Nursing Care of the Patient With Seizures and Epilepsy
Content
Seizures and Epilepsy A seizure is an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness (LOC), motor or sensory ability, and/or behavior. A single seizure may occur for no known reason. Some seizures are caused by a pathologic condition of the brain, such as a tumor. In this case, once the underlying problem is treated, the patient is often asymptomatic. The National Institute of Neurological Disorders and Stroke define epilepsy as two or more seizures experienced by a person. It is a chronic disorder in which repeated unprovoked seizure activity occurs. It may be caused by an abnormality in electrical neuronal activity; an imbalance of neurotransmitters, especially gamma aminobutyric acid (GABA); or a combination of both. Etiology: Primary or idiopathic epilepsy is not associated with any identifiable brain lesion or other specific cause; however, genetic factors most likely play a role in its development. Secondary seizures result from an underlying brain lesion, most commonly a tumor or trauma. Risk Factors: Genetic predisposition – absence seizures tend to occur in families Acute febrile state – particularly among infants and children under the age of 2 years Head trauma – may be early or late onset (up to 9 months) and incidence is increased when the head trauma includes a skull fracture Cerebral edema – especially when it occurs acutely and seizure activity tends to disappear when the edema is successfully treated Abrupt cessation of antiepileptic drugs (AEDs) – as a rebound activity Infection – if intracranial, a result of increased intracranial pressure; if systemic, a result of the persistent febrile state Metabolic disorder – a result of insufficient or excessive chemicals within the brain such as occurs with hypoglycemia or hyponatremia Exposure to toxins – especially those associated with rubber and tanning industries (leather tanning, not sun tanning) Brain tumor – if benign, seizures are caused by the increased bulk associated with the tumor; if malignant, associated with the ability of the brain tissue to function Hypoxia – results in a decreased oxygen level of the brain; necessary for neuronal activity Acute drug and alcohol withdrawal – dehydration that accompanies withdrawal creating a toxic level of the drug in the body Fluid and electrolyte imbalances – results in abnormal levels of nutrients required for neuronal function
With older adult clients, increased seizure incidence is associated with cerebrovascular diseases.
Triggers: Pathophysiology:
Increased physical activity Excessive stress Overwhelming fatigue Acute alcohol ingestion Excessive caffeine intake Exposure to flashing lights Specific chemicals, such as cocaine, aerosols and inhaling glue products
Generalized Seizures Involve both cerebral hemispheres. 6 kinds: The tonic-clonic seizure (also called a grand mal seizure) lasting 2 to 5 minutes begins with a tonic phase that causes stiffening or rigidity of the muscles, particularly of the arms and legs, and immediate loss of consciousness. Clonic or rhythmic jerking of all extremities follows. The patient may bite his or her tongue and may become incontinent of urine or feces. Fatigue, acute confusion, and lethargy may last up to an hour after the seizure. Occasionally, only tonic or clonic movement may occur. A tonic seizure is an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes. The clonic seizure lasts several minutes and causes muscle contraction and relaxation. The absence seizure is more common in children and tends to run in families. It consists of brief (often just seconds) periods of loss of consciousness and blank staring as though the person is daydreaming. The patient's eyes may flutter, and automatisms (involuntary behaviors) such as lip smacking and picking at clothes may also occur. He or she is not aware of these behaviors. The patient returns to baseline immediately after the seizure. Left undiagnosed or untreated, the seizures may occur frequently throughout the day, interfering with school or other daily activity. The myoclonic seizure causes a brief jerking or stiffening of the extremities that may occur singly or in groups. Lasting for just a few seconds, the contractions may be symmetric (both sides) or asymmetric (one side).
In an atonic (akinetic) seizure, the patient has a sudden loss of muscle tone, lasting for seconds, followed by postictal (after the seizure) confusion. In most cases, these seizures cause the patient to fall, which may result in injury. This type of seizure tends to be most resistant to drug therapy.
A tonic-clonic seizure progresses through distinct phases including the prodromal, tonic, clonic, and postictal phases.
The prodromal phase of irritability and tension may precede the seizure by several hours or days. Some individuals experience an aura In the tonic phase, there is a major tonic contraction (increased tonus) of the voluntary muscles so that the body stiffens with legs and arms extended. If standing, the person falls to the ground. The jaw snaps shut and the tongue may be bitten in the process. The person may defecate or urinate. The clonic phase is characterized by violent, rhythmic, muscular contractions accompanied by hyperventilation. The face is contorted, the eyes roll, and there is excessive salivation with frothing from the mouth. Profuse sweating and a tachycardia are common. During the postictal phase, the clonic jerking gradually subsides in frequency and amplitude over a period of about 30 seconds, although it may be longer. The involved cells cease firing. The extremities are limp, breathing is quiet, and the pupils, which may be equal or unequal, begin to respond to the light reflex. With awakening, most patients are confused, disoriented, and amnesic for the event. Headache, generalized muscle aching, and fatigue are common. If undisturbed, the patient often falls into a deep sleep for several hours. Partial or focal/local seizure: affect one hemisphere of the brain. 2 kinds: Complex partial seizures: May cause loss of consciousness (syncope), or “black out,” for 1 to 3 minutes. Characteristic automatisms behaviors that the client is unaware of, such as lip smacking or picking at clothes) may occur as in absence seizures. The patient is unaware of the environment and may wander at the start of the seizure. In the period after the seizure, he or she may have amnesia (loss of memory). Because the area of the brain most often involved in this type of epilepsy is the temporal lobe, complex partial seizures are often called psychomotor
seizures or temporal lobe seizures. Simple partial seizure: The patient remains conscious throughout the episode. He or she often reports an aura (unusual sensation) before the seizure takes place. This may consist of a “déjà vu” (already seen) phenomenon, perception of an offensive smell, or sudden onset of pain. During the seizure, the patient may have one-sided movement of an extremity, experience unusual sensations, or have autonomic symptoms. Autonomic changes include a change in heart rate, skin flushing, and epigastric discomfort. Jacksonian march: seizure may begin in the fingers of one side, and “march” or spread to the hand, wrist, forearm, and arm on the same side of the body.
Unclassified or idiopathic seizures do not fit into other categories. These types of seizures account for half of all seizures activities and occur for no known reason.
Diagnostic Imaging and Laboratory Tests: Laboratory tests should include alcohol and illicit drug levels and screens for the presence of excessive toxins, if suspected. In addition, cerebrospinal fluid may be obtained for analysis. Diagnostic procedures include: Electroencephalogram (EEG): An EEG records electrical activity and may identify the origin of seizure activity. Magnetic resonance imaging (MRI), computed tomography imaging (CT)/ computed axial tomography (CAT) scan, positron emission tomography (PET) scan, cerebrospinal fluid (CSF) analysis, skull x-ray, can all be used to identify or rule out potential causes of seizures. Medical Management: Medications: Most seizures can be completely or almost completely controlled through the administration of antiepileptic drugs (AEDs), sometimes referred to as anticonvulsants, for specific types of seizures. The health care provider introduces one antiepileptic drug (AED) at a time to achieve seizure control. If the chosen drug is not effective, the dosage may be increased or another drug introduced. At times, seizure control is achieved only through a combination of drugs. The dosages are adjusted to achieve therapeutic blood levels without causing major side effects. RN Considerations: Teach patients to take their drugs on time to maintain therapeutic blood
levels and maximum effectiveness. Emphasize the importance of taking their antiseizure medications as prescribed. Instruct patients that they can build up sensitivity to the drugs as they age. If sensitivity occurs, tell them they will need to have blood levels of this drug checked frequently to adjust the dose. In some cases, the antiseizure effects of drugs can decline and will lead to an increase in seizures. Because of this potential for “drug decline and sensitivity,” patients need to keep their scheduled laboratory appointments. Emphasize that AEDs must not be stopped even if the seizures have stopped. Discontinuing these drugs can lead to the recurrence of seizures or the life-threatening complication of status epilepticus.
Surgical Management: Vagal Nerve Stimulation Last Resort Vagal nerve stimulation (VNS) may be performed for control of continuous simple or complex partial seizures. Patients with generalized seizures are not candidates for surgery because VNS may result in severe neurologic deficits. The stimulating device (much like a cardiac pacemaker) is surgically implanted in the left chest wall. An electrode lead is attached to the left vagus nerve, tunneled under the skin, and connected to a generator. The procedure usually takes 2 hours with the patient under general anesthesia. The stimulator is activated by the physician either in the operating room or, more commonly, 2 weeks after surgery. Programming is adjusted gradually over a period of time. The pattern of stimulation is individualized to the patient's tolerance. The generator runs continuously, stimulating the vagus nerve according to the programmed schedule. The patient can activate the VNS with a handheld magnet when experiencing an aura, thus aborting the seizure. Patients experience a change in voice quality, which signifies that the vagus nerve has been stimulated. They usually report a relief in intensity and duration of seizures and an improved quality of life. RN Implications: Observe for complications after the procedure such as hoarseness (most common), cough, dyspnea, neck pain, or dysphagia (difficulty swallowing). Teach the patient to avoid MRIs, microwaves, shortwave radios, and ultrasound diathermy (a physical therapy heat treatment)
Conventional Surgical Procedures
Last resort. The largest group of conventional surgical candidates includes those with complex partial seizures in the frontal or temporal lobe. Before surgery, the patient is admitted to a special inpatient observation unit. While there, he or she has continuous electroencephalogram (EEG) recording, close observation, and in many hospitals, video monitoring at all times except during personal care activities. The patient is taken off all AEDs. After the seizure area is identified, electrodes may be surgically implanted into the brain tissue to identify the extent of the focal area. This step is followed by additional continuous EEG and video monitoring, as well as close observation by the nursing staff. The area is surgically removed if vital areas of brain function will not be affected. Another surgical approach, the partial corpus callosotomy, may be used to treat tonic-clonic or atonic seizures in patients who are not candidates for other surgical procedures. The surgeon sections the anterior two thirds of the corpus callosum, preventing neuronal discharges from passing between the two hemispheres of the brain.
Nursing Care of a Patient During Seizure: Protect the patient from injury (move furniture away, hold head in lap if on the floor). Position client to provide a patent airway. Be prepared to suction oral secretions. Turn the client to the side to decrease the risk of aspiration. Loosen restrictive clothing. Do not attempt to restrain the client. Do not attempt to open jaw or insert airway during seizure activity (may damage teeth, lips, and tongue). Do not use padded tongue blades. Document onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence). Before the Seizure: what was the patient doing, Did they complain of not feeling well (headache, nausea, vomiting, fever muscle pain) During the Seizure: movements of the arms and legs, both sides affected or just one or even just one extremity, any automatic behaviors, pupils dilated or the eyes deviated to one side, skin color
change, did the patient stop breathing, incontinent of stool or urine, conscious or unconscious. After the seizure: how long it lasted, was the patient lethargic, uncoordinated or weak upon waking, was there confusion or loss of memory.
Post Seizure: Maintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. Check vital signs. Assess for injuries. Perform neurological checks. Allow the client to rest if necessary. Reorient and calm the client (may be agitated or confused). Institute seizure precautions including placing the bed in the lowest position and padding the side rails to prevent future injury. Determine if client experienced an aura, which can possibly indicate the origin of seizure in the brain. Try to determine possible trigger (fatigue).
Status Epilepticus: Status Epilepticus is a medical emergency. It is prolonged seizure activity occurring over a 30-min time frame. The complications associated with this condition are related to decreased oxygen levels, inability of the brain to return to normal functioning, and continued assault on neuronal tissue. This acute condition requires immediate treatment to prevent loss of brain function, which may become permanent. Common causes of status epilepticus include: Sudden withdrawal from antiepileptic drugs Infections Acute alcohol or drug withdrawal Head trauma Cerebral edema
Metabolic disturbances
Medications used to treat status epilepticus: As prescribed, administer a loading dose of diazepam (Valium) or lorazepam (Ativan) followed by a continuous infusion of phenytoin (Dilantin). RN Management (ABC’s): Maintaining a patent airway to ensure adequate ventilation Suctioning as necessary to prevent obstruction of the airway and possible aspiration Providing oxygen by nasal cannula as ordered Protecting the IV site to allow for continuous access for medication Protecting the patient from injury Perform a neurological assessment every 5 to 10 minutes
With older adult clients, increased seizure incidence is associated with cerebrovascular diseases.
Triggers: Pathophysiology:
Increased physical activity Excessive stress Overwhelming fatigue Acute alcohol ingestion Excessive caffeine intake Exposure to flashing lights Specific chemicals, such as cocaine, aerosols and inhaling glue products
Generalized Seizures Involve both cerebral hemispheres. 6 kinds: The tonic-clonic seizure (also called a grand mal seizure) lasting 2 to 5 minutes begins with a tonic phase that causes stiffening or rigidity of the muscles, particularly of the arms and legs, and immediate loss of consciousness. Clonic or rhythmic jerking of all extremities follows. The patient may bite his or her tongue and may become incontinent of urine or feces. Fatigue, acute confusion, and lethargy may last up to an hour after the seizure. Occasionally, only tonic or clonic movement may occur. A tonic seizure is an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes. The clonic seizure lasts several minutes and causes muscle contraction and relaxation. The absence seizure is more common in children and tends to run in families. It consists of brief (often just seconds) periods of loss of consciousness and blank staring as though the person is daydreaming. The patient's eyes may flutter, and automatisms (involuntary behaviors) such as lip smacking and picking at clothes may also occur. He or she is not aware of these behaviors. The patient returns to baseline immediately after the seizure. Left undiagnosed or untreated, the seizures may occur frequently throughout the day, interfering with school or other daily activity. The myoclonic seizure causes a brief jerking or stiffening of the extremities that may occur singly or in groups. Lasting for just a few seconds, the contractions may be symmetric (both sides) or asymmetric (one side).
In an atonic (akinetic) seizure, the patient has a sudden loss of muscle tone, lasting for seconds, followed by postictal (after the seizure) confusion. In most cases, these seizures cause the patient to fall, which may result in injury. This type of seizure tends to be most resistant to drug therapy.
A tonic-clonic seizure progresses through distinct phases including the prodromal, tonic, clonic, and postictal phases.
The prodromal phase of irritability and tension may precede the seizure by several hours or days. Some individuals experience an aura In the tonic phase, there is a major tonic contraction (increased tonus) of the voluntary muscles so that the body stiffens with legs and arms extended. If standing, the person falls to the ground. The jaw snaps shut and the tongue may be bitten in the process. The person may defecate or urinate. The clonic phase is characterized by violent, rhythmic, muscular contractions accompanied by hyperventilation. The face is contorted, the eyes roll, and there is excessive salivation with frothing from the mouth. Profuse sweating and a tachycardia are common. During the postictal phase, the clonic jerking gradually subsides in frequency and amplitude over a period of about 30 seconds, although it may be longer. The involved cells cease firing. The extremities are limp, breathing is quiet, and the pupils, which may be equal or unequal, begin to respond to the light reflex. With awakening, most patients are confused, disoriented, and amnesic for the event. Headache, generalized muscle aching, and fatigue are common. If undisturbed, the patient often falls into a deep sleep for several hours. Partial or focal/local seizure: affect one hemisphere of the brain. 2 kinds: Complex partial seizures: May cause loss of consciousness (syncope), or “black out,” for 1 to 3 minutes. Characteristic automatisms behaviors that the client is unaware of, such as lip smacking or picking at clothes) may occur as in absence seizures. The patient is unaware of the environment and may wander at the start of the seizure. In the period after the seizure, he or she may have amnesia (loss of memory). Because the area of the brain most often involved in this type of epilepsy is the temporal lobe, complex partial seizures are often called psychomotor
seizures or temporal lobe seizures. Simple partial seizure: The patient remains conscious throughout the episode. He or she often reports an aura (unusual sensation) before the seizure takes place. This may consist of a “déjà vu” (already seen) phenomenon, perception of an offensive smell, or sudden onset of pain. During the seizure, the patient may have one-sided movement of an extremity, experience unusual sensations, or have autonomic symptoms. Autonomic changes include a change in heart rate, skin flushing, and epigastric discomfort. Jacksonian march: seizure may begin in the fingers of one side, and “march” or spread to the hand, wrist, forearm, and arm on the same side of the body.
Unclassified or idiopathic seizures do not fit into other categories. These types of seizures account for half of all seizures activities and occur for no known reason.
Diagnostic Imaging and Laboratory Tests: Laboratory tests should include alcohol and illicit drug levels and screens for the presence of excessive toxins, if suspected. In addition, cerebrospinal fluid may be obtained for analysis. Diagnostic procedures include: Electroencephalogram (EEG): An EEG records electrical activity and may identify the origin of seizure activity. Magnetic resonance imaging (MRI), computed tomography imaging (CT)/ computed axial tomography (CAT) scan, positron emission tomography (PET) scan, cerebrospinal fluid (CSF) analysis, skull x-ray, can all be used to identify or rule out potential causes of seizures. Medical Management: Medications: Most seizures can be completely or almost completely controlled through the administration of antiepileptic drugs (AEDs), sometimes referred to as anticonvulsants, for specific types of seizures. The health care provider introduces one antiepileptic drug (AED) at a time to achieve seizure control. If the chosen drug is not effective, the dosage may be increased or another drug introduced. At times, seizure control is achieved only through a combination of drugs. The dosages are adjusted to achieve therapeutic blood levels without causing major side effects. RN Considerations: Teach patients to take their drugs on time to maintain therapeutic blood
levels and maximum effectiveness. Emphasize the importance of taking their antiseizure medications as prescribed. Instruct patients that they can build up sensitivity to the drugs as they age. If sensitivity occurs, tell them they will need to have blood levels of this drug checked frequently to adjust the dose. In some cases, the antiseizure effects of drugs can decline and will lead to an increase in seizures. Because of this potential for “drug decline and sensitivity,” patients need to keep their scheduled laboratory appointments. Emphasize that AEDs must not be stopped even if the seizures have stopped. Discontinuing these drugs can lead to the recurrence of seizures or the life-threatening complication of status epilepticus.
Surgical Management: Vagal Nerve Stimulation Last Resort Vagal nerve stimulation (VNS) may be performed for control of continuous simple or complex partial seizures. Patients with generalized seizures are not candidates for surgery because VNS may result in severe neurologic deficits. The stimulating device (much like a cardiac pacemaker) is surgically implanted in the left chest wall. An electrode lead is attached to the left vagus nerve, tunneled under the skin, and connected to a generator. The procedure usually takes 2 hours with the patient under general anesthesia. The stimulator is activated by the physician either in the operating room or, more commonly, 2 weeks after surgery. Programming is adjusted gradually over a period of time. The pattern of stimulation is individualized to the patient's tolerance. The generator runs continuously, stimulating the vagus nerve according to the programmed schedule. The patient can activate the VNS with a handheld magnet when experiencing an aura, thus aborting the seizure. Patients experience a change in voice quality, which signifies that the vagus nerve has been stimulated. They usually report a relief in intensity and duration of seizures and an improved quality of life. RN Implications: Observe for complications after the procedure such as hoarseness (most common), cough, dyspnea, neck pain, or dysphagia (difficulty swallowing). Teach the patient to avoid MRIs, microwaves, shortwave radios, and ultrasound diathermy (a physical therapy heat treatment)
Conventional Surgical Procedures
Last resort. The largest group of conventional surgical candidates includes those with complex partial seizures in the frontal or temporal lobe. Before surgery, the patient is admitted to a special inpatient observation unit. While there, he or she has continuous electroencephalogram (EEG) recording, close observation, and in many hospitals, video monitoring at all times except during personal care activities. The patient is taken off all AEDs. After the seizure area is identified, electrodes may be surgically implanted into the brain tissue to identify the extent of the focal area. This step is followed by additional continuous EEG and video monitoring, as well as close observation by the nursing staff. The area is surgically removed if vital areas of brain function will not be affected. Another surgical approach, the partial corpus callosotomy, may be used to treat tonic-clonic or atonic seizures in patients who are not candidates for other surgical procedures. The surgeon sections the anterior two thirds of the corpus callosum, preventing neuronal discharges from passing between the two hemispheres of the brain.
Nursing Care of a Patient During Seizure: Protect the patient from injury (move furniture away, hold head in lap if on the floor). Position client to provide a patent airway. Be prepared to suction oral secretions. Turn the client to the side to decrease the risk of aspiration. Loosen restrictive clothing. Do not attempt to restrain the client. Do not attempt to open jaw or insert airway during seizure activity (may damage teeth, lips, and tongue). Do not use padded tongue blades. Document onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence). Before the Seizure: what was the patient doing, Did they complain of not feeling well (headache, nausea, vomiting, fever muscle pain) During the Seizure: movements of the arms and legs, both sides affected or just one or even just one extremity, any automatic behaviors, pupils dilated or the eyes deviated to one side, skin color
change, did the patient stop breathing, incontinent of stool or urine, conscious or unconscious. After the seizure: how long it lasted, was the patient lethargic, uncoordinated or weak upon waking, was there confusion or loss of memory.
Post Seizure: Maintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. Check vital signs. Assess for injuries. Perform neurological checks. Allow the client to rest if necessary. Reorient and calm the client (may be agitated or confused). Institute seizure precautions including placing the bed in the lowest position and padding the side rails to prevent future injury. Determine if client experienced an aura, which can possibly indicate the origin of seizure in the brain. Try to determine possible trigger (fatigue).
Status Epilepticus: Status Epilepticus is a medical emergency. It is prolonged seizure activity occurring over a 30-min time frame. The complications associated with this condition are related to decreased oxygen levels, inability of the brain to return to normal functioning, and continued assault on neuronal tissue. This acute condition requires immediate treatment to prevent loss of brain function, which may become permanent. Common causes of status epilepticus include: Sudden withdrawal from antiepileptic drugs Infections Acute alcohol or drug withdrawal Head trauma Cerebral edema
Metabolic disturbances
Medications used to treat status epilepticus: As prescribed, administer a loading dose of diazepam (Valium) or lorazepam (Ativan) followed by a continuous infusion of phenytoin (Dilantin). RN Management (ABC’s): Maintaining a patent airway to ensure adequate ventilation Suctioning as necessary to prevent obstruction of the airway and possible aspiration Providing oxygen by nasal cannula as ordered Protecting the IV site to allow for continuous access for medication Protecting the patient from injury Perform a neurological assessment every 5 to 10 minutes
