Unit 1: Seizures Flashcards
1
Q
Seizure
A
- uncontrolled, sudden, excessive discharge of electrical activity
- manifestations range from behavior changes to loss of consciousness
2
Q
Manifestations of a seizure
A
-can range from behavior changes to loss of consciousness
3
Q
Cryptogenic Seizure
A
a seizure of unknown etiology
-no association w/ previous insults to the CNS that are known to increase risk of seizure activity
4
Q
Cryptogenic
A
of unknown etiology
5
Q
Possible causes of cryptogenic/unprovoked seizures
A
- Possible genetics affecting sodium channels
- Possible mutations affecting activity of the neurotransmitter GABA
6
Q
Psychogenic Seizures
A
“psychiatric conversion disorder”
-have no abnormal electrical discharges
7
Q
Epilepsy
A
- chronic disorder
- two seizures unprovoked by any immediately identifiable cause occurring more than 24 hours apart
8
Q
Nonepileptic Seizures
A
- “secondary seizures”
- those provoked by other disorders and conditions
9
Q
Causes of Provoked Nonepileptic Seizures
A
- Structural (lesions to the brain)
- Trauma
- Infection
- Surgery
- Tumors
- Stroke
- Inadequate oxygen to the brain
- metabolic (electrolyte disturbances)
- substance abuse
- prescription meds
- toxins
10
Q
Types of Seizures
A
- Absence Seizure
- Atonic-Seizure
- Tonic-Clonic Seizure
- Myoclonic Seizure
11
Q
Absence Seizures
A
sudden interruption of activities; may have a blank stare
- absence of activities
- sudden onset
- possibly a brief upward deviation of the eyes
- unresponsive when spoken to
- duration: few seconds to half a minute
- rapid recovery
- of generalized onset
12
Q
Atonic Seizure
A
sudden loss of muscle tone: head, trunk, jaw, or limbs
-lasting 1-2 seconds
13
Q
Tonic-clonic Seizures
A
sequence w/ muscle contraction (tonic) followed by repetitive muscle jerking (clonic)
14
Q
Myoclonic Seizures
A
sudden involuntary contraction of muscle groups
-spasticity
15
Q
Clinical Manifestations
A
- ranges from rhythmic jerking of all extremities and loss of consciousness (tonic-clonic) to episodes of apparent day dreaming (absence)
- unilateral, rhythmic muscle movements
- automatisms (repetitive unconscious movements; lip smacking, chewing, or swallowing)
- sudden loss of motor tone (atonic)
- incontinence
16
Q
Phases of a seizure
A
- pre-ictal
- ictal
- post-ictal
17
Q
Pre-ictal Phase
A
just before the initiation of a seizure
- experience an aura; sensory change prior to the seizure activity
- pleasant or unpleasant odors
- visualizations/hallucinations
- sense of “butterflies” in the stomach
- sense of Deja vu
- intense feeling a seizure is about to happen
18
Q
Ictal Phase
A
actual seizure activity
19
Q
Post-ictal Phase
A
period after seizure
- lasts 5 to 30 minutes
- altered state of consciousness
- drowsiness, confusion, disorientation, nausea, hypoxia, headache, and migraine
- recovery phase of seizure
- experience exhaustion and depression following seizure; taking 1 to 2 days for full recovery
- poor attention span; may have diminished short-term memory
20
Q
Diagnosis of Seizures
A
- via imaging (CT, MRI)
- laboratory work up to r/o causes (lesions, tumors, metabolic, and other disorders)
- EEG monitoring for abnormal electrical activity
- stress (found when deprived of sleep), causes an increase in cortical activity and is a key trigger for seizures
21
Q
Surgical Management
A
- Vagal Nerve Stimulator (VNS)
- Deep Brain Stimulation
- Remove offending brain tissue
22
Q
Vagal Nerve Stimulator (VNS)
A
- stimulation that is constant or activated by magnet for those that have an aura
- stimulation of the vagus nerve (CN X) can control seizure activity via alterations in the release of norepinephrine, increasing levels of GABA (inhibitory neurotransmitter), and/or by the inhibition of aberrant cortical activity in the reticular activating system
- generator implanted into a small “pouch” in the left chest below the clavicle
- access to the vagal nerve is established via incision in the neck
- generator either continuously stimulates the vagus nerve, or the patient carries a small hand-held magnet with which he can activate the program with the presence of an aura
- post-op or within 2-week period, generator is activated and programmed specifically to patient
23
Q
Deep Brain Stimulation
A
used to treat uncontrolled seizure activity
- implanting electrodes into the brain that release electrical impulses
- electrodes are placed in deep brain structures (thalamus, hippocampus, and internal capsule) and are programmed to activate when the seizure activity is sensed
24
Q
Partial Corpus Callostomy
A
removal of brain tissue that has been identified as containing a seizure focus through surgical excision or laser ablation
- for intractable seizures that have been localized to a specific area of the brain
- a craniotomy is performed and the connection between the R and L hemispheres of the brain is disrupted partially or totally severed
- procedure reduces the frequency and severity of the seizures b/c electrical activity can no longer spread from one hemisphere to the other
25
Pre-op for Partial Corpus Callostomy
-before procedure, patient evaluated in a dedicated epilepsy monitoring unit; w/ surgically placed EEG electrodes on the surface of the brain to specifically identify areas of the brain tissue involved in seizure activity
26
Medical Management
- Antiepileptic Medications (AEDs) or Anticonvulsants (mainstay or therapy)
- Ketogenic Diet
27
Antiepileptic or Anticonvulsant Medications
- almost always provide complete control of seizures
- never should be abruptly stopped; can precipitate status epilepticus
- all suppress CNS
- Carbamazepine (Tegretol)
- Gabapentin (Neurontin)
- Lamotrigine (Lamictal)
- Levetiracetam (Keppra)
- Phenytoin (Dilantin)
- Valproate (Valproic Acid, Depakote)
28
Carbamazepine (Tegretol)
- control of seizures
- decrease incidence of seizures
- Side Effects: hepatitis, aplastic anemia (body stops producing enough new blood cells), allergy, dizziness, ataxia (impaired balance, coordination), blurred/double vision, nausea, and behavioral changes
- Interventions: monitor for visual changes, monitor liver function, CBC, do not crush or chew sustained-release capsules
29
Gabapentin (Neurontin)
- control of seizures
- decrease incidence of seizures
- Side Effect: somnolence, fatigue, dizziness, ataxia (impaired balance, coordination), weight gain
- Interventions: monitor for increased appetite and weight gain; monitor for dizziness, ataxia
30
Lamotrigine (Lamictal)
- control of seizures
- decrease incidence of seizures
- for absence, tonic-clonic, myoclonic seizures
- Side Effect: somnolence, dizziness, nausea, rash
- Interventions: monitor for dizziness, nausea/vomiting; rash can be life-threatening when given w/ valproic acid (depakote)
31
Levetiracetam (Keppra)
- control of seizure
- decrease incidence and severity of seizure
- tonic-clonic
- Side Effect: fatigue, ataxia, loss of appetite, cough/runny nose
- Interventions: monitor for ataxia, monitor for loss of appetite
32
Phenytoin (Dilantin)
-control of seizure
-diminished seizure activity
-treatment/prevention of tonic-clonic
-Side Effects: gingival hyperplasia, nystagmus, hirsutism, myelosuppression, ataxia, rash, folate deficiency, drug-induced lupus
-Interventions:
>serum levels monitored
>total serum levels 10-20 mcg/ml
>Dilantin (free) levels: 90% bound to protein (1-2 mcg/ml)
>at high doses can develop nystagmus
>increases levels and prolongs half-life of coumadin
>monitor CBC
>monitor for gingival hyperplasia (care w/ teeth brushing)
33
Valproate/Valproic Acid (Depakote)
- control of seizures
- suppression of seizure activity
- absence, myoclonic, tonic-clonic
- Side effects: tremors, hair loss, elevated liver enzymes, liver failure, pancreatitis, amenorrhea, thrombocytopenia (low platelets)
- Interventions: monitor for tremor, monitor for hair loss, monitor liver function, monitor CBC, monitor coagulation
34
Ketogenic Diet
- high in fat (up to 90%)
- low in carbohydrates
- induces ketosis
35
Complication: Status Epilepticus
seizure activity lasting longer than 5 minutes, or two or more seizures w/o full recovery of consciousness
- seizures lasting longer than 30 minutes can cause respiratory failure, brain damage, and death
- causes: head trauma, hydrocephalus, acute drug or alcohol withdrawal, metabolic disturbances, or abrupt withdrawal of anticonvulsive medications
- Airway, breathing, circulation (ABC) interventions must be initiated immediately
- pts are intubated, and ABGs monitored
- establish peripheral IV
- Lorazepam (Ativan) or Midazolam (Versed) both benzodiazepines are first line in immediate tx of seizure
- to stabilize the patient, a loading dose of phenytoin (Dilantin) or Levetiracetam (Keppra) (anticonvulsants) is administered along w/ around the clock dosing
- when refractory to all interventions, patient placed on high doses of Propofol (Diprivan) or placed in a pentobarbital coma; monitoring of cardiovascular status and continuous EEG monitoring
36
Nursing Management: Assessment + Analysis
clinical manifestations of seizures vary depending on the etiology of the disorder and the area of brain involved
- tonic movement
- clonic movements
- loss of consciousness (LOC)
- aura
- automatisms (lip smacking, chewing)
- loss of motor tone
37
Nursing Diagnoses
- Risk for ineffective breathing pattern r/t decreased LOC secondary to the postictal state
- Risk for injury r/t tonic-clonic motor activity
- Ineffective coping r/t uncertainty and inability to control seizures
38
Nursing Assessments
- Airway
- Vital Signs
- Seizure Activity
- Presence of Aura
39
Assessments: Airway
during the seizure and postictal state, the patient may have a compromised airway secondary to decreased level of consciousness
40
Assessments: Vital Signs
- BP, HR, and Oxygen saturation monitored during and after seizure
- elevations in HR and BP may develop during the seizure
- respiratory changes including airway compromise may develop after seizure
41
Assessments: Seizure Activity
observe start of movements & activity before, during, and after seizure
- observe type of movements
- time the seizure
- accurately diagnose and treat seizure
42
Assessments: Presence of Aura
may experience an aura in advance of a seizure, allowing patient to assume a safe position
43
Nursing Actions/Interventions
- Set up suction equipment at bedside
- Have oxygen available at bedside
- Safety Measures
- IV access
- Document Specifics of Seizure
44
Interventions: Set up suction
may be unable to protect their airway after seizure activity
| -may require suctioning of the oral airway
45
Interventions: Have oxygen available
during the postictal phase, the pt may require supplemental oxygen to maintain the oxygen saturation within normal limits
46
Interventions: Safety Measures
- bed in lowest position, suction at bedside, oral airway at bedside
- not forcing any object into the mouth (for fear of biting tongue, breaking teeth, causing injury etc.)
- loosening of restrictive clothing
- turn patient to the side (left; reduce risk of aspiration)
- do not restrain patients movement; can guide movement to prevent injury
47
Interventions: IV catheter per order
IV access may be needed to administer medications to stop the seizure activity
48
Interventions: Document Specifics of Seizure; Observed seizure activity
- documentation should provide the date, time, and duration
- clear description of seizure
- sequence of seizure progression
- preictal and postictal observations
49
Nursing Teachings
- Medication Regimen
- Medic alert bracelet
- Driving Restrictions
