SEIZURE DISORDERS

On completion of this chapter, the learner will be able to:

1- Explain the various types and causes of seizures and
develop a plan
2- Apply the nursing process for a patient with epilepsy
Seizures are episodes of abnormal motor, sensory, autonomic, or psychic
activity (or a combination of these) that result from sudden
excessivedischarge from cerebral neurons. The International League
Against Epilepsy (ILAE) has defined epilepsy as at least two unprovoked
seizures occurringmore than 24 hours apart. The ILAE differentiates
between three main seizure types:
1.Generalized seizures occur in and rapidly engage bilaterally distributed
networks.
2.Focal seizures are thought to originate within one hemisphere in the
brain.
3. The unknown type includes epileptic spasms.
Seizures may also be characterized as “provoked,” or related to acute,
reversible conditions such as structural, metabolic, immune, infectious or
unknown etiologies.
Pathophysiology
The underlying cause is an electrical disturbance (dysrhythmia) in thenerve
cells in one section of the brain; these cells emit abnormal, recurring,
uncontrolled electrical discharges. Associated with loss of consciousness,
excess movement or loss of muscle tone or movement, and disturbances of
behavior, mood, sensation, and perception may also occur.
Causes of seizures include:
Cerebrovascular disease
Hypoxemia of any cause, including vascular insufficiency
Fever (childhood) , Head injury & Hypertension
CNS infections, Metabolic and toxic conditions (e.g.,
kidney injury, hyponatremia,hypocalcemia,
hypoglycemia, pesticide exposure)
Brain tumor, Drug and alcohol withdrawal and Allergies
Clinical Manifestations
Depending on the location of the discharging neurons, seizures may range
from a simple staring episode (generalized absence seizure) to prolonged
convulsive movements with loss of consciousness.
The initial pattern of the seizures indicates the region of the brain in which
the seizure originates
Assessment and Diagnostic Findings
The diagnostic assessment is aimed at determining the type of seizures, their
frequency and severity, and the factors that precipitate them.
History:
- Developmental history is taken, including events of pregnancy and
childbirth, to seek evidence of pre-existing injury.
- The patient is alsoquestioned about illnesses or head injuries that may
have affected thebrain.
Physical examination: neurologic evaluations
Laboratory examination: include biochemical, hematologic, and serologic
studies.
Diagnostic examinations: MRI is used to detect structural lesions
Diagnostic procedure: The EEG assists in classifying the type of seizure.
Nursing Management
During a Seizure
A major responsibility of the nurse is to observe and record the sequence
of signs. The nature of the seizure usually indicates the type of treatment
required. Before and during a seizure, the patient is assessed and the
following items are documented:
1. Circumstances before the seizure (visual, auditory, or olfactory stimuli;
tactile stimuli; emotional or psychological disturbances; sleep;
hyperventilation)
2. Occurrence of an aura (a premonitory or warning sensation, which can
be visual, auditory, or olfactory)
3. First thing the patient does in the seizure—where the movements or the
stiffness begins, conjugate gaze position, and the position of the head at
the beginning of the seizure.
Note: This information gives clues to the location of the seizure origin in
the brain.
4. Type of movements in the part of the body involved
 5. Areas of the body involved (turn back bedding to expose patient)
6. Size of both pupils and whether the eyes are open
7. Whether the eyes or head are turned to one side
8. Presence or absence of automatisms (involuntary motor activity,
such as lip smacking or repeated swallowing)
9. Incontinence of urine or stool Duration of each phase of the seizure
10. Unconsciousness, if present, and its duration
11. Any obvious paralysis or weakness of arms or legs after the
seizure
12. Inability to speak after the seizure
13. Movements at the end of the seizure
14. Whether or not the patient sleeps afterward
15. Cognitive status (confused or not confused) after the seizure
In addition to providing data about the seizure, nursing care is directed
at preventing injury and supporting the patient, not only physically but also
psychologically. Consequences such as anxiety, embarrassment, fatigue,
and depression can be devastating to the patient.
After a Seizure
1. After seizure, document the events leading to and occurring during and
after the seizure and prevent complications (e.g., aspiration, injury).
Note: hypoxia, vomiting, and pulmonary aspiration are common after
seizure
2. To prevent complications, the patient is placed in the side-lying position
to facilitate drainage of oral secretions
3. Suctioning is performed, if needed, to maintain a patent airway and
prevent aspiration.
4. Seizure precautions are maintained
 The Epilepsies
Epilepsy is a group of syndromes characterized by unprovoked, recurring
seizures. Epileptic syndromes are classified by specific patterns of clinical
features, including age at onset, family history, and seizure type. Epilepsy
can be primary (idiopathic) or secondary(when the cause is known such as
a brain tumor).hart 66-4

Care of the Patient During and After epilepsy

Care during epileptic attack

1. Provide privacy, and protect the patient from curious onlookers. (The
patient who has an aura may have time to seek a safe, private place.) Ease
the patient to the floor, if possible.
2. Protect the head with a pad to prevent injury (from striking a hard
surface).
3. Loosen constrictive clothing and remove eyeglasses.
4. Push aside any furniture that may injure the patient during the seizure.
If the patient is in bed, remove pillows and raise side rails.
5. Do not attempt to pry open jaws that are clenched in a spasm or
attempt to insert anything in the mouth during a seizure. Broken teeth
and injury to the lips and tongue may result from such an action.
6. Do not attempt to restrain the patient during the seizure, because
muscular contractions are strong and restraint can produce injury.
7. If possible, place the patient on one side with head flexed forward,
which allows the tongue to fall forward and facilitates drainage of
saliva and mucus.
8. If suction is available, use it if necessary to clearsecretions.
Nursing Care After the epileptic attack
1. Keep the patient on one side to prevent aspiration.
2. Make sure the airway is patent.
3. On awakening, reorient the patient to the environment.
4. If the patient is confused or wandering, guide the patient gently to abed
or chair.
5. If the patient becomes agitated after a seizure (postictal), stay a
distance away, but close enough to prevent injury until the patient is
fully aware.
 Adapted from American Association of Neuroscience Nurses (AANN). (2016a). Care
of adults and children with seizures and epilepsy: AANN clinical practice guideline
series. Chicago, IL: Author.

Prevention
Society-wide efforts are the key to prevention of epilepsy. Head injury is
one of the main causes of epilepsy that can be prevented. Through highway
safety programs and occupational safety precautions, lives can besaved and
epilepsy due to head injury prevented.
Medical Management
The management of epilepsy is individualized to meet the needs of each
patient and not just to manage and prevent seizures. Management differs
from patient to patient, because some forms of epilepsy arise from brain
damage and others result from altered brain chemistry.
Pharmacologic Therapy
Many medications are available to control seizures. The objective is to
achieve seizure control with minimal side effects. Medication therapy
controls—ratherthan cures—seizures. Medications are selected on the basis
of the type of seizure being treated and the effectiveness and safety of the
medications. If properly prescribed and taken, medications control seizures
in 70% to 80%of patients with seizures.

Table 66-4 lists select anticonvulsant medications.

Select Anticonvulsant Medications

TABLE 66-4

The medication levels in the blood are monitored, because the rate of drug
absorption varies among patients. The manifestations of drug toxicity are
variable, and any organ system may be involved. For example, gingival
hyperplasia can be associated with long-term use of phenytoin. Periodic
physical and dental examinations and laboratory tests are performed for
patients receiving this medicine.
Surgical Management
Surgery is indicated for patients whose epilepsy results from intracranial
tumors, abscesses, cysts, or vascular anomalies. Some patients have
intractable seizure disorders that do not respond to medication.
 When seizures are refractory to medication in adolescents and adults with
focal seizures, a vagal nerve stimulator (VNS) may be implanted under the
clavicle. The device is connected to the vagus nerve in the cervical area,
where it delivers electrical signals to the brain to control and reduce seizure
activity.
Another surgical option for patients with refractory seizure activity is the
responsive neurostimulation system (RNS). This is a surgically implanted
device withelectrodes that sense and record brain electrical activity. The
RNS works by interrupting brainwave activity before a clinical seizure can
occur

vagal nerve stimulator

R.L. has epilepsy, uses a

demonstration neurostimulator
device to show the location of
the apparatus implanted in his
skull.
 NURSING PROCESS
The Patient with Epilepsy
Assessment
The patient is asked about the factors or events that may precipitate the
seizures. The nurse determines whetherthe patient has an aura before an
epileptic seizure, which may indicate theorigin of the seizure (e.g., seeing
a flashing light may indicate that the seizure originated in the occipital
lobe). Observation and assessmentduring and after a seizure. The effects
of epilepsy on the patient’s lifestyle are assessed. What limitations are
imposed by the seizure disorder? Does the patient participate in any
recreational activities? Have any social contacts? Is the patient working,
and is it a positive or stressful experience? What coping mechanisms are
used? in addition to patient`s knowledge about epilepsy and its treatment
regimen.

NURSING DIAGNOSES
Based on the assessment data, major nursing diagnoses may include the
following:
Risk for injury related to seizure activity
Fear related to the possibility of seizures
Ineffective individual coping related to stresses imposed by epilepsy
Deficient knowledge related to epilepsy and anticonvulsant
medications
COLLABORATIVE PROBLEMS/POTENTIAL
COMPLICATIONS
The major potential complications for patients with epilepsy are status
epilepticus and medication side effects (toxicity).
Planning and Goals
The major goals for the patient may include:
1. Prevention of injury
2. Control of seizures
3. Achievement of a satisfactory psychosocial adjustment,
4. Acquisition of knowledge and understanding about the condition
5. And absence of complications.
Nursing Interventions
1- PREVENTING INJURY
Injury prevention for the patient with seizures is a priority. Patients for
whom seizure precautions are instituted should have pads applied to the
side rails while in bed.
2- REDUCING FEAR OF SEIZURES
Fear that a seizure may occur unexpectedly can be reduced by the patient’s
adherence to the prescribed treatment regimen. Cooperation of the patient
and family and their trust in the prescribed regimen are essential for control
of seizures. The nurse emphasizes that the prescribed anticonvulsant
medication must be taken on a continuing basis and that drug dependence
or addiction does not occur.
In an effort to control seizures, factors that may precipitate them are
identified.

3- IMPROVING COPING MECHANISMS

Epilepsy may be accompanied by feelings of stigmatization, alienation,
depression, and uncertainty. The patient must cope with the constant fear
of a seizure and the psychological consequences
4- PROVIDING PATIENT AND FAMILY EDUCATION
Ongoing education and encouragement should be given to patients to
enable them to overcome any problems associated with epilepsy. he
patient with epilepsy should carry an emergency medical identification
card or wear a medical information bracelet. The patient and family need
to be educated about medications as well as care duringa seizure.
5- MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
Status epilepticus is the major potential complication of epilepsy.The
patient and family are instructed about side effects and are given specific
guidelines to assess and report signs and symptoms that indicate
medication overdose.
 Quality and Safety Nursing Alert
Patients with epilepsy are at risk for status epilepticus from having
their medication regimen interrupted.

6- PROMOTING HOME, COMMUNITY-BASED, AND

TRANSITIONAL CARE
Educating Patients About Self-Care. Thorough oral hygiene after each
meal, gum massage, daily flossing, and regular dental care areessential to
prevent or control gingival hyperplasia in patients receiving phenytoin.
The patient is also educated to inform all health care providers of the
medication being taken, because of the possibility of drug interactions.
Written patient education materials must be appropriate for the patient’s
reading level and must be provided in alternative formats if warranted.
Continuing and Transitional Care. Because epilepsy can be lifelong,
health promotion is important.
Evaluation
Expected patient outcomes may include:
1. Sustains no injury during seizure activity
a. Adheres to treatment regimen and identifies the hazards of stopping
the medication
b. Can identify appropriate care during seizure; caregivers can do so
as well
2. Indicates a decrease in fear
3. Displays effective individual coping
4. Exhibits knowledge and understanding of epilepsy
a. Identifies the side effects of medications
b. Avoids factors or situations that may precipitate seizures (e.g.,
flickering lights, hyperventilation, alcohol)
c. Follows a healthy lifestyle by getting adequate sleep and eating
meals at regular times to avoid hypoglycemia
5. Absence of complications
66-6 HEALTH PROMOTION
Strategies for the Patient with Epilepsy
1- Take anticonvulsant medications daily as prescribed to keep the drug
 level constant to prevent seizures. Never discontinue medications,
even if there is no seizure activity.
2- Keep a medication and seizure record (in electronic or paper format),
noting when medications are taken and any seizure activity.
3- Notify the primary provider if unable to take medications due to
illness.
4- Have anticonvulsant medication serum levels checked regularly.
When testing is prescribed, report to the laboratory for blood
samplingbefore taking morning medication.
5- Avoid activities that require alertness and coordination (driving,
operating machinery) until after the effects of the medication have
been evaluated.
6- Report signs of toxicity so that dosage can be adjusted. Common signs
include drowsiness, lethargy, dizziness, difficulty walking,
hyperactivity, confusion, inappropriate sleep, and visual disturbances.
Avoid over-the-counter medications unless approved by the primary
provider.
7- Carry a medical alert bracelet or identification card specifying thename
of the anticonvulsant medication and primary provider.
8- Avoid seizure triggers, such as alcoholic beverages, electrical
shocks,stress, caffeine, constipation, fever, hyperventilation, and
hypoglycemia.
9- Take showers rather than tub baths to avoid drowning if seizure
occurs; never swim alone.
10- Exercise in moderation in a temperature-controlled environment to
avoid excessive heat.
11- Develop regular sleep patterns to minimize fatigue and insomnia.
Be aware of and use the Epilepsy Foundation of America (EFA)
special services, including help in obtaining medications,
vocational rehabilitation, and coping with epilepsy.

Status Epilepticus
Status epilepticus (acute prolonged seizure activity) is a series of
generalized seizures that occur without full recovery of consciousness
between attacks. The term has been broadened to include continuous
clinical or electrical seizures (on EEG) lasting at least 30 minutes, even
without impairment of consciousness. It is considered a medical emergency.
Status epilepticus produces cumulative effects such as respiratory arrest,
fatal brain damage due to repeated episodes of cerebral anoxia and edema.
Factors that precipitate status epilepticus include interruption of
anticonvulsant medication, fever, concurrent infection, or other illness.
Medical Management
The goals of treatment are to stop the seizures as quickly as possible, to
ensure adequate cerebral oxygenation, and to maintain the patient in a
seizure-free state.
An airway and adequate oxygenation are established. If the patient remains
unconscious and unresponsive, an endotracheal tube is inserted. IV
diazepam (Valium), lorazepam (Ativan), or fosphenytoin is given slowly in
an attempt to halt seizures immediately. Other medications (phenytoin,
phenobarbital) are given later to maintain a seizure-free state.
Vital signs and neurologic signs are monitored on a continuing basis. If
initial treatment is unsuccessful, general anesthesia with a short-acting
barbiturate may be used.
Nursing Management
1- The nurse initiates ongoing assessment and monitoring of respiratory
and cardiac function because of the risk for delayed depression of
respiration and blood pressure secondary to administration of
anticonvulsant medications and sedatives to halt the seizures.
2- Nursing assessment also includes monitoring and documenting the
seizure activity and the patient’s responsiveness.
3- The patient is turned to a side-lying position, if possible, to assist in
draining pharyngeal secretions.
4- Suction equipment must be available because of the risk of aspiration.
5- The IV line is closely monitored, because it may become dislodged
during seizures.
6- A person who has received long-term anticonvulsant therapy has a
significant risk for fractures resulting from bone disease (osteoporosis,
osteomalacia, and hyperparathyroidism), which is a side effect of.
Therefore, during seizures, the patient is protected from injury with the
use of seizure precautions and is monitored closely.
7- The patient having seizures can inadvertently injure nearby people, so
nurses should protect themselves.