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Module Two: Recognition and Care
of Seizures and Emergencies
There is an option for the participant to listen to audio synced
to PowerPoint presentation, along with the option to
download the modules in PDF format
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Objectives of ModuleTwo:
Upon completion of Module Two-the participant will:
Recognize
seizures.
generalized and partial types of
Demonstrate
Identify
situation.
basic first aid for seizure types.
when a seizure may become an emergency
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Types of Seizures
 Generalized
 Involves
the whole
brain from the onset
 Types:
 Absence
 Myoclonic
 Clonic
(also called
localization related, focal)
 Begins in one side of
brain
 Can spread to other
side
 Types:
 Simple
 Tonic
 Tonic-clonic
 Atonic
 Partial
(drop attack)
partial
 Complex partial
 Secondary generalized
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Revised Terminology and Concepts for
Classification of Seizures/Epilepsies
 Generalized
and focal seizures redefined
 Generalized: “occurring
in and rapidly
engaging bilaterally distributed networks”
 Focal
(partial): occurring “within networks
limited to one hemisphere and either discretely
localized or more widely distributed”
 Types
of generalized seizures simplified, while
focal seizures described in relation to
manifestations
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Parts of a Seizure
 Prodrome
– changes in behavior, mood or
feelings that may occur hours or days before a
seizure
 Aura
- Symptoms correspond to the area of brain
affected by the abnormal electrical activity. Most
commonly seen with complex partial seizures.
 Ictus- What
activity
is seen/felt during abnormal electrical
 Postictal- What
to baseline
is seen/felt until the brain recovers
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Simple Partial Seizures
 Sometimes
called ‘auras’, is the first
symptom of a seizure
 No
change in consciousness/awareness
 What
is seen/felt correlates with abnormal
electrical activity in a part of the brain
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Examples of Simple Partial
Seizures

Sensory
 Smells
 Sensations
 Visual changes
 Auditory symptoms

Autonomic
 Dilated pupils
 Queasy Stomach
 Skin flushing
 Pallor, etc.

Motor
 Unilateral jerking of face,
arm, and/or leg
 may spread from one part
of body to others
 May be unable to speak
 Can involve any part of the
body

Psychic
 Dejà-vu, jamais vu, out of
body experience
 Feelings of fear, anxiety,
happiness, depression
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Nursing Care During Seizure
Simple Partial
 Promote
safety
 Guide patient to a
safe place
 Stay within arm’s
reach
 Stay
calm
 Observe
the patient
 Speak calmly
 Assess awareness
 Reassure
 Time
the seizure
 Document
event
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Complex Partial Seizures

May start as simple partial

Awareness is impaired,
though may be difficult
to assess

May or may not hear,
understand, see, respond
or recall events during
seizure

Duration: seconds to
minutes

seizure or start suddenly
Automatisms: unusual and
repetitive behaviors
 Motor
signs include:
 One or both sides of body
 May be stiffening, jerking,
twitching, or absence of
movement
 May involve any part of
the body including jaw,
swallowing muscles,
shoulders
 Can spread from one
body area to others
 Post-ictal
fatigue, confusion,
sleepiness, headache
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Nursing Care During
Complex Partial Seizure
 Promote




safety
Guide patient away from potential dangers.
Do not restrain patient
 Patient may become combative if restrained
 If safe, let patient wander in an enclosed area
Assist patient to lie down if there is a loss of tone
Stay calm
 Observe
behavior and time the seizure
 Observe
post ictal state (patient may be confused or
tired)


Reorient and reassure
Stay with the patient until he/she returns to baseline
 Document
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Secondarily Generalized
Seizures
 Starts
in focal brain area then spreads from
one side to include the other side
 That
is, the seizure may start as a simple partial
seizure or as a complex partial seizure
 May
spread slowly or rapidly to a generalized
seizure, usually causing patient to fall
 Electrographically, seizure
brain
involves both sides of
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Secondarily Generalized
Seizures
 Eyes
may roll back, may fall to ground or lean over
 Body
becomes rigid (tonic) and then jerks (clonic)
 May
involve incontinence of bladder and/or bowel
 May
have forced head turn or eye deviation to side
 May
involve one side of body more than the other
 Lasts
5 minutes or less
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Review of Partial Seizures
 Video
introducing partial seizures and what
they look like from epilepsy.com
 Understanding
(available 1/1/2014)
Partial Seizures
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Primary Generalized Seizures
 Involve
both hemispheres at the onset
 Types
of primary generalized seizures:
 Absence
 Myoclonic
 Tonic
 Atonic
 Clonic
 Tonic-clonic
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Absence Seizures (Previously
called petit mal)
 Sudden
onset of behavioral arrest
 May
involve eyelid fluttering
 Duration: 5-30 seconds
 Usually occurs many times/day, difficult to identify
clinically because of brief duration
 Returns
to baseline almost immediately
 Possible
anterograde or retrograde amnesia
 Hyperventilation and/or flashing lights may
precipitate seizures
 Classic EEG pattern
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Nursing Care: Absence Seizure
 Promote
 Stay
safety
within reach
 Falling
 Stay
unlikely
calm
 Observe
behavior
and time the
seizure
 Observe
postictal
behavior
 Usually returns to
baseline immediately
 Reorient
 If
photo-sensitive, avoid
exposure to flashing
lights or patterns
 Document seizure
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Tonic-Clonic Seizures
(previously called grand mal or major motor)
 Often
begins with an ictal cry (loud groan)
 Body
may be tonic – posturing or stiffening
of all muscles
 Person may appear as if not breathing as
chest muscles are rigid
 Clonic
movements – rhythmic jerking of
head and extremities
 May
have forced eye deviation upward
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Tonic-Clonic Seizures
 Duration: Generally
lasts from seconds to 1-2
minutes
 Excessive salivation(collection of drooling)
 May involve tongue biting
 May involve bladder and/or bowel incontinence
 May turn dusky or cyanotic
 Postictally, may have
 Confusion
 Headache
 Muscle ache
 Sedation or fatigue for minutes to hours
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Nursing Care: Generalized
Tonic-Clonic Seizure

Stay calm

Promote safety
 Cushion fall if possible
 Support head

Loosen restrictive clothing

Place NOTHING between teeth

NO food or drink until able to swallow

Do not forcefully reposition or restrain the movements
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Nursing Care: Generalized TonicClonic Seizure
 Promote
Safety
 Place patient in side-lying position as soon as possible
 Due to size or location of teenagers and adults, may
need to wait until seizure is subsiding before turning
to side
 Side-lying position promotes drainage of saliva from
mouth
 May need to reposition head to keep airway clear
 In hospital, suctioning may help maintain airway,
especially if seizure is long
 Observe
behavior and time the seizure
 Assess for injury after the seizure is over
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Post Ictal Nursing Care: Tonic
Clonic Seizure
 Observe
behavior
 May be sleepy,
confused, combative,
difficulty talking, and
unable to remember
 If
sleepy, continue in
side-lying position to
protect the airway
 Gently
restrain, if
needed, to avoid injury
 Reassure/reorient
 Assess
for injury
 Monitor
duration of
postictal state
 Confusion may last
minutes
 Sleepiness may last
minutes to hours
 NPO until able to swallow
 Document
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Tonic Seizures
 Sustained
bilateral stiffening or posturing
 Usually brief but can last minutes
 May cause fall if standing or sitting
 Sudden, very
 Significant
unpredictable
risk of injury due to loss of protective
reflexes, ie. cough, righting reflex
 May
have change in breathing patterns or
look like not breathing or may appear pale
or cyanotic
 Can
occur in clusters, sometimes along
with other seizure types
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Atonic Seizures
 Atonic-
also called “drop attacks”

Sudden loss of tone

Drop of head with or without slight bending of knees
Drop of head, trunk or entire body
May fall backwards or forward if sitting or standing


 Impaired
awareness may be present but not
discernible
 Usually
very brief, variable intensity (mild to forceful)
 Significant


risk of injury
High risk for head lacerations, fractures, and other injuries
Often require helmets and safety gear
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Myoclonic Seizures

Very brief, fast muscle contractions of the head, arms, legs,
face, trunk and/or body




Single jerk or clusters
Unilateral or bilateral, can be specific muscle groups
May cause loss of balance or fall
May drop objects

Often occur when drifting to sleep or shortly after
awakening

Impaired awareness may not be discernible

Clusters may precede a generalized tonic-clonic seizure

Some myoclonus may not be epilepsy-related
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Nursing Care: Tonic, Atonic and
Myoclonic Seizures

Stay calm

Promote safety
 Be sure safety gear is worn, if ordered
 Cushion fall if possible – support head
 Clear area of harmful objects or surfaces
 Loosen restrictive clothing
 Place NOTHING between teeth
 There is no danger of the person swallowing their
tongue
 NO food or drink until able to swallow

Turn to side-lying position if not able to protect airway
 Do not forcefully reposition
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Nursing Care: Tonic, Atonic and
Myoclonic Seizures
 Observe
behavior and time the
seizure/seizure cluster
 Post
ictal care:
 Observe
behavior
 Reassure and re-orient
 Assess for injury
 NO food or drink until able to swallow
 Assess return to baseline state
 Document
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Febrile Seizures
 Prolonged
 Frequency
 2%
- 5% of children
in United States
 Most
often in
children aged: 3
mos-5 years
 Associated
≥ 101
with fever
 13%
 5%
A
> 10 minutes
> 30 minutes
prolonged 1st febrile
seizure, implies the
next seizure will likely
be prolonged
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Febrile Seizures

Simple febrile seizure
Generally lasts a few minutes and does not require
treatment
 Occurs within 24 hours of fever onset
 Usually generalized tonic clonic seizure
 No localizing deficits afterwards
 No prior history of non-febrile seizures
 No current intracranial infection
 No other neurological/developmental abnormalities
 No family history of non-febrile seizure

 Complex febrile seizure
 Last > 15 minutes
 Have focal features or
 Recur within 24 hours
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Responding to Seizures:
Summary of General First Aid
 Stay
calm/speak quietly
 Time
the seizure
 Promote





safety
Help person to floor or
safe place,
Prevent or cushion fall if
possible
Support head
Remove harmful objects
Make comfortable
 Maintain open airway
 Place nothing in mouth
between teeth
 Keep
onlookers away
 Stay
with person until
seizure ends
 Reorient
patient
and reassure
 Assess
frequently until
back to baseline
May need to sleep/rest
 Nothing to eat or drink until
able to swallow
 Assess for injury

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Review of Generalized Seizures
 Video
introducing generalized seizures and
what they look like from www.epilepsy.com
Understanding Generalized Seizures
(available January 2014)
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TIPS FOR SEIZURE OBSERVATION
AND RECORDING
When watching a seizure, observe:
 What
happens before, during and after the event
 Write
down what happened as soon as you can
 Include
as much information as possible
 Download
Tips for Seizure Observation and
Recording by clicking here
(available January 2014)
© 2007 epilepsy.com A service of the Epilepsy
Therapy Development Project
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Tips for Seizure Observation
Before the Seizure

What was person doing at time of event
Change in mood or behavior hours or days
before


‘Warning’ or ‘aura’ shortly before event

Possible triggers or precipitants

When seizures occurs – date, time, duration
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

Tips for Seizure Observation:
During the Seizure
Change in awareness, alertness,
confusion
Changes in muscle tone

Movements – jerking or twitching,
unable to move, body turning, falls

Automatic or repeated movements
– lip smacking, chewing,
swallowing, picking at clothes,
rubbing hands, tapping feet,
dressing or undressing

Walking, wandering, running

Changes in color of skin, sweating,
breathing, loss of bladder or bowel
control

PART OF BODY INVOLVED
Ability to talk and understand

Changes in thinking,
remembering, emotions,
perceptions

Sensations – changes in seeing,
hearing, smells, tastes, feelings


Facial expression, pupil size, eye
blinking or position, drooling
+ Tips for Seizure Observation
What Happens After Event
 Response
to voice or touch
 Awareness
 Memory
 Ability
of name, place, time
for events
to talk or communicate
 Weakness
 Changes
or numbness
in mood or how person acts
 Fatigue, sedation
+ Tips for Seizure Observation
How Long It Lasted
 Duration
of aura, seizure, after-effects or
postictal phase
 How long
activity
before person returns to normal
© 2007 epilepsy.com A service of the Epilepsy Therapy Development Project
Adapted with permission from the Comprehensive Epilepsy Center, Beth Israel Deaconess
Medical Center, Boston, Massachusetts, 2006.
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Post Ictal Nursing Care: All Patients
 Monitor
 Assess
until returns to baseline
cognitive state
 Speak
calmly and quietly –reorient and
reassure
 Allow
to sleep if desired
 Do
not restrain: may cause aggression in some
people
 Assess
for injury, postictal paralysis, mood or
behavior change
 Document
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When to Seek Medical Attention
 History
of seizure recurrence in person with
rare or well-controlled seizures
 Person
with known epilepsy but occurrence of
new seizure type
 Persistent
to patient
side effects of treatment bothersome
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When to Call for Emergency Help
 When seizures..
 approach 5 minutes
in
duration or per patient’s
seizure action plan
 one seizure occurs after
another
 last longer than typical
events
 When person..
 doesn’t return
to
baseline in usual period
of time
 has first seizure
 has suspected injury
 is pregnant or diabetic
 When
observer is unsure
or uncomfortable
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Injuries from Seizures
 Immediate
 Lacerations
 Bruises
 Burns
 Head
trauma
 Fractures
 Drowning/near
drowning
 Delayed
 Fever
 Aspiration
pneumonia
 Subdural hematomas
 Fractures (delayed
recognition)
 Change
in seizures
or seizure
emergencies
Return to index
Seizure Assessment Algorithm
Reprinted with permission from the American Association of Neuroscience Nurses