Epilepsy

Nursing care management

 What is Epilepsy?
A brain disorder characterized by an enduring predisposition to generate
epileptic seizures and by the neurobiological, cognitive, psychological, and
social consequences of this condition
It is one of the most frequent Central Nervous System (CNS) disorders and
for some the second neurological disease
It is currently considered by the International League Against Epilepsy
(ILAE) and the International Bureau for Epilepsy (IBE), as a disease and not
a disorder
 What is Epilepsy?
• It has been known since ancient times, by the name of ¨Morbo Sacro¨ or
¨Sacred Disease¨ and the ¨ataques¨ or epileptic seizures with the term
¨epilambaneim¨ which means ¨attack¨, ¨ surprise¨, ¨ seize of¨, or ¨ fall on
itself¨, from which derives the term through which it is currently known:
Epilepsy.
 What is Epilepsy?
One of the earliest descriptions of a secondary generalized tonic-clonic
seizure was recorded over 3000 years ago in Mesopotamia; the seizure was
attributed to the god of the moon.
Almost 2000 years Hippocrates first described it in his book "The Sacred
Disease“ he rejected ideas regarding the divine etiology of epilepsy and
concluded that the cause was excessive phlegm leading to abnormal brain
consistency.
 What is Epilepsy?
• It has been known since ancient times and is considered a modern disease.
• According to reports from the World Health Organization (WHO), an
estimated 50 to 69 million people suffer from this disease, the majority
living in developing countries, where the quality of life is worse and the
incidence of infections of the nervous system central nervous system
(CNS) is greater, and it can be asserted that epilepsy affects 1-2% of the
population
• International statistics show annual mortality rates of 2.1 per 100,000
inhabitants per year, varying from 1 to 8 in the different countries
 What is Epilepsy?
• A seizure is an abnormal, unregulated electrical discharge that occurs
within the brain’s cortical gray matter and transiently interrupts normal
brain function; a seizure typically causes altered awareness, abnormal
sensations, focal involuntary movements, or convulsions (widespread
violent involuntary contraction of voluntary muscles).
 ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology

Epilepsia, Volume: 58, Issue: 4, Pages: 512-521, First published: 08 March 2017, DOI: (10.1111/epi.13709)
Classification
Focal Onset
• The excess neuronal discharge
occurs in one cerebral cortex, and
most often results from structural
abnormalities; revised terminology
for partial seizures has been
proposed; in this system, partial
seizures are called focal seizures
 Classification of Seizure

Generalized Onset
• The aberrant electrical discharge
diffusely involves the entire cortex
of both hemispheres from the onset,
and consciousness is usually lost;
generalized seizures result most
often from metabolic disorders and
sometimes from genetic disorders.
 Classification of Seizure

Unknown Onset
• The aberrant electrical discharge
diffusely involves the entire cortex
of both hemispheres from the onset,
and consciousness is usually lost;
generalized seizures result most
often from metabolic disorders and
sometimes from genetic disorders.
 Epilepsy types : Generalized Epilepsy
• Absence/Petit Mal
• Myoclonic
• Atonic
• Tonic
• Tonic–clonic seizures
 Absence/Petit Mal

Typical Atypical
• Berhentinya aktivitas motoric secara tiba- • Gerakan seperti hentakan berulang
tiba yang bisa ditemukan pada wajah
• Kehilangan kesadaran sementara secara dan ekstremitas dan disertai
singkat,yang di sertai dengan tatapan dengan perubahan kesadaran.
kosong
• Sering tampak kedipan mata berulang saat
episode kejang terjadi. Episode kejang
terjadi kurang dari 30 detik
 Myoclonic
• Kejang yang ditandai dengan gerakan kepala seperti terjatuh secara tiba-tiba dan di
sertai dengan flexi
• Konstraksi otot tubuh cepat, sinkron , bilateral atau mengenai kelompok otot tertentu
• Biasanya terjadi pada pagi hari, setelah bangun tidur pasien mengalami sentakan
yang tiba tiba
• Bisa bersifat ringan, timbul gerakan tanpa diketahui orang lain
• Bersifat parah, hingga menyebabkan jatuh dan terluka
• Berkala, tiba tiba sampai tak terduga
Atonic Clonic
• Kehilangan tonus otot secara • Gerakan menyentak, berulang
mendadak pada kelompok otot
tertentu (otot leher seolah-olah
jatuh)
• Berlangsung sinkat, kesadaran
dapat hilang sesaat atau tidak
sama sekali
 Tonic-clonic seizure/ Grand mal
• Serangan terjadi secara tiba-tiba
• Jatuh sabil menjerit/berteriak/hilang kesadaran
• Pernafasan berhenti sejenak, tubuh kaku
• Urine keluar karena knostraksi tonik
• Membuka mata, tampak letih dan tertidur
• Tidak ingat apa yang terjadi dan nyeri kepala
• Mengalami fase aura sebelum terjadi serangan (sakit kepala/iritabilitas)
 Epilepsy type : Focal Epilepsies
(unifocal & multifocal)
• Focal aware seizures: the patient being fully aware of themself and their environment
throughout the seizure, even if immobile. If awareness is preserved, the seizure is a focal
aware seizure.
• Focal impaired awareness seizures: the patient being fully aware of them self and their
environment throughout the seizure, even if immobile
• Focal motor seizures: involves motor activity (movement) and may be due to either an
increase or decrease in contraction in a muscle or group of muscles.
• Focal non-motor seizures :sensory, cognitive, bahavioral & emotional
• Focal to bilateral tonic–clonic seizures: known as a 'secondary generalized seizure'.
Consciousness is impaired. Motor components in such a situation include tonic and
clonic features
 Epilepsy type : Combined Generalised
and Focal Epilepsies
• Have both generalized and focal seizures
 Pathophysiology
Secara umum patofisiologi epilepsi diakibatkan oleh tidak seimbangnya neuron eksitasi dan inhibisi.

• Eksitasi adalah alat atau proses tapi bukan substansi signaling (perangkat pensignalan), hanya
sebagai respon sel postsinaptik (sel penerima neurotransmitter) terhadap substansi pensignalan
tersebut.
• Inhibisi adalah aktivitas hiperpolarisasi (menjadi lebih polar) secara ionik untuk merubah
potensial transmembran dari keadaan ledakan treshold (ambang pembuka untuk eksitasi).

Eksitasi (berlebihan)
•Ion masuk -Na+, Ca2+
•Neurotransmitter yang berpengaruh glutamat, aspartat, asetilkolin

Inhibisi (kurang)
•Ion masuk -CI-, arus K+ keluar
•Neurotransmitter yang berpengaruh -GABA
 Etiology
• Genetic : Chromosome and Gene abnormalities (Chromosomal 22q deletion
or duplication syndromes, single -gene mutations: Autosomal dominant
nocturnal frontal lobe epilepsy is caused by mutations in the CHRNA4,
CHRNB2, or CHRNA2 genes; it is characterized by nocturnal motor seizures.
• Structural: Malformation of cortical development, vascular malformation,
tumour, traumatic brain injury
• Metabolic : hypoglycaemia or acidosis
• Immune
• Infectious
• Unknown : Febrile infection related epylepsi syndrome
 Phases
• The prodromal phase involves mood or behaviour 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.
 Clinical Manifestations

• Aura: An aura (unusual sensations) precedes seizures in about 20% of

people who have a seizure disorder.
• Short duration: Almost all seizures are relatively brief, lasting from a
few seconds to a few minutes; most seizures last 1 to 2 minutes.
• Postictal state: When a seizure stops, people may have a headache, sore
muscles, unusual sensations, confusion, and profound fatigue; these after-
effects are called the postictal state.
 Clinical Manifestations

• Todd paralysis: In some people, one side of the body is weak, and the
weakness lasts longer than the seizure (a disorder called Todd paralysis).
• Visual hallucinations: Visual hallucinations (seeing unformed images)
occur if the occipital lobe is affected.
• Convulsions: A convulsion (jerking and spasms of muscles throughout
the body) occur if large areas on both sides of the brain are affected.
 Assessment and Diagnostic Findings

• Prolactin study: To differentiate generalized tonic-clonic or complex

partial seizure from psychogenic nonepileptic seizure in adults and older
children.
• Serum studies of anticonvulsant agents: Judicious testing of serum levels
of antiepileptic drugs (AEDs) may help to improve the care for patients
with seizures and epilepsy
• Neuroimaging studies.: brain magnetic resonance imaging (MRI) or head
computed tomography (CT) scanning, may show structural abnormalities
that could be the cause of a seizure.
 Assessment and Diagnostic Findings

• Electroencephalography: Interictal epileptiform discharges or focal

abnormalities on electroencephalography (EEG) strengthen the diagnosis of
epileptic seizures and provide some help in determining the prognosis.
• Video- EEG: Video-EEG monitoring is the criterion standard for
classifying the type of seizure or syndrome or for diagnosing
pseudoseizures; that is, for establishing a definitive diagnosis of spells with
impairment of consciousness.
• 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).
 Medical Management

• Monotherapy: it decreases the likelihood of adverse effects and avoids

drug interactions & may be less expensive than polytherapy.
• Anticonvulsant therapy.
• Discontinuing anticonvulsant agents.
• Ketogenic diet. The ketogenic diet, which relies heavily on the use of fat,
such as hydrogenated vegetable oil shortening (e.g., Crisco), has a role in
the treatment of children with severe epilepsy;
 Medical Management

• Atkins diet: (low-carbohydrate :10g/day) diet that mimics the ketogenic

diet but does not restrict protein, calories.
• Vagal nerve stimulation: VNS is a palliative technique that involves
surgical implantation of a stimulating device
• Implantable neurostimulator:: a device that is implanted into the
cranium, senses, and records electrocorticographic patterns and delivers
short trains of current pulses to interrupt ictal discharges in the brain.
 Medical Management

• Lesionectomy: an operation to remove a lesion -- a damaged or

abnormally functioning area -- in the brain. Brain lesions include tumours,
scars from a head injury or infection, abnormal blood vessels, and
hematomas (a swollen area filled with blood
• Activity modification and restrictions: Driving, ascending heights,
working with fire or cooking, using power tools and other dangerous
equipment, taking unsupervised baths, and swimming.
• Long-term monitoring
 Pharmacologic Management

• Anticonvulsants, other. These agents prevent seizure recurrence and

terminate clinical and electrical seizure activity;
• Anticonvulsants, barbiturates. Like benzodiazepines, barbiturates bind
to the gamma-aminobutyric acid (GABA) receptor, enhancing the actions
of GABA by extending GABA-mediated chloride channel openings and
allowing neuronal hyperpolarization.
• Anticonvulsants, succinimide. These agents reduce current in T-type
calcium channels.
 Pharmacologic Management

• Anticonvulsants, neuronal potassium channel opener: Stabilizes

neuronal KCNQ (Kv7) channels in the open position, increasing the
stabilizing membrane current and preventing bursts of action potentials
during the sustained depolarizations associated with seizures
• Anticonvulsants, hydantoins: stabilize sodium channels and prevent the
return of the channels to the active state.
 Nursing Assessment

History Physical exam

• Keluhan utama
• Riwayat kesehatan masa lalu
• Riawayay kesehatan sekarang
• Riwayta kesehatan keluarga
• Vital Sign, 02 saturation
• LOC/ Tingkat kesadaran
• Type of seizures, duration
• The colouring of skin & mucous
membrane (Wajah dan bibir
tampak kebiruan)
 Nursing Diagnosis

• Risk for trauma or suffocation related to loss of large or small muscle

coordination
• Risk for ineffective airway clearance related to neuromuscular impairment.
• Situational low self-esteem related to stigma associated with the condition.
• Deficient knowledge related to information misinterpretation.
• Risk for injury related to weakness, balancing difficulties, cognitive
limitations or altered consciousness.
 Nursing Care Planning and Goals

• The patient or caregiver will verbalize understanding of factors that

contribute to the possibility of trauma and or suffocation and take steps to
correct the situation.
• The patient or caregiver will identify actions or measures to take when
seizure activity occurs.
• The patient or caregiver will identify and correct potential risk factors in
the environment.
 Nursing Care Planning and Goals
• The patient or caregiver will demonstrate behaviors to restore positive
self-esteem.
• The patient or caregiver will participate in treatment regimen or activities
to correct factors that precipitated a crisis.
• The patient or caregiver will verbalize understanding of the disorder and
various stimuli that may increase potentiate seizure activity.
 Nursing Care Planning and Goals

• The patient or caregiver will Demonstrate behaviours, lifestyle changes to reduce risk
factors and protect self from injury
• The patient or caregiver will Able to modify the environment as indicated to enhance safety.
• The patient or caregiver will maintain treatment regimen to control or eliminate seizure
activity
• The patient or caregiver will recognize the need for assistance to prevent accidents or
injuries.
• The patient or caregiver will maintain effective respiratory pattern with airway patent or
aspiration prevented.
 Nursing Interventions
(Prevent trauma/injury)

• Hindari dan jauhkan pasien dari penggunaan benda/alat yang mambahayakan:

Glass thermometer
• Berikan posisi yang nyaman
• Posisikan kepala kesamping pada saat melakukan suctioniong
• Persiapkan/posisikan Guedell canulle untuk menghindari injuri mukosa mulut
dan kerusakan gigi
• Catat gejala dan karakteristik tipe kejang, frekuensi kejang
• Kolaborasi: Obat /monitor efek samping/monitor keseimbangan elektrolit
 Nursing Interventions
(Promote airway clearance)

• Loosen clothing from neck or chest and abdominal areas

• Maintain in lying position, flat surface
• Suction as needed
• Remove teeth or other objects from the mouth
• Supervise supplemental oxygen or bag ventilation as needed
 Nursing Interventions
(Improve self-esteem)

• Encourage/anjurkan pasien untuk melakukan aktivitas

• Anjurkan pasien untuk mengungkapkan perasaanya
• Bantu pasien untuk menyadari bahwa perasaanya normal dan tidak merasa
bersalah
• Kaji dam monitor hal-hal yang dapat menigkatkan self-esteem
• Anjurkan pasien untuk bergabung dengan support group epilepsi
 Nursing Interventions
(Enforce education about the disease)

• Diskusikan fakto pencetus kejang (flashing lights, hyperventilation, loud

noises, video games, TV viewing)
• Ajarkan pasien tentang pentingnya personal hygiene (good oral hyegien
and regular dental care)
• Ajarkan pasien untuk mengkonsumsi obat secara teratur seuai anjuran
dokter
 Evaluation

Goals are met