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NCP: Seizure Disorders

NCP: Seizure Disorders

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Published by: Javie on Oct 03, 2009
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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. Theaura 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
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.

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

Cerebrovascular accident (CVA)/stroke
Craniocerebral trauma (acute rehabilitative phase)
Psychosocial aspects of care
Substance dependence/abuse rehabilitation

Patient Assessment Database
May report:
Fatigue, general weakness
Limitation of activities/occupation imposed by self/significant other (SO)/healthcare
provider or others
May exhibit:
Altered muscle tone/strength
Involuntary movement/contractions of muscles or muscle groups (generalized tonic-clonic
May exhibit:
Ictal: Hypertension, increased pulse, cyanosis
Postictal: Vital signs normal or depressed with decreased pulse and respiration
May report:

Internal/external stressors related to condition and/or treatment
Irritability; sense of helplessness/hopelessness
Changes in relationships

May exhibit:
Wide range of emotional responses
May report:
Episodic incontinence
May exhibit:
Ictal: Increased bladder pressure and sphincter tone
Postictal : Muscles relaxed, resulting in incontinence (urinary/fecal)
May report:
Food sensitivity nausea/vomiting correlating with seizure activity
May exhibit:
Dental/soft-tissue damage (injury during seizure)
Gingival hyperplasia (side effect of long-term phenytoin [Dilantin] use)
May report:
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

May exhibit:
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\u20135 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\u201330 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\u20133 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

May report:
Headache, muscle/back soreness postictally
Paroxysmal abdominal pain during ictal phase (may occur during some partial/focal
seizures without loss of consciousness)
May exhibit:

Guarding behavior
Alteration in muscle tone
Distraction behavior/restlessness

May exhibit:
Ictal: Clenched teeth, cyanosis, decreased or rapid respirations; increased mucous
Postictal: Apnea
May report:
History of accidental falls/injuries, fractures
Presence of allergies
May exhibit:
Soft-tissue injury/ecchymosis
Decreased general strength/muscle tone
May report:
Problems with interpersonal relationships within family/socially
Limitation/avoidance of social contacts
May report:

Familial history of epilepsy
Drug (including alcohol) use/misuse
Increased frequency of episodes/failure to improve

Discharge plan
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.
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\u2019s test: Determines hemispheric dominance (done as a presurgical evaluation before temporal lobectomy).

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