Joyce Estes RN, MSN

• By the end of this module, the student will be able to:
• Explain what a seizure is and the incidence of patients who have seizures.
• Differentiate between seizures and epilepsy.
• Discuss the causes of seizure activity.
• Discuss the types of seizures based on the type of movement presented with each.

• Discuss the stages of a seizure and apply to the assessment and document of seizure activity.
• Compare types and activity of childhood seizures with the adult seizure.
• Discuss the various diagnosis, treatments and medications used to manage seizure disorders.
• Describe the appropriate nursing diagnosis and interventions for the management of seizures.

• 400 AD-The Greek physician Hippocrates writes the first book on epilepsy.
• Seizures were known as “convulsions or fits”
• 1494-women with seizures were thought to be witches
• Some people known to have seizures and epilepsy:
– Socrates
– Charles Dickens
– Vincent Van Gogh
– Alfred Nobel
– Richard Burton
– Agatha Christie
Notice those people with seizures/epilepsy are gifted writers, thinkers, painters.

• A seizure is the clinical event that result from abnormal nerve cell (neuronal) activity.
– Excessive bursts of disorganized electrical impulses from neurons in the cerebral cortex.
– Epilepsy is two or more unprovoked seizures.
– Thought to be an imbalance of neurotransmitters, or abnormal neuronal, or both.

• According to the Epilepsy Foundation®, more than 2 million people in the United States and about 65 million worldwide suffer from epilepsy.
• In the United States, about 150,000 new cases are diagnosed each year,
• About 300,000 people with epilepsy are under the age of 14
• 500,000 are over the age of 65.
• One in ten people will have a seizure at some point during their life. http://www.epilepsyfoundation.org/

• Epilepsy is a generic term used to define a variety of disorders characterized by recurring seizures.
• Epilepsy means that a person has an underlying condition that affects the delicate systems which govern how electrical energy behaves in the brain, making it susceptible to recurring seizures.

• A seizure is a brief, temporary disturbance in the electrical activity of the brain.
• Seizures are a symptom of epilepsy.
• Having a seizure does not necessarily mean that a person has epilepsy.
• People can experience different types of seizures.

• In about 70% of people with epilepsy, the cause is not known (idiopathic)
• In the remaining 30%, the most common causes are:
- Head trauma
- Infection of brain tissue
- Brain tumor and stroke
- Heredity
- Lead poisoning
- Prenatal disturbance of brain development

• Heart disease
• Heat illness (or heat intolerance)
• High fever
• Illicit drugs, such as angel dust (PCP), cocaine, amphetamines
• Kidney or liver failure
• Low blood sugar
• Phenylketonuria (PKU), which can cause seizures in infants
• Poisoning

• Stroke
• Toxemia of pregnancy
• Uremia related to kidney failure
• Very high blood pressure (malignant hypertension)
• Venomous bites and stings (see snake bite)
• Withdrawal from alcohol after drinking a lot on most days
• Withdrawal from certain drugs, including some painkillers and sleeping pills
• Withdrawal from benzodiazepines (such as Valium)

• Sometimes no cause can be identified, called idiopathic seizures.
• Usually are seen in children and young adults but can occur at any age.
• There may be a family history of epilepsy or seizures.

• The kind of seizure a person has depends on where in his brain the abnormal electrical activity starts and where it spreads.
• The seizure may be classified according to the movement that is experienced.

• Generalized seizure
– Involve the whole brain and loss of consciousness
• Absence: characterized by brief loss of consciousness
• Tonic-clonic: characterized by rhythmic jerking of muscles
• Partial seizure
– Involve only part of the brain; may or may not include loss of consciousness
• Symptoms relate to the part of the brain affected
2007 14

• 1. "Grand Mal" or Generalized tonic-clonic-
Unconsciousness, convulsions, muscle rigidity
• 2. Absence-Brief loss of consciousness
• 3. Myoclonic-Sporadic (isolated), jerking movements
• 4. Clonic-Repetitive, jerking movements
• 5. Tonic-Muscle stiffness, rigidity
• 6. Atonic -Loss of muscle tone

• Tonic-Clonic-involves the whole brain at once.
– More commonly known.
– The muscles contract simultaneously, becoming very rigid and the person may cry out as breath is forced out of the lungs when the diaphragm contracts.
– Person loses consciousness and will fall down if standing.
– Rhythmic jerking of the head, legs, and arms may occur as massive signals from the brain stimulate the muscles to alternately tense and relax.

• Injuries and accidents may occur, such as tongue biting and urinary incontinence.
• http://www.youtube.com/watch?v=dZwFhSL1 bK0
(please remove the word neurology from the screen after starting this video. )
• This tonic-clonic seizure shows a good example of the movement and the tonic-clonic movement that disrupts the diaphragm. Notice the sucking and blowing out of air.

• ABSENCE (formerly known as petit-mal)
– generalized seizure a brief loss of consciousness, which usually lasts no more than a few seconds.
– The person is essentially “absent.”
– Frequently overlooked, often being mistaken for daydreaming.
– Autonomic phenomena
– Behavioral phenomena
– Motor phenomena

• These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of
"losing time."
• http://www.youtube.com/watch?v=BzIs8YeafZM

http://www.ieaecell.org/epilepsy-03.html

The symptoms of a partial seizure relate to the normal function of the brain area that is involved. The person may experience involuntary movements or tingling, light flashes, or other symptoms. You may hear these called focal seizures. There are two forms of partial seizures, simple and complex.

• Simple partial seizures are generally brief and do not involve loss of consciousness.
• Simple partial seizures may cause jerking motions or hallucinations, but the person often remains aware of what is happening
• http://www.youtube.com/watch?v=dKItDS30nvc
• Although the child is having simple partial, she also looks as if she my be having some complex there at the end. Her eyes have become dysconjugate .

• A person having this type of seizure will be unaware of his surroundings during the seizure, may wander aimlessly, run, do a series of repetitive movements (automatisms), pick at clothes, chew, mumble and, to a casual onlooker, appear to be drunk.
• http://www.youtube.com/watch?v=XGzpD1u42Bc

(from vanumu.com)

• Some patients may experience a Prodromal phase which can occur hours or days before the seizure begins.
• Some symptoms are:
– Sleep disturbances
– Lightheadedness
– Feelings of being uncomfortable

• Stage 1-Aura is also known as “Pre-ictal”
– This stage is a beginning. Not every patient has an aura, but it is considered the “warning stage” .
Auras are usually visual, auditory or a strange feeling or smell. Some may have tingling or the feeling of déjà vu.
– Nausea and vomiting are a common aura for some patients who experience seizures
– “Feeling butterflies” is a common aura.
– There are as many auras as there are seizures.
Each patient has their own descriptions.

• When with a patient who has an aura, you have the opportunity to get them to a safe place.
• Once they are safely positioned, you will have the opportunity to watch them during the seizures and take the appropriate actions.
• Documentation should include the time the aura started and the symptoms. Important is to note if the patient was cognitive at during the aura.

• Stage 2-The ictal stage is the actual event.
• The goal is to protect the patient from injury
– Turn the patient on their side to keep the airway clear.
Maintain the airway; use oxygen and suction as needed.
– Loosen any restrictive clothing.
– Do not restrain the patient or stop movement. Guide the movement if necessary. Especially those patients who want to walk around.
– Note the time the seizure began and ended.
– NEVER FORCE ANYTHING INTO THE
PATIENT’S MOUTH!!

• Stage 3-During the post-ictal stage, the brain is in a state of recovery.
– Patient may become confused or disoriented.
– With tonic-clonic seizures or some complexpartial, the patient will become extremely drowsy and fall to sleep. This can last from 5-30 minutes.
• Take the patient’s vital signs.
• Perform neurological checks.
• Allow the patient to rest.
• Keep the patient on their side.

• Assess the patient for any bleeding inside the mouth when awake. (Do not put your fingers into their mouth).
• Many seizure patient will bite and chew their tongues or cheeks.
• Patient may need oxygen at this time.

• When observing and documenting the seizure, the following is important:
– Date, time and duration of the seizure, was there more than one.
– Description of the seizure: movement, staring, blinking, automatisms,
– Was there more than one type of seizure? If you are not sure of the type, document the movements of the seizure.
– Which body part was first involved?
– How long did the seizure last?
– Was there an aura?
• What was involved in the aura? Visual, Auditory, GI disturbances?
• What did the patient do after the seizure (post-ictal)?
– Drowsy, weak?
– Did the patient resume normal behavior?
– Was the patient aware the seizure took place?
– How long did it take for the patient to return to pre-seizure status

• Observations and documentation during the seizure:
– Was there any eye deviations or changes in the pupil size, eye fluttering.
– Level of Consciousness, was the patient able to follow commands
– Presence of apnea, cyanosis, salivation
– Movement and progression of motor activity; was a side more active during the seizure? (R vs. L)
– Lip smacking or other automatisms
– Biting of tongue or lip.

• With first seizure, patient should go to the
Emergency Room.
• Did they or did they experience a seizure?
• First-a thorough past and present medical history!!!
• Alcohol or drug use, medications
• Detailed information regarding the seizure: aura, movement, LOC, any injuries associated with the seizure.

• Laboratory studies
– CBC, Metabolic Package,
– Drug screen, Urine drug screen
– Other labs to rule out medical conditions:
• Lumbar puncture (Meningitis)
• Prolactin-will increase 3x’s the normal after seizure for
12 hours after seizures.

• Head CT Scan-r/o stroke, head injury, tumors
• MRI-can identify possible epilepsy lesions
• Electroencephalogram-EEG-electrical signals of the brain are recorded.
– This electrical activity is detected by electrodes, or sensors, placed on the patient's scalp and transmitted to a machine that records the activity

NORMAL
Epileptic spikes and waves

Electrodes connected to scalp
.
The EEG shows the abnormal
“waves” that are associated with the seizure.
The brain waves consist of
Beta
Alpha
Theta
Delta
See the next slide for what these waves are associated with.

http://www.angelfire.com/journal/ldps/SleepingDisorders

• Antiepileptic drugs (AED)
The drug should be:
– 1. highly effective, but exhibit a low incidence of toxicity.
– 2. effective against more than one type of seizure and for mixed seizures.
– 3. long acting and nonsedative so that the client is not incapacitated with sleep or excessive drowsiness.
– 4. tolerated by the client and inexpensive, since the client may have to take it for years or the rest of his/her life.
– 5. control seizures and permit a client to function effectively in any environment.
– 6. Tolerance to the therapeutic effects of the drug should not develop.

• (1) to increase motor cortex threshold to reduce its response to incoming electric or chemical stimulation.
• (2) to depress or reduce the spread of a seizure discharge from its focus (origin) by depressing synaptic transport or decreasing nerve conduction

•
Barbiturates – phenobarbital. One of the first anticonvulsants used.
• Benzodiazepine- To suppress the propagation of diazepam (Valium) seizure activity produced by foci in the cortex, thalamus, and limbic areas.
• Hydantoins - Inhibit spread of seizure .
– Phenytoin (Dilantin).
• Blurred vision, gingival hyperplasia
• Elevated incidence of birth defects in children of mothers taking phenytoin.

• divalproex (Depakote). Derived from valproaic acid. Has been used during pregnancy but has been associated with spina bifida, fatal hepatic problems in infants
• www.drugs.com/pregnancy/divalproex-sodium.html
•Carboxamides (Oxazolidinediones)
Carbamazepine (Carbatrol, Tegretol)
Oxcarbazepine (Trileptal)
•GABA Analogues
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Tiagabine (Gabitril)

• About 20% of patients with epilepsy do not respond well to drug therapy. (Intractable seizures) These patients may undergo procedures to remove the foci of the seizures or to stop the progression of the seizures.
• The presurgical work-up is comprehensive and is directed at the identification of the seizures and the area of the brain it is located.

• Was approved for use in adults and children over 12 with partial-onset seizures and cannot be controlled by AEDs
– An implantable programmed signal generator is placed in the left upper chest. A bipolar VNS lead connects the lead to the left vagus nerve in the neck.
– This sends stimulation to the brain stem which sends info to othe rest of the brain and interrupting the seizure.

Vagus Nerve Stimulator
Approved since 1997

• One of the oldest treatments for epilepsy
• It is intended to maintain starvation or fasting metabolism over a long period of time. In a fasting state, it creates ketones, a by-product of fat-burning metabolism.
• The diet is very high in fat and low in carbohydrates. High fats=ketones.
• It has been found that seizures often lessen or disappear during periods of fasting in some individuals with epilepsy.

• Diet has been used mostly in children with difficult-to-control, generalized epilepsies –
• Recommended for children ages 2 through 12 who have been diagnosed with a generalized type of epilepsy and are not responding to drugs.
• Initiation of the diet usually takes place in the hospital
• Patient should be monitored for potential side effects such as vomiting, low blood sugar, dehydration, and seizures.

• Continuous seizures that last at least 5 minutes, or there are 2 or more seizures together with no recovery between the seizures.
• Usually a tonic-clonic seizure, in 50% of patients it is usually their first seizure. (Hickey,
2009).
• Although there are many types of status epilepticus, this information is based on the tonic-clonic seizure the most common and constitutes a medical emergency.

• Initial nursing management:
– ABCs
– Position for airway clearance, suction to maintain patency.
– Oxygen at 100% via nasal cannula. (turn it up!)
Monitor with pulse oximetry. Severe status can cause extreme cerebral hypoxia and can result in severe irreversible neurological deficits.
– Secure IV access with frequent vital sign monitoring.
– Protect the patient from injury
– Provide information to to the family.

• Medications used for SE are:
– Benzodiazepines
• Valium
• Lorazepam
• These are ordered by mg per kg.
• The dose is usually given every 5 minutes until the seizure stops.

• Each medical facility has its own policy for the safety of patients with seizures. Most protocols or standards of care include:
– Safety concerns-
• Side rails up, padded.
• Call bell at bedside, within patient’s reach
• O2 and suction at bedside, check function at the beginning of each shift
• Bed in low position
• Remove glasses, sharp objects when seizing
• Maintain IV access

• Ineffective Breathing Pattern related to neuromuscular dysfunction during seizure.
• Ineffective airway clearance related to inability to control secretions during seizure.
• Risk for injury related to seizure activity
• Fear related to the possibility of seizures
• Deficient knowledge related to epilepsy and its control

• Educate patient and family on:
– Recognition of seizures and their safety
– Compliance with medications
– Driving and seizure activity
– Medical ID bracelet
– Family Support
– Community Resources

• A major advance in recent epileptology is the recognition of epileptic syndromes that allows an accurate diagnosis and management of seizure disorders.
• Important clinical features include
– the type of seizures
– their localization
– frequency
– sequence of events
– circadian distribution
– precipitating factors
– age at onset
– mode of inheritance
– physical or mental symptoms and signs
– prognosis, and response to treatment (epilepsy.com/professionals)

• Children are more likely to experience seizures than adults.
• Newborns and young children have seizures most frequently. Their seizures are often caused by problems around the time of birth, including injuries during birth or infections.
• The types of seizures that children experience are different from those in adults and may be associated with an epileptic syndrome.

• Infantile spasms are an age-specific disorder beginning during the first 2 years of life.
– Peak age of onset is between 4 and 6 months.
Approximately 90% of infantile spasms begin before 12 months of age.
– Rare for infantile spasms to begin during the first 2 weeks of life or after 18 months.

• Febrile seizures involve contractions in the child’s muscles—either mild (such as stiffening of the child’s limbs) or severe (tonic-clonic).
– Triggered by fever.
– Fairly common: About 2 to 5 percent of children in the United States experience a febrile seizure.
– Usually happen in children between 6 months and
5 years of age. Children who have febrile seizures often have a family history of this type of seizure.

• Neonatal period is the most vulnerable period of life for developing seizures.
• Neonatal epileptic seizures often constitute a neurological emergency demanding urgent diagnosis and management.
• Neonatal seizures are paroxysmal, repetitive, and stereotyped events. They are usually clinically subtle.
• There is no recognizable post-ictal state.
• Generalized tonic-clonic seizures probably do not occur.

• The diagnosis of this syndrome in a child with seizures is based on five criteria:
– normal neurologic examination
– negative evaluation for another etiology of the seizures
– normal developmental and intellectual outcome
– positive family history of newborn or infantile seizures with benign outcome
– onset of seizures during the neonatal or early infantile period)

• There are 5 main types of neonatal seizures:
• Subtle seizures (50%)
• Tonic seizures (5%)
• Clonic seizures (25%)
• Myoclonic seizures (20%)
• Non-paroxysmal repetitive behaviors

• Severe causes are usually the cause.
• Hypoxic-ischemic encephalopathy is the most common cause (80% of all seizures in the first
2 days of life).
• Previously common acute metabolic disturbances such as electrolyte and glucose abnormalities are now unusual causes.

Classified as an idiopathic, localization-related epileptic syndrome. It is characterized by:
– nocturnal generalized seizures, probable focal onset
– diurnal partial seizures arising from the lower rolandic area
Both daytime and nighttime seizures may occur, although in most children the seizures usually occur during sleep.
• The disorder always begins during childhood.
• Age range is from 3 to 13 years, with the peak incidence occurring between the 7th and 8th year of life.
• Somewhat more common in boys than in girls.
• Most affected children have normal intelligence and normal findings on the neurologic examination.
• The disorder is usually familial.
(http://professionals.epilepsy.com/page/syndromes_benign.html 2013)

• The most common pediatric seizure.
• 25% of children with non-febrile seizures.
Seizures are infrequent, usually nocturnal, and remit within 1 to 3 years from onset.
• Brief or prolonged seizures, even status epilepticus, may be the only clinical event of the patient’s lifetime.
• Ictal autonomic manifestations are frequent and may occasionally appear in isolation as in pure autonomic seizures.

• Nursing care for children is the same but should include:
– Safety should include the rails of the crib, or bed so the child does not roll out.
– Children’s brain cannot recover from status well.
Medications should be given ASAP.
– Rectal benzodiazepines may be used for seizure control.

• For school age and adolescents, the school should know the type of seizure and what to expect from the child.
• Parental/Caregiver support is a must!
• Some young girls may experience seizures in conjunction with puberty and their menstrual cycle. Hormones play a large part in seizure activity.

• 1. In teaching family members how to care for a patient during a seizure, the nurse should include which of these measures?
a. Begin cardiac compressions b. Sit the client in an upright position c. Do not force anything into the patient’s mouth d. Hold the patient down so not to injure himself

• An ictal assessment should include the following: (Select all that apply) a. Name, address b. Time the event started c. Movement of extremities d. Vocalizations e. Cognition during the event

• One out of ten people will experience a seizure at least once in their life.
– True
– False

• Upon entering the patient’s room at the end of the seizure, the patient can tell the nurse everything that happened during the seizure.
The nurse realizes that this patient experienced a: a. Complex Partial Seizure b. Generalized Tonic-Clonic c. Myoclonic Seizure d. Simple Partial Seizure

• Status Epilepticus is a: (select all that apply) a. an medical emergency b. Name for a generalized seizure c. Continuous seizure lasting for longer that 5 minutes d. A possible fatal condition

• Epilepsy Foundation www.epilepsyfoundation.org
• Ignatavicius, Donna (2010) Medical-Surgical Nursing,
Patient-Centered Collaborative Care. Elsevier St.
Louis, Missouri.
• Hickey, Joanne (2009) The Clinical Practice of
Neurological and Neurosurgical Nursing 6 th ed. ,
Lippincott, Williams, & Wilkins, Philadelphia, PA.
• KSA competencies for pre-licensure (2013) qsen.org.
• EEG, Vagus Nerve Stimulator http://www.nlm.nih.gov/medlineplus/seizures.html