Unit 1: Seizures Flashcards
Seizure
- uncontrolled, sudden, excessive discharge of electrical activity
- manifestations range from behavior changes to loss of consciousness
Manifestations of a seizure
-can range from behavior changes to loss of consciousness
Cryptogenic Seizure
a seizure of unknown etiology
-no association w/ previous insults to the CNS that are known to increase risk of seizure activity
Cryptogenic
of unknown etiology
Possible causes of cryptogenic/unprovoked seizures
- Possible genetics affecting sodium channels
- Possible mutations affecting activity of the neurotransmitter GABA
Psychogenic Seizures
“psychiatric conversion disorder”
-have no abnormal electrical discharges
Epilepsy
- chronic disorder
- two seizures unprovoked by any immediately identifiable cause occurring more than 24 hours apart
Nonepileptic Seizures
- “secondary seizures”
- those provoked by other disorders and conditions
Causes of Provoked Nonepileptic Seizures
- Structural (lesions to the brain)
- Trauma
- Infection
- Surgery
- Tumors
- Stroke
- Inadequate oxygen to the brain
- metabolic (electrolyte disturbances)
- substance abuse
- prescription meds
- toxins
Types of Seizures
- Absence Seizure
- Atonic-Seizure
- Tonic-Clonic Seizure
- Myoclonic Seizure
Absence Seizures
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
Atonic Seizure
sudden loss of muscle tone: head, trunk, jaw, or limbs
-lasting 1-2 seconds
Tonic-clonic Seizures
sequence w/ muscle contraction (tonic) followed by repetitive muscle jerking (clonic)
Myoclonic Seizures
sudden involuntary contraction of muscle groups
-spasticity
Clinical Manifestations
- 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
Phases of a seizure
- pre-ictal
- ictal
- post-ictal
Pre-ictal Phase
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
Ictal Phase
actual seizure activity
Post-ictal Phase
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
Diagnosis of Seizures
- 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
Surgical Management
- Vagal Nerve Stimulator (VNS)
- Deep Brain Stimulation
- Remove offending brain tissue
Vagal Nerve Stimulator (VNS)
- 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
Deep Brain Stimulation
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
Partial Corpus Callostomy
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
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
Medical Management
- Antiepileptic Medications (AEDs) or Anticonvulsants (mainstay or therapy)
- Ketogenic Diet
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)
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
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
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)
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
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)
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
Ketogenic Diet
- high in fat (up to 90%)
- low in carbohydrates
- induces ketosis
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
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
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
Nursing Assessments
- Airway
- Vital Signs
- Seizure Activity
- Presence of Aura
Assessments: Airway
during the seizure and postictal state, the patient may have a compromised airway secondary to decreased level of consciousness
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
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
Assessments: Presence of Aura
may experience an aura in advance of a seizure, allowing patient to assume a safe position
Nursing Actions/Interventions
- Set up suction equipment at bedside
- Have oxygen available at bedside
- Safety Measures
- IV access
- Document Specifics of Seizure
Interventions: Set up suction
may be unable to protect their airway after seizure activity
-may require suctioning of the oral airway
Interventions: Have oxygen available
during the postictal phase, the pt may require supplemental oxygen to maintain the oxygen saturation within normal limits
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
Interventions: IV catheter per order
IV access may be needed to administer medications to stop the seizure activity
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
Nursing Teachings
- Medication Regimen
- Medic alert bracelet
- Driving Restrictions
