NUR 317 - Seizure Disorders

Seizure

• Sudden and abnormal electrical discharge of neurons in brain, interrupting normal function

• May accompany other disorders or occur spontaneously without apparent cause

Seizure vs epilepsy

A seizure is a one time event while epilepsy is multiple seizures (aka seizure disorder)

Causes of seizure

• Systemic

  • Hypertension

  • Stroke epilepsy

  • Lupus

  • Pre-eclampsia

  • Brain infection

  • Brain tumor

  • Brain injury

• Metabolic

  • Acidosis

  • Electrolyte imbalances

    • Sodium, blood glucose

  • Hypoxemia

  • Substance use or withdrawal

  • Medications

  • Illicit drugs

  • Alcohol

  • Poisoning

  • Dehydration or water intoxication

  • Fever

Phases of seizures

• Prodromal phase

• Aural phase

• Ictal phase

  • Tonic phase

  • Clonic phase

• Postictal phase

  • Can last hours to days

Generalized seizures

• Seizures occur over both sides of the brain

• Awareness impaired a few seconds to several minutes

• 30% of people with epilepsy have generalized seizures

Tonic-clonic seizures

• Characterized by loss of consciousness and falling (if standing)

• Body stiffens (tonic) with subsequent jerking of extremities (clonic)

• Cyanosis, excessive salivation, incontinence, and tongue or cheek biting may occur

Generalized seizures postictal phase

• Muscle soreness, fatigue

• Patient may sleep for hours

• May not feel normal for hours to days

• No memory of seizure

Tonic seizures

• Sudden onset of increased tone in the extensor muscles

• Sudden stiff movements

• Most often occur in sleep

• Affects both sides of the body

• Patients will fall if they are standing

• Usually lasts less than 20 seconds

• Patient usually stays aware

Clonic seizures

• Begin with loss of awareness and sudden loss of muscle tone

• Rhythmic limb jerking, that may or may not be symmetric, follows

• Clonic seizures are rare

Atonic seizures

• Also called drop attack

• Involves sudden, brief loss of muscle tone

• Begins suddenly with the person falling to the ground

• Typically lasts less than 15 seconds

• Brief loss of consciousness and brief post-ictal confusion

• Great risk for head injury - often protective helmets are needed

Typical absence seizures

• Staring spell

• Person is usually unresponsive when spoken to

• Lasts only a few seconds

• Often goes unnoticed

• Multiple episodes per day when untreated

Atypical absence seizures

• Staring spell with other manifestations

• Eye blinking

• Jerking movements of the lips

• Often lasts more than 10 seconds (up to 30 seconds)

• Gradual beginning and end

• To adulthood

Focal seizures

(Formally called partial seizures or partial focal seizures)

• Seizures occur in one hemisphere of the brain

• Manifestations based on function of area of brain involved

• 60% of people with epilepsy have focal seizures

Motor focal seizures

• Atonic (loss of tone)

• Tonic (sustained stiffening)

• Clonic (rhythmic jerking)

• Myoclonic (irregular, rapid jerking)

• Some people show strange behavior - Lip smacking or other repetitive, purposeless actions (automatisms)

Non-motor focal seizures

• Emotional manifestations - fear or joy, strange feelings

• Racing heart

• Goose bumps

• Waves of heat or cold

Focal awareness

• Conscious, alert

• Unusual feelings or sensations

  • Sudden and unexplainable feelings of joy, anger, sadness, or nausea

  • May hear, smell, taste, see, or feel things that are not real

Focal impaired awareness

• Loss of consciousness or alteration in awareness

• Eyes remain open but cannot interact

  • May display strange behaviors

  • Automatisms

    • Ex. person counting money will continue counting, person walking will continue walking without awareness

  • Difficulty remembering recent actvity

• Lasts 1-2 minutes, but patient may be fatigued after and not return to activity for hours

Status epilepticus

• Continuous seizure activity or when seizures recur in rapid succession without return to consciousness between seizures

  • Neurons become exhausted and cease to function

  • Permanent brain damage can result

• Any seizure lasting > 5 minutes

• Neurologic emergency

Refractory status epilepticus

Continued activity despite 1st and 2nd line therapy

Nonconvulsive status epilepticus

Long or repeated focal impaired awareness seizures

Convulsive status epilepticus (CSE)

• Prolonged and repeated tonic-clonic or other motor seizures

• Can cause ventilatory insufficiency, hypoxemia, cardiac dysrhythmias, hyperthermia, and systemic acidosis

• Can be fatal

Complications of seizures

• Effect on lifestyle is most common complication of seizure disorder

  • Depression

  • Social stigma still exists

  • Ineffective coping

  • Discrimination

  • Driving sanctions

Diagnostic studies for seizures

• Comprehensive health history

  • Including accurate description of seizures

• EEG

  • May help determine type of seizure and pinpoint seizure focus

  • Many patients do not have abnormal findings

• Magnetoencephalography in conjunction with EEG

  • Greater sensitivity for detecting small magnetic fields generated by neuronal activity

• Other

  • CBC, serum chemistries, liver and kidney function

  • UA to rule out metabolic disorders

  • CT or MRI to rule out structural lesions

Seizure interprofessional care

• Most seizures

  • are self-limiting

  • rarely cause bodily injury

• Immediate medical care for:

  • Status epilepticus

  • Significant bodily harm

  • First-time seizure

• Seizure disorders are primarily treated with antiseizure drugs

  • Prevent seizures with minimal drug side effects

  • Cure is not possible

Seizure mediation therapy

• Medications stabilize nerve cell membranes and prevent spread of the epileptic discharge

• Initiate therapy with a single drug

• May need combination of drugs

  • Usually no more than 2 medications

• Therapeutic ranges are guides

• Newer drugs do not require serum drug levels

Seziure medication therapy patient teaching

Patients need to:

• Take medication(s) regulalry and continuously (often for life)

• Understand importance of following the specific drug regimen

• Know what to do if a dose is missed

Broad spectrum seizure medication therapy

• Gabapentin (Neurontin)

• Topiramate (Topamax)

• Lamotrigine (Lamictal)

• Tiagabine (Gabitril)

• Levetiracetam (Keppra)

• Zonisamide (Zonegran)

Pregabalin (Lyrica)

Additional treatment for focal seizures

Status epilepticus medication therapy

• Initially, rapid-acting IV lorazepam (Ativan) or diazapam (Valium)

• Followed by long-acting drugs

Primary drugs for treatment of generalized tonic-clonic seizures

• Phenytoin (Dilantin)

• Carbamazepine (Tegretol)

• Divalproex (Depakote)

Primary drugs for treatment of generalized non-motor and myoclonic seizures

• Ethosuximide (Zarontin)

• Divalproex (Depakote)

• Clonazepam (Klonopin)

Primary drugs for treatment of focal seizures

• Carbamazepine (Tegretol)

• Lamotrigine (Lamictal)

• Levetiracetam (Keppra)

Seizure medication side effects

Common side effects often involve the CNS and include:

• Diplopia

• Drowsiness

• Ataxia

• Mental slowing

Seizure medication therapy considerations

• Can medication be given 1-2X/day?

• Medications should be routinely reviewed and adjusted as needed

• If weaning is to occur the patient must:

  • be seizure free for a prolonged period (e.g. 2-5 yrs)

  • have a normal neurologic examination

  • have a normal EEG

Serizure gerontologic considerations

• Many experience a 1st single seizure

• More responsive to antiseizure drugs

• More likely to experience side effects at lower doses

  • Don’t excrete medications as well

• Medication sondierations

  • Do not give phenytoin in patients with liver issues

  • Carbamazepine increases bone and cognitive issues

Seizures surgical therapy

• Must have a defined site of origin

• Surgical resection of that area

• Laser ablation

• Radiosurgery

• Hemispherectomy (for severe cases)

Vagal nerve stimulation seizure therapy

• Adjunct to medications when surgery is not feasible

• Exact mechanism not known

• Thought to interrupt synchronization of epileptic brain-wave activity and stop excessive discharge of neurons

Seizure diet therapy

• Ketogenic diet has been effective in controlling seizures for some

  • High-fat, low carbohydrate diet

  • Ketones pass into the brain and replace glucose as an energy source

  • Equally effective in children and adults

Seizure nursing assessment - triggers

• Sleep deprivation

• Flashing lights

• Illness

• Dietary changes

• Certain medications

• Missed medications

• Specific foods (caffeine)

• Alcohol

• Etc

Seizure nursing assessment - prior to seizure

• Aura

• Mentation changes

• Abnormal behaviors

• Etc

Seizure nursing assessment - during seizure

• Onset of seizure

• Activity -

  • *body parts involved

  • *sequence of movement

  • *autonomic signs

• Etc

Seizure nursing assessment - after seizure

• Bitten tongue, soft tissue damage

• Abnormal respiratory rate

• Weakness, paralysis, ataxia (postictal)

• Absent or abnormal breath sounds

• Airway occlusion

• Incontinence

• Etc

Seizure patients hospital care

• Seizure pads on bed rails

• Bed rails up, bed in lowest position

• Resuscitation equipment at bedside

• Oxygen equipment at bedside

• Suction equipment at bedside

In event of a seizure:

• Observe, maintain patient safety and document

• Ensure ABC’s and Safety:

  • Maintain patent airway

  • Support head

  • Protect - turn to side, loosen constrictive clothing, ease to the floor

  • Do not restrain patient or place any objects in their mouth

Post-seizure care

• Ensure safety and continue assessments

  • Neuro assessments

  • Assess for injuries

• Allow for periods of rest and sleep

Seizure nursing interventions and care

• Emotional support and identification of coping mechanisms

• Does patient have a medical alert bracelet or ID card?

• Seizure response service dog

Seizure safety measures

• Wear helmet if risk for head injury

• Carpeting in home/on stairs

• Protective padding/cushions on sharp corners, handles, faucets, etc.

Seizure education

• Promote general health habits (diet, exercise)

• Instruct to avoid excessive alcohol, fatigue, and loss of sleep

• Assist to identify events or situations precipitating seizures and avoid if possible

• Education regarding prevention of recurring seizures

  • Adherence to medication, do not adjust dose without physician instruction

  • Keep routine appointments

  • Teach family members emergency management