Seizure Disorders

SEIZURE DISORDERS seizures (convulsions) are the result of uncontrolled electrical discharges from the nerve cells of the cerebral cortex and are characterized by sudden, brief attacks of altered consciousness, motor activity, and/or sensory phenomena. seizures can be associated with a variety of cerebral or systemic disorders as a focal or generalized disturbance of cortical function. sensory symptoms arise from the parietal lobe; motor symptoms arise from the frontal lobe. the phases of seizure activity are prodromal, aural, ictal, and postictal. the prodromal phase involves mood or behavior changes that may precede a seizure by hours or days. the aura is a premonition of impending seizure activity and may be visual, auditory, or gustatory. the ictal stage is characterized by seizure activity, usually musculoskeletal. the postictal stage is a period of confusion/somnolence/irritability that occurs after the seizure. the main causes for seizures can be divided into six categories: toxic agents: poisons, alcohol, overdoses of prescription/nonprescription drugs (with drugs the leading cause). chemical imbalances: hyperkalemia, hypoglycemia, and acidosis. fever: acute infections, heatstroke. cerebral pathology: resulting from head injury, infections, hypoxia, expanding brain lesions, increased intracranial pressure. eclampsia: prenatal hypertension/toxemia of pregnancy. idiopathic: unknown origin. seizures can be divided into two major classifications (generalized and partial). generalized seizure types include tonic-clonic, myoclonic, clonic, tonic, atonic, and absence seizures. partial (focal) seizures are the most common type and are categorized as either (1) simple (partial motor, partial sensory) or (2) complex.

CARE SETTING community; however, may require brief inpatient care on a medical or subacute unit for stabilization/treatment of status epilepticus.

RELATED CONCERNS cerebrovascular accident (cva)/stroke craniocerebral trauma (acute rehabilitative phase) psychosocial aspects of care substance dependence/abuse rehabilitation

patient assessment database ACTIVITY/REST may report:

may exhibit:

fatigue, general weakness limitation of activities/occupation imposed by self/significant other (so)/healthcare provider or others altered muscle tone/strength involuntary movement/contractions of muscles or muscle groups (generalized tonic-clonic seizures)

CIRCULATION may exhibit:

ictal: hypertension, increased pulse, cyanosis postictal: vital signs normal or depressed with decreased pulse and respiration

EGO INTEGRITY may report:

may exhibit:

internal/external stressors related to condition and/or treatment irritability; sense of helplessness/hopelessness changes in relationships wide range of emotional responses

ELIMINATION may report:

episodic incontinence

may exhibit:

ictal: increased bladder pressure and sphincter tone postictal : muscles relaxed, resulting in incontinence (urinary/fecal)

FOOD/FLUID may report: may exhibit:

food sensitivity nausea/vomiting correlating with seizure activity dental/soft-tissue damage (injury during seizure) gingival hyperplasia (side effect of long-term phenytoin [dilantin] use)

NEUROSENSORY may report:

may exhibit:

history of headaches, recurring seizure activity, fainting, dizziness history of head trauma, anoxia, cerebral infections prodromal phase: vague changes in emotional reactivity or affective response preceding aura in some cases and lasting minutes to hours presence of aura (stimulation of visual, auditory, hallucinogenic areas) postictal: weakness, muscle pain, areas of paresthesia/paralysis seizure characteristics: (ictal, postictal) generalized seizures: tonic-clonic (grand mal): rigidity and jerking posturing, vocalization, loss of consciousness, dilated pupils, stertorous respiration, excessive salivation (froth), fecal/urinary incontinence, and biting of the tongue may occur and last 2–5 min. postictal phase: patient sleeps 30 min to several hours, then may be weak, confused, and amnesic concerning the episode, with nausea and stiff, sore muscles myoclonic: short abrupt muscle contractions of arms, legs, torso; may not be symmetrical; lasts seconds clonic: muscle contraction with relaxation resembling myoclonic movements but with slower repetitions; may last several minutes tonic: abrupt increase in muscle tone of torso/face, flexion of arms, extension of legs; lasts seconds atonic: abrupt loss of muscle tone; lasts seconds; patient may fall absence (petit mal): periods of altered awareness or consciousness (staring, fluttering of eyes) lasting 5–30 sec, which may occur as many as 100 times a day; minor motor seizures may be akinetic (loss of movement), myoclonic (repetitive motor contractions), or atonic (loss of muscle tone). postictal phase: amnesia for seizure events, no confusion, able to resume activity status epilepticus: defined as 30 or more minutes of continuous generalized seizure activity or two or more sequential seizures without full recovery of consciousness in between, possibly related to abrupt withdrawal of anticonvulsants and other metabolic phenomena. if absence seizures are the pattern, problem may go undetected for a period of time because patient does not lose consciousness partial seizures: complex (psychomotor/temporal lobe): patient generally remains conscious, with reactions such as dream state, staring, wandering, irritability, hallucinations, hostility, or fear. may display involuntary motor symptoms (lip smacking) and behaviors that appear purposeful but are inappropriate (automatism) and include impaired judgment and, on occasion, antisocial acts; lasts 1–3 min. postictal phase: absence of memory for these events, mild to moderate confusion simple (focal-motor/jacksonian): often preceded by aura (may report deja vu or fearful feeling); no loss of consciousness (unilateral) or loss of consciousness (bilateral); convulsive movements and temporary disturbance in part controlled by the brain region involved (e.g., frontal lobe [motor dysfunction], parietal [numbness, tingling], occipital [bright, flashing lights], posterotemporal [difficulty speaking]). convulsions may march along limb or side of body in orderly progression. if restrained during seizure, patient may exhibit combative and uncooperative behavior; lasts seconds to minutes

PAIN/DISCOMFORT may report:

headache, muscle/back soreness postictally

may exhibit:

paroxysmal abdominal pain during ictal phase (may occur during some partial/focal seizures without loss of consciousness) guarding behavior alteration in muscle tone distraction behavior/restlessness

RESPIRATION may exhibit:

ictal: clenched teeth, cyanosis, decreased or rapid respirations; increased mucous secretions postictal: apnea

SAFETY may report: may exhibit:

history of accidental falls/injuries, fractures presence of allergies soft-tissue injury/ecchymosis decreased general strength/muscle tone

SOCIAL INTERACTION may report:

problems with interpersonal relationships within family/socially limitation/avoidance of social contacts

TEACHING/LEARNING may report:

discharge plan considerations:

familial history of epilepsy drug (including alcohol) use/misuse increased frequency of episodes/failure to improve drg projected mean length of inpatient stay: 4.4 days may require changes in medications, assistance with some homemaker/maintenance tasks relative to issues of safety, and transportation refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES electrolytes: imbalances may affect/predispose to seizure activity. glucose: hypoglycemia may precipitate seizure activity. blood urea nitrogen (bun): elevation may potentiate seizure activity or may indicate nephrotoxicity related to medication regimen. complete blood count (cbc): aplastic anemia may result from drug therapy. serum drug levels: to verify therapeutic range of antiepileptic drugs (aeds). toxicology screen: determines potentiating factors such as alcohol or other drug use. skull x-rays: identifies presence of space-occupying lesions, fractures. electroencephalogram (eeg) may be done serially: locates area of cerebral dysfunction; measures brain activity. brain waves take on characteristic spikes in each type of seizure activity; however, up to 40% of seizure patients have normal eegs because the paroxysmal abnormalities occur intermittently. video-eeg monitoring, 24 hours (video picture obtained at same time as eeg): may identify exact focus of seizure activity (advantage of repeated viewing of event with eeg recording). computed tomography (ct) scan: identifies localized cerebral lesions, infarcts, hematomas, cerebral edema, trauma, abscesses, tumor; can be done with or without contrast medium. magnetic resonance imaging (mri): localizes focal lesions. positron emission tomography (pet): demonstrates metabolic alterations, e.g., decreased metabolism of glucose at site of lesion. single photon emission computed tomography (spect): may show local areas of brain dysfunction when ct and mri are normal. magnetoencephalogram: maps the electrical impulses/potential of brain for abnormal discharge patterns. lumbar puncture: detects abnormal cerebrospinal fluid (csf) pressure, signs of infections or bleeding (i.e., subarachnoid, subdural hemorrhage) as a cause of seizure activity (rarely done). wada’s test: determines hemispheric dominance (done as a presurgical evaluation before temporal lobectomy).

NURSING PRIORITIES

1. 2. 3. 4. 5.

prevent/control seizure activity. protect patient from injury. maintain airway/respiratory function. promote positive self-esteem. provide information about disease process, prognosis, and treatment needs.

DISCHARGE GOALS 1. 2. 3. 4. 5.

seizures activity controlled. complications/injury prevented. capable/competent self-image displayed. disease process/prognosis, therapeutic regimen, and limitations understood. plan in place to meet needs after discharge.

nursing diagnosis: trauma/suffocation, risk for risk factors may include weakness, balancing difficulties cognitive limitations/altered consciousness loss of large or small muscle coordination emotional difficulties possibly evidenced by [not applicable; presence of signs and symptoms establishes an actual diagnosis.] desired outcomes/evaluation criteria—patient will: risk detection (noc) verbalize understanding of factors that contribute to possibility of trauma and/or suffocation and take steps to correct situation. risk control (noc) demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury. modify environment as indicated to enhance safety. maintain treatment regimen to control/eliminate seizure activity. caregivers will: knowledge: personal safety (noc) identify actions/measures to take when seizure activity occurs.

ACTIONS/INTERVENTIONS

RATIONALE

seizure precautions (nic)

independent explore with patient the various stimuli that may precipitate seizure activity.

alcohol, various drugs, and other stimuli (e.g., loss of sleep, flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity.

ACTIONS/INTERVENTIONS

RATIONALE

seizure precautions (nic)

independent discuss seizure warning signs (if appropriate) and usual seizure pattern. teach so to recognize warning signs and how to care for patient during and after seizure.

enables patient to protect self from injury and recognize changes that require notification of physician/further intervention. knowing what to do when seizure occurs can prevent injury/complications and decreases so’s feelings of helplessness.

keep padded side rails up with bed in lowest position, or place bed up against wall and pad floor if rails not available/appropriate.

minimizes injury should seizures (frequent/generalized) occur while patient is in bed. note: most individuals seize in place and if in the middle of the bed, individual is unlikely to fall out of bed.

encourage patient not to smoke except while supervised.

may cause burns if cigarette is accidentally dropped during aura/seizure activity.

evaluate need for/provide protective headgear.

use of helmet may provide added protection for individuals who suffer recurrent/severe seizures.

use tympanic thermometer when necessary to take temperature.

reduces risk of patient biting and breaking glass thermometer or suffering injury if sudden seizure activity should occur.

seizure management (nic) maintain strict bedrest if prodromal signs/aura experienced. explain necessity for these actions.

patient may feel restless/need to ambulate or even defecate during aural phase, thereby inadvertently removing self from safe environment and easy observation. understanding importance of providing for own safety needs may enhance patient cooperation.

stay with patient during/after seizure.

promotes patient safety.

turn head to side/suction airway as indicated. insert plastic bite block only if jaw relaxed.

helps maintain airway and reduces risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. note: wooden tongue blades should not be used because they may splinter and break in patient’s mouth. (refer to nd: airway clearance/breathing pattern, ineffective, risk for)

cradle head, place on soft area, or assist to floor if out of bed. do not attempt to restrain.

gentle guiding of extremities reduces risk of physical injury when patient lacks voluntary muscle control. note: if attempt is made to restrain patient during seizure, erratic movements may increase, and patient may injure self or others.

document preseizure activity, presence of aura or unusual behavior, type of seizure activity (e.g., location/duration of motor activity, loss of consciousness, incontinence, eye activity, respiratory impairment/cyanosis), and frequency/recurrence. note whether patient fell, expressed vocalizations, drooled, or had automatisms (e.g., lipsmacking, chewing, picking at clothes).

helps localize the cerebral area of involvement.

ACTIONS/INTERVENTIONS

RATIONALE

seizure management (nic)

independent perform neurological/vital sign check after seizure, e.g., level of consciousness, orientation, ability to comply with simple commands, ability to speak; memory of incident; weakness/motor deficits; blood pressure (bp), pulse/respiratory rate.

documents postictal state and time/completeness of recovery to normal state. may identify additional safety concerns to be addressed.

reorient patient following seizure activity.

allow postictal “automatic” behavior without interfering while providing environmental protection.

investigate reports of pain.

observe for status epilepticus, i.e., one tonic-clonic seizure after another in rapid succession.

collaborative

patient may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety. may display behavior (of motor or psychic origin) that seems inappropriate/irrelevant for time and place. attempts to control or prevent activity may result in patient becoming aggressive/combative. may be result of repetitive muscle contractions or symptom of injury incurred, requiring further evaluation/intervention. this is a life-threatening emergency that if left untreated could cause metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased intracranial pressure, airway obstruction, and respiratory arrest. immediate intervention is required to control seizure activity and prevent permanent injury/death. note: although absence seizures may become static, they are not usually life-threatening.

administer medications as indicated:

antiepileptic drugs (aeds), e.g., phenytoin (dilantin), primidone (mysoline), carbamazepine (tegretol), clonazepam (klonopin), valproic acid (depakene), divalproex (depakote), acetazolamide (diamox), ethotoin (peganone), methsuximide (celotin), fosphenytoin (cerebyx);

ACTIONS/INTERVENTIONS

specific drug therapy depends on seizure type, with some patients requiring polytherapy or frequent medication adjustments. aeds raise the seizure threshold by stabilizing nerve cell membranes, reducing the excitability of the neurons, or through direct action on the limbic system, thalamus, and hypothalamus. goal is optimal suppression of seizure activity with lowest possible dose of drug and with fewest side effects. cerebyx reaches therapeutic levels within 24 hr and can be used for nonemergent loading while waiting for other agents to become effective. note: some patients require polytherapy or frequent medication adjustments to control seizure activity. this increases the risk of adverse reactions and problems with adherence.

RATIONALE

seizure management (nic)

collaborative topiramate (topamax), ethosuximide (zarontin), lamotrigine (lamictal), gabapentin (neurontin);

adjunctive therapy for partial seizures or an alternative for patients when seizures are not adequately controlled by other drugs.

phenobarbital (luminal);

potentiates/enhances effects of aeds and allows for lower dosage to reduce side effects.

lorazepam (ativan);

used to abort status seizure activity because it is shorter acting than valium and less likely to prolong postseizure sedation.

diazepam (valium, diastat rectal gel);

may be used alone (or in combination with phenobarbital) to suppress status seizure activity. diastat, a gel, may be administered rectally, even in the home setting, to reduce frequency of seizures and need for additional medical care.

glucose, thiamine.

may be given to restore metabolic balance if seizure is induced by hypoglycemia or alcohol.

monitor/document aed drug levels, corresponding side effects, and frequency of seizure activity.

standard therapeutic level may not be optimal for individual patient if untoward side effects develop or seizures are not controlled.

monitor cbc, electrolytes, glucose levels.

identifies factors that aggravate/decrease seizure threshold.

prepare for surgery/electrode implantation as indicated.

vagal nerve stimulator, magnetic beam therapy, or other surgical intervention (e.g., temporal lobectomy) may be done for intractable seizures or well-localized epileptogenic lesions when patient is disabled and at high risk for serious injury. success has been reported with gamma ray radio surgery for the treatment of multiple seizure activity that has otherwise been difficult to control.

nursing diagnosis: airway clearance/breathing pattern, risk for ineffective risk factors may include neuromuscular impairment tracheobronchial obstruction perceptual/cognitive impairment possibly evidenced by [not applicable; presence of signs and symptoms establishes an actual diagnosis.] desired outcomes/evaluation criteria—patient will: respiratory status: ventilation (noc) maintain effective respiratory pattern with airway patent/aspiration prevented.

ACTIONS/INTERVENTIONS

RATIONALE

airway management (nic)

independent encourage patient to empty mouth of dentures/foreign objects if aura occurs and to avoid chewing gum/sucking lozenges if seizures occur without warning. place in lying position, flat surface; turn head to side during seizure activity.

reduces risk of aspiration/foreign bodies lodging in pharynx.

loosen clothing from neck/chest and abdominal areas.

promotes drainage of secretions; prevents tongue from obstructing airway.

insert plastic airway or soft roll as indicated and only if jaw is relaxed.

facilitates breathing/chest expansion.

suction as needed.

collaborative

if inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning/respiratory support if required. airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue. reduces risk of aspiration/asphyxiation. note: risk of aspiration is low unless individual has eaten within the last 40 min.

administer supplemental oxygen/bag ventilation as needed postictally.

prepare for/assist with intubation, if indicated.

may reduce cerebral hypoxia resulting from decreased circulation/oxygenation secondary to vascular spasm during seizure. note: artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in/out of lungs during sustained contraction of respiratory musculature. as seizure abates, respiratory function will return unless a secondary problem exists (e.g., foreign body/aspiration). presence of prolonged apnea postictally may require ventilatory support.

nursing diagnosis: self-esteem, (specify situational or chronic) low may be related to stigma associated with condition perception of being out of control possibly evidenced by verbalization about changed lifestyle fear of rejection; negative feelings about body change in self-perception of role change in usual patterns of responsibility lack of follow-through/nonparticipation in therapy desired outcomes/evaluation criteria—patient will: self-esteem (noc) identify feelings and methods for coping with negative perception of self. verbalize increased sense of self-esteem in relation to diagnosis. verbalize realistic perception and acceptance of self in changed role/lifestyle.

ACTIONS/INTERVENTIONS

RATIONALE

self-esteem enhancement (nic)

independent discuss feelings about diagnosis, perception of threat to self. encourage expression of feelings.

reactions vary among individuals, and previous knowledge/experience with this condition affects acceptance of therapeutic regimen. verbalization of fears, anger, and concerns about future implications can help patient begin to accept/deal with situation.

identify possible/anticipated public reaction to condition. encourage patient to refrain from concealing problem.

provides opportunity to problem-solve response, and provides measure of control over situation. concealment is destructive to self-esteem (potentiates denial), blocking progress in dealing with problem, and may actually increase risk of injury/negative response when seizure does occur.

explore with patient current/past successes and strengths.

focusing on positive aspects can help alleviate feelings of guilt/self-consciousness and help patient begin to accept manageability of condition.

avoid overprotecting patient; encourage activities, providing supervision/monitoring when indicated.

participation in as many experiences as possible can lessen depression about limitations. observation/supervision may need to be provided for such activities as gymnastics, climbing, and water sports.

determine attitudes/capabilities of so. help individual realize that his/her feelings are normal; however, guilt and blame are not helpful.

negative expectations from so may affect patient’s sense of competency/self-esteem and interfere with support received from so, limiting potential for optimal management/personal growth.

ACTIONS/INTERVENTIONS

RATIONALE

self-esteem enhancement (nic)

independent stress importance of staff/so remaining calm during seizure activity.

refer patient/so to support group, e.g., epilepsy foundation of america, national association of epilepsy centers, and delta society’s national service dog center.

discuss referral for psychotherapy with patient/so.

anxiety of caregivers is contagious and can be conveyed to the patient, increasing/multiplying individual’s own negative perceptions of situation/self. provides opportunity to gain information, support, and ideas for dealing with problems from others who share similar experiences. note: some service dogs have ability to sense/predict seizure activity, allowing patient to institute safety measures, increasing independence and personal sense of control. seizures have a profound effect on personal self-esteem, and patient/so may feel guilt over perceived limitations and public stigma. counseling can help overcome feelings of inferiority/self-consciousness.

nursing diagnosis: knowledge, deficient [learning need] regarding condition, prognosis, treatment regimen, self-care, and discharge needs may be related to lack of exposure, unfamiliarity with resources information misinterpretation lack of recall; cognitive limitation possibly evidenced by questions, statement of concerns increased frequency/lack of control of seizure activity lack of follow-through of drug regimen desired outcomes/evaluation criteria—patient will: knowledge: illness care (noc) verbalize understanding of disorder and various stimuli that may increase/ potentiate seizure activity. adhere to prescribed drug regimen. knowledge: personal safety (noc) initiate necessary lifestyle/behavior changes as indicated.

ACTIONS/INTERVENTIONS

RATIONALE

teaching: disease process (nic)

independent review pathology/prognosis of condition and lifelong need for treatments as indicated. discuss patient’s particular trigger factors (e.g., flashing lights, hyperventilation, loud noises,video games, tv viewing).

provides opportunity to clarify/dispel misconceptions and present condition as something that is manageable within a normal lifestyle.

review possible effects of hormonal changes.

alterations in hormonal levels that occur during menstruation and pregnancy may increase risk of seizures.

discuss significance of maintaining good general health, e.g., adequate diet, rest, moderate exercise, and avoidance of exhaustion, alcohol, caffeine, and stimulant drugs.

regularity and moderation in activities may aid in reducing/controlling precipitating factors, enhancing sense of general well-being, and strengthening coping ability and self-esteem. note: too little sleep or too much alcohol can precipitate seizure activity in some people.

review importance of good oral hygiene and regular dental care.

reduces risk of oral infections and gingival hyperplasia.

identify necessity/promote acceptance of actual limitations; discuss safety measures regarding driving, using mechanical equipment, climbing ladders, swimming, and hobbies.

reduces risk of injury to self or others, especially if seizures occur without warning.

discuss local laws/restrictions pertaining to persons with epilepsy/seizure disorder. encourage awareness but not necessarily acceptance of these policies.

although legal/civil rights of persons with epilepsy have improved during the past decade, restrictions still exist in some states pertaining to obtaining a driver’s license, sterilization, workers’ compensation, and required reportability to state agencies.

teaching: prescribed medication (nic) review medication regimen, necessity of taking drugs as ordered, and not discontinuing therapy without physician supervision. include directions for missed dose.

recommend taking drugs with meals, if appropriate.

discuss nuisance and adverse side effects of particular drugs, e.g., drowsiness, fatigue, lethargy, hyperactivity, sleep disturbances, gingival hypertrophy, visual disturbances, nausea/vomiting, rashes, syncope/ataxia, birth defects, aplastic anemia.

ACTIONS/INTERVENTIONS

lack of cooperation with medication regimen is a leading cause of seizure breakthrough. patient needs to know risks of status epilepticus resulting from abrupt withdrawal of anticonvulsants. depending on the drug dose and frequency, patient may be instructed to take missed dose if remembered within a predetermined time frame. may reduce incidence of gastric irritation, nausea/vomiting. may indicate need for change in dosage/choice of drug therapy. promotes involvement/participation in decisionmaking process and awareness of potential long-term effects of drug therapy, and provides opportunity to minimize/prevent complications.

RATIONALE

teaching: prescribed medication (nic)

independent provide information about potential drug interactions and necessity of notifying other healthcare providers of drug regimen.

review proper use of diazepam rectal gel (diastat) with patient and so/caregiver as appropriate.

knowledge of anticonvulsant use reduces risk of prescribing drugs that may interact, thus altering seizure threshold or therapeutic effect. for example, phenytoin (dilantin) potentiates anticoagulant effect of warfarin (coumadin), whereas isoniazid (inh) and chloramphenicol (chloromycetin) increase the effect of phenytoin (dilantin), and some antibiotics (e.g., erythromycin) can cause elevation of serum level of carbamazepine (tegretol), possibly to toxic levels.

encourage patient to wear identification tag/bracelet stating the presence of a seizure disorder.

useful in controlling serial or cluster seizures. can be administered in any setting and is effective usually within 15 min. may reduce dependence on emergency department visits.

stress need for routine follow-up care/laboratory testing as indicated, e.g., cbc should be monitored biannually and in presence of sore throat/fever, signs of other infection.

expedites treatment and diagnosis in emergency situations. therapeutic needs may change and/or serious drug side effects (e.g., agranulocytosis or toxicity) may develop.

potential considerations following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities) injury, risk for—weakness, balancing difficulties, cognitive limitations/altered consciousness, loss of large or small muscle coordination. self-esteem (specify)—stigma associated with condition, perception of being out of control, personal vulnerability, negative evaluation of self/capabilities. therapeutic regimen: ineffective management—social support deficits, perceived benefit (versus side effects of medication), perceived susceptibility (possible long periods of remission).