Seizures Case Study
P.L. is a 44-year-old single woman who had a subarachnoid hemorrhage from a
ruptured aneurysm at the age of 42. During her stay at the rehabilitation facility, she
had an onset of tonic-clonic seizures that occurred almost every day. The seizures
were attributed to a structural infarcted area resulting from her brain injury. She has
been maintained on phenytoin (Dilantin) since that time. She had a fairly successful
rehabilitation and returned to work as an attorney. She has slight residual left-sided
weakness but is able to drive and manage her home. She has been seizure free for the
last year but comes to the clinic today accompanied by her mother because she has
experienced three seizures in the past 2 weeks, the most recent one 2 days ago. She
had blood drawn for a phenytoin level yesterday after making her clinic appointment.
As you review her clinic record, you note that P.L. lives with her 65-year-old
mother who works at the city library. P.L.'s last visit to the clinic was 2 months ago. At
that time she had complained of acid reflux after eating and was advised to eat small,
frequent meals and sleep with the head of her bed elevated. Today P.L. tells you that
she is afraid she will have to stop working because she cannot risk having a seizure in
the courtroom or at the office.
Your assessment at this visit includes the following:
•
Vital signs: BP 134/86, heart rate (HR) 68 beats/min, respiration rate (RR) 14
breaths/minute, temperature 98.2° F (36.8° C)
•
Ht 5 ft 6 in, Wt 168 lb ,a 20-lb increase in the last year
•
The lab reports that her phenytoin level is 6.0 mcg/mL (therapeutic level 10 to
20 mcg/mL).
•
P.L. cannot describe the seizures because she was alone at the time. She had
no impending warning of a seizure but awoke on the floor with bruising on her
arms and legs and had experienced urinary incontinence.
•
She reports that she has taken her medication faithfully, takes no other
prescription medications, says that she is under stress at work, and has not been
sleeping well. Her acid reflux is worse, so she has been using antacid tablets
and ginger tea to prevent it. A friend gave her some St. John's wort to help her
control her stress, which she has been using daily along with valerian to help her
sleep; she finds these herbal products effective.
1.
P.L. has experienced tonic-clonic seizures. Select the characteristics of a tonic-clonic seizure.
There are 4 correct answers.
Stiffening of the body followed by jerking of the extremities
Loss of consciousness with falling to the ground if patient is upright
Starts in one part of the body and spreads to involve jerking movements of the whole
body
May be accompanied by cyanosis, excessive salivation, and incontinence
Usually lasts 3 to 5 minutes
Usually precipitated by flashing lights and hyperventilation
The patient has no memory of the seizure
2.
P.L. told you that she has experienced no sensory warning or aura before the seizures. Based
on this information, P.L.'s seizures can be classified as
Absence seizures
Generalized seizures.
Simple focal seizures.
Complex focal seizures
3.
P.L. asks you if she will have to undergo another electroencephalogram (EEG) at this time. In
responding to her, select those factors that would apply to the use of an EEG in determining
the cause of P.L.'s increasing seizures. There are 4 correct answers
Many patients with seizure disorders have normal EEGs between seizures.
EEGs are useful only if patients experience a seizure during the test.
An EEG may be able to identify if P.L. has a new seizure focus present in the brain.
P.L.'s phenytoin level may have more diagnostic value than the findings of an EEG
Continuous EEG monitoring is the only way to determine why P.L. is having increased
seizures.
An abnormal EEG always indicates a seizure disorder.
EEGs should be performed within 24 hours of a suspected seizure.
4.
P.L.'s current history and the results of her phenytoin level give you some clues regarding her
increase in seizures.
Biopsychologic conditions such as stress and insomnia may alter the levels of
neurotransmitters in the brain, lowering seizure threshold and precipitating seizures.
Phenytoin dosage is based on body size and weight gain may cause lower blood levels of the
drug.
5.
Antacids interfere with the absorption of phenytoin, causing lower blood levels of the drug.
St. Johns Wort interferes with metabolism of drugs that use the cytochrome P450 enzyme
system and thus may alter blood levels of phenytoin.
6.
After interviewing P.L., you identify a nursing diagnosis of ineffective self-health
management related to lack of knowledge regarding seizure control. Select the teaching
statements that would be appropriate to help P.L. meet the goals of optimal seizure control
and therapeutic drug levels of antiseizure medication. There are 5 correct answers.
Do not use any prescription or over-the-counter medications or herbal products
without first checking with your health care provider.
If you miss a dose of phenytoin, take a double dose at the next scheduled time.
Have your blood drawn daily for phenytoin levels until your seizures stop.
Try to avoid excessive alcohol intake, fatigue, and loss of sleep.
An additional drug will have to be added to your regimen because the phenytoin is not
controlling your seizures.
You can have good seizure control as you have had in the past when your therapeutic
levels of phenytoin are reestablished.
Use relaxation therapy and biofeedback to reduce stress instead of herbal products.
Eat regular meals and snacks in between if feeling shaky, faint, or hungry.
7. P.L.’s mother tells you that she is afraid P.L. will have a seizure while is with
her, and she doesn’t know what to do. You explain that she should
Turn her to the side and loosen ant tight clothing
Promote a return to consciousness by yelling P.L.’s name
Protect P.L. from injury by restraining her arms and legs.
Call an ambulance because a seizure is a medical emergency
8.
As P.L. is checking out of the clinic, she falls to the floor and has a tonic-clonic seizure. You
arrive just as the seizure stops. You prioritize assessment of P.L.'s
Breathing
Heart rate.
Level of consciousness.
Injuries sustained during the seizure.
9.
Which activity would you most appropriately delegate to unlicensed assistive personnel (UAP)
following P.L.'s seizure (select all that apply)?
Call 911
Obtain P.L.'s vital signs.
Obtain a pillow and blanket for P.L.'s comfort.
Assess P.L.'s level of consciousness every 5 minutes.
Determine why the seizure occurred.
10. Select the interventions that would be appropriate for P.L during the postictal phase of her
seizure. There are 6 correct answers
Vagal nerve stimulator adverse effects are: horseness, dyspnea, tingling in the neck
and coughing.