Seizures

SEIZURES Seizures consist of abnormal motor and sensory activity, and are due to a sudden, excessive discharge from cerebral neurons. Seizures are symptoms of underlying neurological brain disorder. Can involve part or all of brain Seizures, generally sudden and transient, should be viewed as a symptom and not a disease

TWO CATEGORIES OF SEIZURES •

Idiopathic o Attributed to a genetic or developmental defect. o The definite cause for the seizure cannot be identifies

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Acquired o Cause for seizure can be identified. o Brain tumors, stroke, hypoxemia (anything that decreases O2 to the brain), head injury, infections, toxic, drug withdrawal, medications, Infants: Fever o Leading cause in elderly: Stroke and cerebral metastasis

RESULTS FROM SEIZURES • • •

Memory Loss: During the seizure and/or for a short time after the seizure Could have brain damage if the seizure is very severe or prolonged At risk for Hypoxia, Vomiting and Aspiration, and Metabolic abnormalities as a result of a seizure

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IMMEDIATE GOAL: Control the Seizure o Long Term: Determine the cause and control it

CLASSIFICATION OF SEIZURES •

Partial Seizures o Simple  Seizures beginning locally.  Are focal in origin and affect only that part of the brain

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Generalized Seizures o Complex  Referred to as “grand mal” seizures. Involved both hemispheres of the brain, causing reaction from both sides of the body

CLINICAL MANIFESTATIONS •

Partial Seizures o Simple Partial Seizures  Elementary Symptoms  No loss of consciousness  Finger or hand shake*  Dizziness  Mouth jerk*  Unintelligent talking*  Unusual or unpleasant sights, sounds, odors, or tastes may be experienced* o Complex Partial Seizures  Complex Symptoms • May be motionless or move automatically • Brief loss of consciousness • Movement is inappropriate for time and place • Excessive emotions: Fear, anger, elation, or irritability exhibited • No recollection of episode once over

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Generalized Seizures – Grand Mal o Involves both hemispheres of the brain o Causes both sides of the body to react  Intense rigidity of the entire body then shaking  Jerky alterations of muscle relaxation and contraction (tonic-clonic); diaphragm and chest muscles contract – known as “epileptic cry”  Tongue chewing  Incontinent of urine and stool  May be in relaxed state, possibly coma  May be difficult to arouse afterwards, may sleep for hours with confusion  Complains of headache and sore muscles afterwards

DIAGNOSTIC EVALUATION • • • • • •

Determine the type of seizure, frequency and severity and any factors that precipitated the seizure Dr will get a developmental history – If past injury or illness Physical and Neuro exam CT/MRI Blood studies EEG

NURSING ASSESSMENT AND MANAGEMENT DURING SEIZURE It is very important to observe and record sequence of symptoms because the type of treatment may be dependent upon the nature of the seizure. Before and during a seizure, the following are assessed and documented: 1- The circumstances before the seizure (visual, auditory, or olfactory stimuli, tactile stimuli, emotional or psychological disturbances, sleep, hyperventilation) 2- The first thing the patient does in a seizure – where the movements or the stiffness starts, conjugate gaze position, and the position o the patient’s head at the beginning of the seizure. This information gives clues to the location of the epileptogenic focus in the brain. 3- Type of movements in the part of the body involved 4- The areas of the body involved (turn back bedding and expose patient) 5- The size of both pupils. Are the eyes open? Did the eyes or head turn to one side? 6- Incontinence of urine or stool 7- Duration of each phase of the seizure 8- Unconsciousness, if present, and its duration 9- Any obvious paralysis or weakness of arms or legs after the seizure 10- Inability to speak after the seizure 11-Movements at the end of the seizure 12-Whether or not the patient sleeps afterward 13-Cognitive status (confused or not) after the seizure • • • • • • • • • • • •

Provide privacy for patient If possible, assist patient to floor Protect head Loosen any constrictive clothing Move furniture – to prevent injury If in bed, raise side rails and remove pillows Never attempt to open jaws that are clenched shut If at all possible, place patient on side with head flexed so that the tongue will fall forward Never attempt to restrain patient Keep patient on side after seizure to prevent aspiration. Assure patient airway – Possible short period apnea Apneic and confused state may follow generalized seizure – reorient Orient confused patient to environment with calmness

AFTER THE SEIZURE • • • • •

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 experiences severe excitement after a seizure, use calm persuasion and gentle restraint

TREATMENT OF SEIZURES •

Anticonvulsants or Antiepileptic Drugs o Mechanism of action is unknown o Trying to control, cannot cure the seizure o Patients may still have seizures while on the medication

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Don’t stop drugs suddenly

These drugs cause drowsiness – CNS Depressants •

Monitor the drug Levels o Dilantin – Level 10-20  Cerebryx  Gum overgrowth – Mouth care is important  Toxic Effects: Peripheral Neuropathy, drowsiness, Blood dyscrasis o Theopholine o Tegretal  Level 8-12  Toxic Effects: Blood Dyscrasias o Klonopin  Toxic Effects: Thrombocytopenia o Depakote  Toxic Effects: Blood Dyscrasis o Neurotin  Toxic Effects: Leukopenia, Hepatoxicity o Phenobarbital

Just because you have a seizure does not mean you have a convulsive disorder A baby who has one seizure due to a high fever – you do not have a convulsive disorder

CONVULSIVE DISORDERS THE EPILEPSIES The Epilepsies are disorders of brain function characterized by recurrent seizures. Epilepsy is not a disease, but a symptom. The epileptic seizure is a manifestation of excessive neuronal discharge. • • • • • • • • • • • • •

Unknown cause Could be inherited Birth trauma Head Injury Infectious diseases Toxicity Circulatory problems Fever Metabolic / Nutritional Disorders Drug and Alcohol intoxication Onset of recurrent may not occur for months or years, if ever A seizure can occur at the time of an injury or at the time of a cerebral event but it is not necessarily epilepsy. The onset of recurrent (Epilepsy)seizures may not occur for months or years.

PATHOPHYSIOLOGY The nerve cells of the body carry messages throughout the body by electrochemical energy which is discharged. When a group of cells continues to fire after the desired task has been done, that particular part of the body behaves erratically. Epilepsy is defined as these repeated, uncontrolled discharges. The physical movements elicited by the body are called seizures.

CLINICAL MANIFESTATIONS •

Already discussed under Seizures

INCREASED INCIDENCE • • • • • •

Aging Stroke Head injury Dementia Infection Alcoholism

DIAGNOSIS • • • •

A detailed history of the type, severity, and frequency of the seizure is very important. Also, precipitating factors must be included The developmental history must be explored CT imaging is done to detect brain lesions and cerebral degenerative changes EEG – done to locate the focus of abnormal discharge

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MRI – Can detect congenital abnormalities of mass lesions such as brain tumors

MEDICAL MANAGEMENT There are many antiepileptic drugs available. However, these drugs are not a cure. The goal is to achieve seizure control. Specific drugs are chosen on the basis of the type of seizure and drug effectiveness • • • •

Individualize treatment Meds are based on type of seizure Increased protein Increases needs Meds are a means of control but does not work on all patients

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Start with one drug o Increase with monitoring drug levels / 2 meds needed adjust dosage due to illness or weight change, stress, or other drugs o The drugs are CNS Depressants

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Status Epilepticus o An Acute Prolonged Seizure Activity  Series of generalized seizure; they occur without full recovery or consciousness between attacks; last at least 30 minutes o A MEDICAL EMERGENCY o Can be caused by a Sudden withdrawal of medication or if a person who has seizures gets a high fever or infection can precipitate SE.

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Stop seizure – as quickly as possible Make sure to get oxygen to the brain • Oxygenation – lack of O2 Maintain client seizure free

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1st way to stop it is to give IV Valium and Ativan Or IV Cerebyx

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Surgical Management o A resective type surgery to remove the abnormal epileptic foci without causing any deficits

NURSING DIAGNOSIS • • • • •

HRF Injury Risk for Aspiration Knowledge deficit about epilepsy Fear related to possibility of having seizure Ineffective coping related to stress of epilepsy

TEACHING •

Take medications daily as prescribed to keep the blood-drug level constant to prevent seizures. Medication should never be discontinued by the patient, even when there is no seizure activity.

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Keep a “drug and seizure chart,” noting when medications are taken and any seizure activity

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Notify the patients physician if patient cannot take medications sue to illness

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Have anticonvulsant serum levels checked regularly. When testing is prescribed, the patient should report to the lab for blood sampling before taking morning medication

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Avoid activities that require alertness and coordination (driving, operating machinery) until after the effects of the medication have been evaluated

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Report signs of toxicity so dosage can be adjusted. Common signs include drowsiness, lethargy, dizziness, difficulty walking, hyperactivity, confusion, inappropriate sleep, and visual disturbances

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Avoid over the counter medications unless approved by the patients physician

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Carry a Medic Alert bracelet or personal identification card specifying the name of the patients anticonvulsant medication and physician

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Avoid seizure “triggers”, such as alcoholic beverages, electrical shocks, stress, caffeine, constipation, fever, hyperventilation, hypoglycemia

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Take showers rather than tub baths to avoid drowning; never swim alone

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Exercise in moderation in a temperature controlled environment to avoid excessive heat

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Develop regular sleep patterns to minimize fatigue and insomnia

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Avail oneself of the Epilepsy Foundation of Americas special services, including help in obtaining medications, vocational rehabilitation, and coping with epilepsy.