a few seconds) with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time."



MYOCLONIC SEIZURES CLONIC SEIZURES

consist of sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects. are repetitive, rhythmic jerks that involve both sides of the body at the same time.

  

TONIC SEIZURES are characterized by stiffening of the muscles. ATONIC SEIZURES consist of a sudden and general loss of muscle
tone, particularly in the arms and legs, which often results in a fall.

II. PARTIAL OR FOCAL SEIZURES: Only part of the brain is involved, so

only part of the body is affected. Depending on the part of the brain having abnormal electrical activity, symptoms may vary.  If the part of the brain controlling movement of the hand is involved, then only the hand may show rhythmic or jerky movements.  If other areas of the brain are involved, symptoms might include strange sensations like a full feeling in the stomach or small repetitive movements such as picking at one's clothes or smacking of the lips.  Sometimes the person with a partial seizure appears dazed or confused. This may represent a complex partial seizure. The term complex is used by doctors to describe a person who is between being fully alert and unconscious.
SYMPTOMS

PARTIAL SEIZURES (PRODUCED BY A SMALL AREA OF THE BRAIN)
1. Simple (awareness is retained) a. Simple Motor b. Simple Sensory c. Simple Psychological 2. Complex (Impairment of awareness) 3. Partial seizure with secondary generalization

a. Jerking, muscle rigidity, spasms, headturning b. Unusual sensations affecting either the vision, hearing, smell taste, or touch c. Memory or emotional disturbances Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements Symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions.

SIDE EFFECTS:
 difficulty falling asleep or staying asleep  uncontrollable eye movements  abnormal body movements

 loss of coordination
 confusion  slowed thinking  slurred speech  dizziness

 headache
 nausea  vomiting  constipation  unwanted hair growth

 coarsening of facial features
 enlargement of lips  overgrowth of gums

PHENYTOIN
is used to control certain type of seizures, and to treat and prevent seizures that may begin during or after surgery to the brain or nervous system.  is an anti-seizure medication (anticonvulsant) used for preventing or treating generalized tonic-clonic (grand mal) seizures, complex partial seizures (psychomotor seizures), and seizures occurring during or after neurosurgery. It may be used alone or with phenobarbital or other anticonvulsants.  DOSING: The dosing of phenytoin is patient specific. It may be given once, twice, 3, or 4 times daily. Doses are often adjusted to find the optimal dose based on measurement of blood levels. Taking phenytoin with food may reduce some of the side effects. Elderly patients, debilitated persons, and patients with certain kidney or liver diseases may need lower doses. The suspension should not be given at the same time as tube feedings since tube feedings bind to phenytoin and reduce its absorption. The recommended adult dose is 100 mg two to four times daily. Some patients may require 200 mg three times daily. Patients stabilized on 100 mg three times daily may receive 300 mg once daily of the extended release capsules.


PHENOBARBITAL


Phenobarbital is a barbiturate, nonselective central nervous system depressant which is primarily used as a sedative hypnotic and also as an anticonvulsant in subhypnotic doses.

INDICATIONS
Oral a. Sedatives

b. Hypnotics, for the short-term treatment of insomnia since they appear to lose their effectiveness for sleep induction and sleep maintenance after 2 weeks. ( c. Preanesthetics d. Long-term anticonvulsants for the treatment of generalized tonicclonic and cortical local seizures. And, in the emergency control of certain acute convulsive episodes, e.g., those associated with status epilepticus, cholera, eclampsia, meningitis, tetanus, and toxic reactions to strychnine or local anesthetics.

DOSAGE AND ADMINISTRATION
PEDIATRIC ORAL DOSAGE (as recommended by the American Academy of Pediatrics):  Preoperative: 1 to 3 mg/kg. ADULT ORAL DOSAGE: 1. Daytime sedative: 30 to 120 mg daily in 2 to 3 divided doses. 2. Bedtime hypnotic: 100 to 320 mg. 3. Anticonvulsant: 50 to 100 mg 2 to 3 times daily. Dosages of phenobarbital must be individualized with full knowledge of their particular characteristics and recommended rate of administration. Factors of consideration are the patient's age, weight, and condition. Parenteral routes should be used only when oral administration is impossible or impractical.



Anticonvulsant use: A therapeutic anticonvulsant level of phenobarbital in serum is 10 to 25 µg/mL. To achieve the blood levels considered therapeutic in children, higher per-kilogram dosages are generally necessary for phenobarbital and most other anticonvulsants. In children and infants, phenobarbital at loading dose of 15 to 20 mg/kg produces blood levels of about 20 µg/mL shortly after administration.
In status epilepticus, it is imperative to achieve therapeutic blood levels of phenobarbital as rapidly as possible. Because a barbiturate-induced depression may occur along with a postictal depression once the seizures are controlled, it is important, therefore, to use the minimal amount required, and to wait for the anticonvulsant effect to develop before administering a second dose. Phenobarbital has been used in the treatment and prophylaxis of febrile seizures. However, it has not been established that prevention of febrile seizures influences the subsequent development of epilepsy.





GINGIVAL HYPERPLASIA






Gingival overgrowth, also known as gingival hyperplasia secondary to drugs, was first reported in the dental literature in the early 1960s in institutionalized epileptic children who were receiving therapy with phenytoin (Dilantin) for the treatment of seizures. Cyclosporine, a potent immunosuppressant widely used since the early 1980s in organ transplant recipients and for psoriasis, and numerous calcium channel blocker agents, including nifedipine and amlodipine, have also been associated with gingival overgrowth. Nifedipine appears to have an additive effect when used together with cyclosporine in transplant recipients with hypertension. In addition, phenobarbital-induced gingival overgrowth has been reported but is rare and needs further evaluation.

Because not all patients on phenytoin, cyclosporine, and/or calcium antagonists develop gingival overgrowth, identifying patients at risk is important in order to take all the necessary measures to minimize the onset and severity of this condition.  Some of the risk factors known to contribute to gingival overgrowth include the presence of gingival inflammation (ie, gingivitis) resulting from poor oral hygiene. Furthermore, the presence of dental plaque may provide a reservoir for the accumulation of phenytoin or cyclosporine. In orthodontic patients, gingival overgrowth has been suggested to be due to nickel accumulation and epithelial cell proliferation.[4]  Several studies have shown that the interaction of phenytoin, cyclosporine, and nifedipine with epithelial keratinocytes, fibroblasts, and collagen can lead to an overgrowth of gingival tissue in susceptible individuals. Phenytoin has been shown to induce gingival overgrowth by its interaction with a subpopulation of sensitive fibroblasts. Cyclosporine has been suggested to affect the metabolic function of fibroblast (eg, collagen synthesis, breakdown), whereas nifedipine, which potentiates the effect of cyclosporine, reduces protein synthesis of fibroblasts. A review of existing literature shows that a cofactor clearly is needed to induce gingival overgrowth. In fact, several lines of evidence point to a modulation of inflammatory processes.




The onset of drug-induced gingival overgrowth in susceptible individuals is insidious. Gingival overgrowth is asymptomatic, except in the presence of poor oral hygiene and dental plaque because patients may develop bleeding with tender and swollen gums. Patients with mal-positioned teeth, periodontal disease, and poor oral hygiene are at risk of developing gingival overgrowth. Severity varies depending on the oral health prior to the beginning of therapy; however, not all patients with poor oral hygiene develop drug-induced gingival overgrowth. Phenytoin-induced gingival overgrowth  This is more likely to occur in patients with gingivitis and dental plaque.  Increased dental plaque has been suggested to induce local inflammation and to serve as a reservoir for phenytoin.



FACTORS THAT DECREASES SEIZURE THRESHOLD


Exposure to neon or laser flashing lights,
lengthy periods of fasting, malnutrition, starvation, lengthy periods of high stress and/or fear, fatigue and exhaustion (i.e., from lack of sleep and/or rest), uncontrolled diabetes, other endocrine and/or metabolic irregularities (like electrolyte or hormonal imbalances), cancer, and certain disorders of the nervous, cardiovascular, and gastrointestinal systems.

IMPORATANCE OF DRUG COMPLIANCE FOR SEIZURE education  Paying attention to medication
for patients and parents, decreasing the complexity of the treatment regimen and younger possibly more motivated mothers in a small family, increased the drug compliance.



Being compliant with medications is vitally important! It gives you the best opportunity to achieve the goals of epilepsy therapy: no seizures and no side effectsSeizure medicines must be taken each and every day as prescribed. If the right amount is not taken at the right time, the medicine may not be able to prevent seizures, or might cause unwanted side effects. The good news is that available treatments can successfully prevent seizures for most people with epilepsy. If the first treatment doesn’t work, others may be more successful. Finding the right medicine at the right dose taken at the right time(s) of the day is often an ongoing process between the patient and their doctor. Any medication change recommended by the doctor is based on the assumption that the patient has been taking the medicine as the doctor thinks that he or she has. If this isn’t true, then the change proposed by the doctor may not have the intended benefit. But everyone is human and taking medicines day in and day out at just the right time and just the right way can be difficult. There are many reasons for noncompliance [link to Causes and Solutions]. For example, taking the right number of pills at the right time can be challenging, particularly if you take more than one type of pill or take pills more than one time each day, or if you are forgetful or have problems with your memory. Here’s a tip if this applies to you: organize your pills in a plastic pill box that can be filled once a week. This makes it easier to know if you’ve taken your pills at the right times or not. Another tip is to time your medications with something you do every day at the same time, such as eat a meal or brush your teeth. Watches that have alarms can also be helpful, as long as you wear one!

IMPORTANCE OF DRUG COMPLIANCE FOR SEIZURE

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