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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. 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
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

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 2–5 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
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

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 secretions
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
considerations: 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
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).

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


1. seizures activity controlled.

2. complications/injury prevented.
3. capable/competent self-image displayed.
4. disease process/prognosis, therapeutic regimen, and limitations understood.
5. 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.


seizure precautions (nic)

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

seizure precautions (nic)

discuss seizure warning signs (if appropriate) and usual enables patient to protect self from injury and recognize
seizure pattern. teach so to recognize warning signs and changes that require notification of physician/further
how to care for patient during and after seizure. 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 minimizes injury should seizures (frequent/generalized)
place bed up against wall and pad floor if rails not occur while patient is in bed. note: most individuals seize
available/appropriate. 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 reduces risk of patient biting and breaking glass
temperature. thermometer or suffering injury if sudden seizure activity
should occur.

seizure management (nic)

maintain strict bedrest if prodromal signs/aura patient may feel restless/need to ambulate or even
experienced. explain necessity for these actions. 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 helps maintain airway and reduces risk of oral trauma but
bite block only if jaw relaxed. 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 gentle guiding of extremities reduces risk of physical
bed. do not attempt to restrain. 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 helps localize the cerebral area of involvement.
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., lip-
smacking, chewing, picking at clothes).

seizure management (nic)

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), documents postictal state and time/completeness of
pulse/respiratory rate. recovery to normal state. may identify additional safety
concerns to be addressed.
reorient patient following seizure activity.

patient may be confused, disoriented, and possibly

allow postictal “automatic” behavior without interfering amnesic after the seizure and need help to regain control
while providing environmental protection. and alleviate anxiety.

may display behavior (of motor or psychic origin) that

seems inappropriate/irrelevant for time and place.
investigate reports of pain. attempts to control or prevent activity may result in
patient becoming aggressive/combative.

may be result of repetitive muscle contractions or

observe for status epilepticus, i.e., one tonic-clonic symptom of injury incurred, requiring further
seizure after another in rapid succession. 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:
collaborative although absence seizures may become static, they are not
usually life-threatening.
administer medications as indicated:

specific drug therapy depends on seizure type, with some

antiepileptic drugs (aeds), e.g., phenytoin (dilantin), patients requiring polytherapy or frequent medication
primidone (mysoline), carbamazepine (tegretol), adjustments.
clonazepam (klonopin), valproic acid (depakene),
divalproex (depakote), acetazolamide (diamox), aeds raise the seizure threshold by stabilizing nerve cell
ethotoin (peganone), methsuximide (celotin), membranes, reducing the excitability of the neurons, or
fosphenytoin (cerebyx); 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.

seizure management (nic)

topiramate (topamax), ethosuximide (zarontin), adjunctive therapy for partial seizures or an alternative for
lamotrigine (lamictal), gabapentin (neurontin); 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

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

glucose, thiamine. may be given to restore metabolic balance if seizure is

induced by hypoglycemia or alcohol.

monitor/document aed drug levels, corresponding side standard therapeutic level may not be optimal for
effects, and frequency of seizure activity. individual patient if untoward side effects develop or
seizures are not controlled.

monitor cbc, electrolytes, glucose levels. identifies factors that aggravate/decrease seizure

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

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
desired outcomes/evaluation criteria—patient will:
respiratory status: ventilation (noc)
maintain effective respiratory pattern with airway patent/aspiration prevented.

airway management (nic)

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

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.

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
suction as needed. patient is unconscious and unable to maintain safe
position of tongue.

reduces risk of aspiration/asphyxiation. note: risk of

collaborative aspiration is low unless individual has eaten within the
last 40 min.
administer supplemental oxygen/bag ventilation as
needed postictally.

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,
prepare for/assist with intubation, if indicated. 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.


self-esteem enhancement (nic)

discuss feelings about diagnosis, perception of threat to reactions vary among individuals, and previous
self. encourage expression of feelings. 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. provides opportunity to problem-solve response, and
encourage patient to refrain from concealing problem. 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, participation in as many experiences as possible can
providing supervision/monitoring when indicated. 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 negative expectations from so may affect patient’s sense
realize that his/her feelings are normal; however, guilt and of competency/self-esteem and interfere with support
blame are not helpful. received from so, limiting potential for optimal
management/personal growth.

self-esteem enhancement (nic)

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

anxiety of caregivers is contagious and can be conveyed

refer patient/so to support group, e.g., epilepsy foundation to the patient, increasing/multiplying individual’s own
of america, national association of epilepsy centers, and negative perceptions of situation/self.
delta society’s national service dog center.
provides opportunity to gain information, support, and
ideas for dealing with problems from others who share
similar experiences. note: some service dogs have ability
discuss referral for psychotherapy with patient/so. 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.

teaching: disease process (nic)

review pathology/prognosis of condition and lifelong provides opportunity to clarify/dispel misconceptions and
need for treatments as indicated. discuss patient’s present condition as something that is manageable within
particular trigger factors (e.g., flashing lights, a normal lifestyle.
hyperventilation, loud noises,video games, tv viewing).

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, regularity and moderation in activities may aid in
e.g., adequate diet, rest, moderate exercise, and avoidance reducing/controlling precipitating factors, enhancing
of exhaustion, alcohol, caffeine, and stimulant drugs. 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 reduces risk of oral infections and gingival hyperplasia.
dental care.

identify necessity/promote acceptance of actual reduces risk of injury to self or others, especially if
limitations; discuss safety measures regarding driving, seizures occur without warning.
using mechanical equipment, climbing ladders,
swimming, and hobbies.

discuss local laws/restrictions pertaining to persons with although legal/civil rights of persons with epilepsy have
epilepsy/seizure disorder. encourage awareness but not improved during the past decade, restrictions still exist in
necessarily acceptance of these policies. 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 lack of cooperation with medication regimen is a leading
ordered, and not discontinuing therapy without physician cause of seizure breakthrough. patient needs to know risks
supervision. include directions for missed dose. 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,

recommend taking drugs with meals, if appropriate. nausea/vomiting.

may indicate need for change in dosage/choice of drug

discuss nuisance and adverse side effects of particular therapy. promotes involvement/participation in decision-
drugs, e.g., drowsiness, fatigue, lethargy, hyperactivity, making process and awareness of potential long-term
sleep disturbances, gingival hypertrophy, visual effects of drug therapy, and provides opportunity to
disturbances, nausea/vomiting, rashes, syncope/ataxia, minimize/prevent complications.
birth defects, aplastic anemia.

teaching: prescribed medication (nic)

provide information about potential drug interactions and
necessity of notifying other healthcare providers of drug
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
review proper use of diazepam rectal gel (diastat) with cause elevation of serum level of carbamazepine
patient and so/caregiver as appropriate. (tegretol), possibly to toxic levels.

useful in controlling serial or cluster seizures. can be

administered in any setting and is effective usually within
encourage patient to wear identification tag/bracelet 15 min. may reduce dependence on emergency
stating the presence of a seizure disorder. department visits.

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