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Seizure Disorders

Seizure Disorders

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Published by: mardsz on Jan 01, 2009
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06/18/2013

 
SEIZURE DISORDERS
Seizures (convulsions) are the result of uncontrolled electrical discharges from the nerve cells of the cerebral cortexand 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 activityand 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 includetonic-clonic, myoclonic, clonic, tonic, atonic, and absence seizures. Partial (focal) seizures are the most common typeand 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)/strokeCraniocerebral trauma (acute rehabilitative phase)Psychosocial aspects of careSubstance dependence/abuse rehabilitation
Patient Assessment Database
ACTIVITY/REST
May report:
Fatigue, general weaknessLimitation of activities/occupation imposed by self/significant other (SO)/healthcare provider or others
May exhibit:
Altered muscle tone/strengthInvoluntary movement/contractions of muscles or muscle groups (generalized tonic-clonicseizures)
CIRCULATION
May exhibit:
Ictal: Hypertension, increased pulse, cyanosisPostictal: Vital signs normal or depressed with decreased pulse and respiration
EGO INTEGRITY
May report:
Internal/external stressors related to condition and/or treatmentIrritability; sense of helplessness/hopelessnessChanges in relationships
May exhibit:
Wide range of emotional responses
ELIMINATION
May report:
Episodic incontinence
 
May exhibit:
Ictal: Increased bladder pressure and sphincter tonePostictal : Muscles relaxed, resulting in incontinence (urinary/fecal)
FOOD/FLUID
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)
NEUROSENSORY
May report:
History of headaches, recurring seizure activity, fainting, dizzinessHistory of head trauma, anoxia, cerebral infectionsProdromal phase: Vague changes in emotional reactivity or affective response precedingaura in some cases and lasting minutes to hoursPresence 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 2–5 min.Postictal phase: Patient sleeps 30 min to several hours, then may be weak,confused, and amnesic concerning the episode, with nausea and stiff, soremusclesMyoclonic: Short abrupt muscle contractions of arms, legs, torso; may not be symmetrical;lasts secondsClonic: Muscle contraction with relaxation resembling myoclonic movements but withslower repetitions; may last several minutesTonic: Abrupt increase in muscle tone of torso/face, flexion of arms, extension of legs;lasts secondsAtonic: Abrupt loss of muscle tone; lasts seconds; patient may fallAbsence (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 (repetitivemotor contractions), or atonic (loss of muscle tone). Postictal phase: Amnesiafor seizure events, no confusion, able to resume activityStatus epilepticus: Defined as 30 or more minutes of continuous generalized seizureactivity 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 doesnot lose consciousness
Partial seizures:
 Complex (psychomotor/temporal lobe): Patient generally remains conscious, withreactions 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 includeimpaired judgment and, on occasion, antisocial acts; lasts 1–3 min. Postictal phase: Absence of memory for these events, mild to moderate confusionSimple (focal-motor/Jacksonian): Often preceded by aura (may report deja vu or fearfulfeeling); 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 inorderly progression. If restrained during seizure, patient may exhibit combativeand uncooperative behavior; lasts seconds to minutes
PAIN/DISCOMFORT
 
May report:
Headache, muscle/back soreness postictallyParoxysmal abdominal pain during ictal phase (may occur during some partial/focalseizures without loss of consciousness)
May exhibit:
Guarding behavior Alteration in muscle toneDistraction behavior/restlessness
RESPIRATION
May exhibit:
Ictal: Clenched teeth, cyanosis, decreased or rapid respirations; increased mucoussecretionsPostictal: Apnea
SAFETY
May report:
History of accidental falls/injuries, fracturesPresence of allergies
May exhibit:
Soft-tissue injury/ecchymosisDecreased general strength/muscle tone
SOCIAL INTERACTION
May report:
Problems with interpersonal relationships within family/sociallyLimitation/avoidance of social contacts
TEACHING/LEARNING
May report:
Familial history of epilepsyDrug (including alcohol) use/misuseIncreased frequency of episodes/failure to improve
Discharge plan
DRG projected mean length of inpatient stay: 4.4 days
 considerations:
May require changes in medications, assistance with some homemaker/maintenance tasksrelative 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 tomedication 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 patientshave 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 seizureactivity (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 atsite of lesion.
 Single photon emission computed tomography (SPECT):
May show local areas of brain dysfunction when CT andMRI 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).

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