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Key Neurochemicals

  • Serotonin: Regulates mood, appetite, sleep, and arousal.
    • Low levels are associated with depression and anxiety.
    • SSRIs target serotonin.
  • Dopamine: Responsible for pleasure, motivation, and reward.
    • Linked to schizophrenia, bipolar disorder, and addiction.
  • Norepinephrine: Affects alertness, arousal, and stress response.
    • Low levels are associated with depression and anxiety.
  • GABA (Gamma Aminobutyric Acid): Calms nervous activity.
    • Lack of GABA may manifest as anxiety or seizures.
  • Glutamate: Involved in learning and memory.
    • Deficiencies are linked to Alzheimer's and dementia.
  • Acetylcholine: Involved in memory, learning and parasympathetic nervous system

Cholinergic vs. Anticholinergic Medications

  • Cholinergic:
    • Activate the parasympathetic nervous system (rest and digest).
    • Associated with being "wet and slow".
    • Increase secretions (salivation, lacrimation, urination, diarrhea, vomiting).
    • Cholinergic crisis: bradycardia, muscle weakness, slow respirations.
  • Anticholinergic:
    • Block acetylcholine, inhibiting the fight or flight system.
    • Associated with being "dry and fast".
    • Mnemonic: "Can't see, can't pee, can't spit, can't poop."
      • Blurry vision (dry eyes).
      • Urinary retention.
      • Dry mouth.
      • Constipation.
    • Increased heart rate.
    • Often disastrous in elderly populations due to impaired metabolism.

Seizures

  • Uncontrolled burst of electrical activity in the brain, causing changes in behavior, sensation, or consciousness.
  • Types:
    • Focal (partial): Occur in one part of the brain.
    • Generalized: Occur all over the brain; more severe symptoms.
    • Tonic-clonic (grand mal): Muscle stiffening followed by rhythmic jerking; loss of consciousness, foaming at the mouth.
    • Absence: Staring into the distance, unresponsiveness.
  • Status Epilepticus:
    • Seizure lasting more than five minutes.
    • Emergent situation due to risk of brain damage or death.

Nursing Actions During a Seizure

  • Note the time the seizure starts.
  • Call a code/rapid response.
  • Lower the patient to the floor, clear the area, and protect from injury.
  • Turn the patient on their side to maintain airway and prevent aspiration.
  • Do not leave patient's side.

Seizure Medications

  • Goal: Prevent or reduce seizure frequency and severity.
  • Do not cure epilepsy.
  • Common side effects: Drowsiness and sedation.
  • Patient teaching:
    • Take medications exactly as prescribed, at the same time each day.
    • Never suddenly stop taking seizure medications (can lead to status epilepticus).
    • Avoid driving and operating heavy machinery.
    • Wear a medical alert bracelet.
    • Avoid alcohol and other CNS depressants.

Phenytoin (Dilantin)

  • Class: Hydantoins.
  • Affects sodium influx in neurons to prevent misfiring.
  • Used for tonic-clonic, partial seizures, and status epilepticus.
  • Therapeutic range: 10−2010-20 mcg/mL.
    • Toxicity symptoms (over 20): Nystagmus, confusion, and ataxia.
  • Side effects:
    • Gingival hyperplasia (swollen, painful gums).
    • Drowsiness and dizziness.
    • Rash or unwanted hair growth (hirsutism).
    • Decreased bone health and folic acid depletion with long-term use.
  • Patient Teaching:
    • Perform frequent oral care.
    • Report changes in speech, confusion, or rash.
    • Use non-hormonal birth control (interferes with oral contraceptive effectiveness).

Barbiturates

  • Enhance GABA activity (calming effect).
  • Very sedating; be concerned about oversedation and respiratory depression.
  • Used for severe seizures (tonic-clonic, status epilepticus).
  • Therapeutic range: 15−4015-40 mcg/mL (monitor for toxicity).
  • Side effects:
    • Confusion, respiratory depression, and ataxia.
    • Low blood pressure.
    • Dependency with long-term use.
  • Nursing Considerations:
    • Closely monitor breathing and prevent falls.
    • Avoid administering with other CNS depressants (alcohol).

Benzodiazepines (e.g., Lorazepam, Diazepam)

  • Used for emergency management of status epilepticus.
  • Lorazepam (Ativan): IV, takes about five minutes to take effect.
  • Diazepam (Valium): IV, takes one to three minutes to take effect.
  • Calm and slow down the system to stop neuronal firing.
  • Also used for alcohol withdrawal and anxiety.
  • Nursing Considerations:
    • Monitor for respiratory depression and sedation.
    • Not for long-term use due to risk of dependence.

Valproic Acid (Depakote)

  • Used for tonic-clonic, absence, mixed seizures, bipolar disorder, and migraine prophylaxis.
  • Can be hepatotoxic (monitor liver function).
  • Highly teratogenic (use contraception).
  • Patient Teaching:
    • Take with food to reduce GI upset.
    • Report signs of bleeding or liver problems (yellowing of skin/eyes, fatigue, abdominal pain).
    • Get routine blood draws.

Stevens-Johnson Syndrome (SJS)

  • Life-threatening skin reaction causing blisters and sloughing of skin and mucous membranes.
  • Caused by certain medications, especially some anticonvulsants (Tegretol/carbamazepine).
  • Early symptoms: Flu-like fever, sore throat, fatigue, painful red rash.
  • Progresses to skin detachment and mucous membrane involvement.
  • Requires immediate discontinuation of the medication and hospitalization.
  • Treatment similar to burn patients (wound care, pain management, fluids).

Carbamazepine (Tegretol)

  • Associated with Stevens-Johnson Syndrome (SJS) and aplastic anemia (bone marrow suppression).
  • Side effects: Drowsiness, dizziness, nausea, vomiting.
  • Avoid grapefruit juice.
  • Patient Teaching:
    • Immediately report any rash.
    • Increased risk of infection and bleeding due to bone marrow suppression.

Levetiracetam (Keppra)

  • Newer anticonvulsant with fewer side effects.
  • Monitor renal function in patients with kidney problems.
  • May cause mood swings.
  • Teach consistent dosing.

Gabapentin

  • Adjunct therapy for seizures and treatment of nerve pain (diabetic neuropathy, neuralgia).
  • Modulates calcium channels and inhibits excitatory neurotransmitter releases.
  • Side effects: Sedation, dizziness, fatigue, peripheral edema.
  • Potential for misuse and dependency; taper off gradually to avoid withdrawal seizures.
  • Take in the evening due to sedating effects.