SEIZURE

MARY KATHERINE ROSS MICHELLE F. TIANO

SEIZURE

Seizures are symptoms of a brain problem. They happen because

of sudden, abnormal electrical activity in the brain. When people

think of seizures, they often think of convulsions in which a

person's body shakes rapidly and uncontrollably. Not all seizures

cause convulsions. There are many types of seizures and some

have mild symptoms. Seizures fall into two main groups. Focal

seizures, also called partial seizures, happen in just one part of

the brain. Generalized seizures are a result of abnormal activity

on both sides of the brain.

ANATOMY

SCALP SKULL

DURA

ANATOMY

• A tough 3-layer sheath that surrounds the brain and spinal cord

• Layers include the dura mater (strongest layer), arachnoid mater (middle layer), and pia mater (closest to the brain)

ANATOMY

THE CEREBRUM• Made up of two cerebral

hemispheres that are connected in the middle

• It is the largest part of the brain • Each area of the cerebrum

performs an important function, such as language or movement

• Higher thought (cognition) comes from the frontal cortex (front portion of the cerebrum)

• Outside of the cerebrum are blood vessels

• There are fluid-filled cavities and channels inside the brain

ANATOMY

THE CEREBELLUM• Located in the lower, back part of

the skull • Controls movement and coordination

THE BRAINSTEM AND PITUITARY GLAND• Responsible for involuntary

functions such as breathing, body temperature, and blood pressure regulation

• Pituitary gland is the "master gland" that controls other endocrine glands in the body, such as the thyroid and adrenal glands

• Pineal gland

ANATOMY

THE CRANIAL NERVES• Twelve large nerves exit the

bottom of the brain to supply function to the senses such as hearing, vision, and taste

THE CEREBRAL BLOOD VESSELS• A complicated system that supplies

oxygenated blood and nutrients to the brain

ANATOMY

ANTERIOR CEREBRAL CIRCULATION• The front of the brain is supplied

by the paired carotid arteries in the neck.

POSTERIOR CEREBRAL CIRCULATION• The back portion of the brain is

supplied by the paired vertebral arteries in the spine.

PATHOPHYSIOLOGY

• A seizure occurs when a portion of the brain becomes overly excited or when nerves in the brain begin to fire together in an abnormal fashion.

• Seizure activity can arise in areas of the brain that are malformed from birth defects or genetic disorders or disrupted from infection, injuries, tumors, strokes, or inadequate oxygenation.

• The pathophysiology of seizures results from an abrupt imbalance between the forces that excite and inhibit the nerve cells such that the excitatory forces take precedence.

• This electrical signal then spreads to the surrounding normal brain cells, which begin to fire in concert with the abnormal cells.

• With prolonged or recurrent seizures over a short period, the risk of future seizures increases as nerve cell death, scar tissue formation, and sprouting of new axons occur.

PATHOPHYSIOLOGY

• Nerve cells between discharges normally have a negative charge internally due to the active pumping of positively charged sodium ions out of the cell.

• Discharge or firing of the nerve cell involves a sudden fluctuation of the negative charge to a positive charge as ions channels into the cell open and positive ions, such as sodium, potassium, and calcium, flow into the cell. Both excitatory and inhibitory control mechanisms act to allow appropriate firing and prevent inappropriate excitation of the cell.

• The pathophysiology of seizures can occur due to increased excitation of the nerve cell, decreased inhibition of the nerve cell, or a combination of both influences.

CAUSES

COMMOM CAUSES• Alcohol abuse• Alcohol withdrawal• Cancer• Concussion• Drug abuse

• Head injury• Insulin reaction• Low blood oxygen• Low blood pressure• Encephalitis

• Low blood sugar• Petit-mal seizure• Stroke • Vasovagal syncope • Epilepsy

LESS COMMON CAUSES• AIDS • Alzheimer's disease

Amyotrophic lateral sclerosis

• Amyloidosis • Brain abscess • Brain tumor • Cerebral aneurysm• Cerebral hemorrhage

• Cerebral arteriovenous malformation

• Depression• Drug interaction • Drug side effect• Drug toxicity• Drug withdrawal • Eclampsia• Epidural hematoma

• Fat embolism• Heatstroke• Hydrocephalus• Hypocalcemia• Hypoglycemia• Hypomagnesemia• Hypotension• Intracerebral

hemorrhage

CAUSES

• Kidney failure • Lead poisoning • Liver failure• Malaria• Meningitis• Multiple sclerosis• Neurofibromatosis• Neurosyphilis• Organophosphate

poisoning

• Parkinson's disease• Phenylketonuria• Pulmonary

embolism• Reye's syndrome• Subarachnoid

hemorrhage• Subdural

hematoma• Tay-Sachs disease

• Thrombotic thrombocytopenic purpura

• Tourette's syndrome

• Whooping cough• Thiamine

deficiency• Sarcoidosis

PROBLEMS

• Aspiration pneumonia • Depression• Injuries that occur during the seizure:

o Fractureso Tongue lacerationo Dental injuryo Shoulder dislocation

• Learning disabilities• Mallory-Weiss tear• Medication side effects• Status epilepticus:

o Seizure that lasts longer than 30 minuteso Multiple episodes of seizure without complete recovery between

episodes• Rhabdomyolysis

TYPES

I. PARTIAL SEIZURE• SIMPLE PARTIAL SEIZURE : affect only a small region of the brain, often

the temporal lobes and/or hippocampi. People who have simple partial seizures retain consciousness.

• COMPLEX PARTIAL SEIZURE : may involve the unconscious repetition of simple actions, gestures or verbal utterances, or simply a blank stare and apparent unawareness of the occurrence of the seizure, followed by no memory of the seizure.

II. GENERALIZED SEIZURES• ABSENCE SEIZURES : involve an interruption to consciousness where

the person experiencing the seizure seems to become vacant and unresponsive for a short period of time (usually up to 30 seconds). Slight muscle twitching may occur.

• MYOCLONIC SEIZURES : involve an extremely brief (< 0.1 second) muscle contraction and can result in jerky movements of muscles or muscle groups.

TYPES

• CLONIC SEIZURES : are myoclonus that are regularly repeating at a rate typically of 2-3 per second. in some cases, the length varies.

• TONIC–CLONIC SEIZURES : involve an initial contraction of the muscles (tonic phase) which may involve tongue biting, urinary incontinence and the absence of breathing. This is followed by rhythmic muscle contractions (clonic phase). This type of seizure is usually what is referred to when the term 'epileptic fit' is used colloquially.

• ATONIC SEIZURES : involve the loss of muscle tone, causing the person to fall to the ground. These are sometimes called 'drop attacks' but should be distinguished from similar looking attacks that may occur in cataplexy.

III. MIXED SEIZURES• Mixed seizure is defined as the existence of both generalized and

partial seizures in the same patient.

TYPES

IV. CONTINUOUS SEIZURES• STATUS EPILEPTICUS : refers to continuous seizure activity with no

recovery between successive seizures. When the seizures are convulsive, it is a life-threatening condition and emergency medical assistance should be called immediately if this is suspected. A tonic-clonic seizure lasting longer than 5 minutes (or two minutes longer than a given person's usual seizures) is usually considered grounds for calling the emergency services.

• EPILEPSIA PARTIALIS CONTINUA : is a rare type of focal motor seizure (hands and face) which recurs every few seconds or minutes for extended periods (days or years). It is usually due to strokes in adults and focal cortical inflammatory processes in children (Rasmussen's encephalitis), possibly caused by chronic viral infections or autoimmune processes.

SIGN & SYMPTOMS

I. ABSENCE SEIZURE• staring • the child suddenly stops what she is doing • a few seconds of unresponsiveness (usually less than 10 seconds, but it

can be up to 20 seconds) that can be confused with daydreaming • no response when you touch your child • the child is alert immediately after the seizure • the child may have many seizures per day

Less common features include:• repetitive blinking • eyes rolling up • head bobbing • automatisms such as licking, swallowing, and hand movements • autonomic symptoms such as dilated pupils, flushing, pallor, rapid

heartbeat, or salivation

SIGNS & SYMPTOMS

II. MYOCLONIC SEIZURE• one or many brief jerks, which may involve the whole body or a single

arm or leg • in juvenile myoclonic epilepsy, these jerks often occur upon waking • the child remains conscious

III. ATONIC SEIZURE• sudden loss of muscle tone • the child goes limp and falls straight to the ground • the child remains conscious or has a brief loss of consciousness • eyelids droop, head nods • jerking • the seizure usually lasts less than 15 seconds, although some may last

several minutes • the child quickly becomes conscious and alert again after the seizure

SIGNS & SYMPTOMS

IV. TONIC-CLONIC SEIZURE• the child cries out or groans loudly • the child loses consciousness and falls down • in the tonic phase, the child is rigid, her teeth clench, her lips may turn

blue because blood is being sent to protect her internal organs, and saliva or foam may drip from her mouth; she may appear to stop breathing because her muscles, including her breathing muscles, are stiff

• heart rate and blood pressure rise • sweating • tremor • in the clonic phase, the child resumes shallow breathing; her arms and

legs jerk quickly and rhythmically; her pupils contract and dilate • at the end of the clonic phase, the child relaxes and may lose control of

her bowel or bladder • following the seizure, the child regains consciousness slowly and may

appear drowsy, confused, anxious, or depressed

SIGNS & SYMPTOMS

SIGNS & SYMPTOMS

V. MOTOR SEIZURE• brief muscle contractions (twitching, jerking, or stiffening), often

beginning in the face, finger, or toe on one side of the body • twitching or jerking spreads to other parts of the body on the same side

near the initial site • other motor seizures may involve movement of the eye and head • the seizure begins the same way each time • the child remains conscious

VI. SENSORY SEIZURES• seeing something that is not there, such as shapes or flashing lights, or

seeing something as larger or smaller than usual • hearing or smelling something that is not there • feeling of pins and needles or numbness in part of the body • the child remains conscious

SIGNS & SYMPTOMS

VII. AUTONOMIC SEIZURES• changes in heart rate • changes in breathing • sweating • goose bumps • flushing or pallor • the child remains conscious • strange or unpleasant sensation in the stomach, chest, or head • changes in heart rate • changes in breathing • sweating • goose bumps • flushing or pallor • the child remains conscious

SIGNS & SYMPTOMS

VIII. PSYCHIC SEIZURES• problems with memory • garbled speech • problems with memory • garbled speech • sudden emotions for no apparent reason, such as fear, depression,

rage, or happiness • feeling as though she is outside her own body • feelings of déjà vu, jamais vu, or knowledge of the future

COMPLEX PARTIAL SEIZURE• warning sign such as a feeling of fear or nausea • loss of awareness • confusion after the seizure • loss of memory about events just before or after the seizure

SIGNS & SYMPTOMS

• loss of awareness • blank stare • walking or running • screaming, yelling, or thrashing, either from sleep or while awake • automatisms such as mouth movements, picking at air or clothing,

repeating words or phrases • confusion after the seizure • loss of memory about events just before or after the seizure

MANAGEMENTINITIAL INTERVENTION

PROPER INTERVENTIONS SHOULD TAKE PLACE AT THE TIME OF SEIZURE ACTIVITY1. Staff observing the seizure activity should notify the nurse and provide an accurate

description of the clinical presentation. The nurse should document the reported observations in the nursing notes.

2. Staff should notify the nurse immediately if the individual continues to seize for more than two (2) consecutive minutes or the individual experiences two (2) or more generalized seizures without full recovery of consciousness between seizures.

a. The nurse should assess the condition of the individual immediately after receiving the call for assistance. The assessment should include the individual’s level of cardio-pulmonary risk. Any action taken, including a request for medical consultation, should be documented in the nursing notes.

b. The nurse should continue to follow the procedures outlined in the guideline for Prolonged Seizure Activity, documenting reported observations, personal observations, actions taken, and the individual’s response to treatment in the nursing notes.

MANAGEMENT

NURSING ASSESSMENT

NURSING ASSESSMENT OF SEIZURE ACTIVITY SHOULD OCCUR AND BE DOCUMENTED IN THE NURSING NOTES.1. Appropriate information about what occurred during the ictal (active seizure)

phase should be documented. If the nurse does not actually witness the seizure, persons present should be consulted to obtain the information.

2. The individual should be monitored during the postictal phase of the seizure. The individual’s postictal condition and activity should be documented. 3. Any action taken, including a request for medical consultation, should be documented in the nursing notes.

DIAGNOSTIC REASONING

SIGNIFICANT OR UNUSUAL FINDINGS SHOULD BE REPORTED IMMEDIATELY TO THE PRIMARY CARE PRESCRIBERThe decision of what to report is based on review of the seizure characteristics as wellas the seizure history which includes :

MANAGEMENT

1. current seizure medications and past history,2. current frequency of seizures, date of last seizure, and type and characteristics of

seizures,3. any complications or injuries related to the seizures,4. neurological consultation reports including results of specified follow-up,5. EEG reports and results, and6. recent serum anticonvulsant levels.

PLANNING

PLANNING STRATEGIES RELATED TO SEIZURE MANAGEMENT SHOULD OCCUR AND BE DOCUMENTED

7. The individual’s risk factors and actual or potential health problems should be included in the health assessment report and also in the Single Plan as needed.

8. If the individual receives psychotropic medication, information about the individual's seizure status and anticonvulsant medications should be discussed and documented as part of the individual’s Psychotropic Drug Review Plan.

MANAGEMENT3. Information regarding the type, frequency, and pattern of seizure activity;

precipitating and associated factors; and trends in seizure activity should be included in the health section of the Single Plan.

4. Information about the potential and actual side effects of the prescribed anticonvulsant medications should be included in the health section of the Single Plan.

5. Training sessions for direct care staff as well as other team members should occur. These sessions should include specific issues related to the individual’s seizures as well as overall observation, management, documentation, and safety issues related to seizure activity.

6. Specific nursing activities developed to eliminate and reduce seizures and to assist the person become more independent in management of the seizure disorder should be included in the Single Plan as needed. This may include activities related to prevention of injuries and secondary complications.

IMPLEMENTATION

PLANS SHOULD BE IMPLEMENTED AND NURSING INTERVENTIONS DOCUMENTED7. All orders for medication, treatment, and diagnostic procedures should be carried

out asprescribed by the primary care prescriber.

MANAGEMENT2. The nursing notes should reflect that diagnostic procedures were completed as

ordered.3. Appropriate injury protective practices should be initiated as prescribed by the

primary care prescriber or recommended by the Interdisciplinary Team. Team recommendations should be included in the Single Plan.

4. The individual’s seizure activity should be accurately documented in the individual’s record. Periodic review to identify trends and changes should be documented in the nursing notes.

5. For additional information on documentation procedures, see the Nursing Documentation Guideline.

EVALUATION

EVALUATION OF THE SEIZURE MANAGEMENT PLAN SHOULD OCCUR AND THE RESULTS DOCUMENTED.6. The nurse should monitor the results of seizure management program and make

recommendations to the primary care prescriber and interdisciplinary team for changes based on the progress noted.

7. Side effects and untoward interactions of medications should be documented in the nursing notes and reported immediately to the primary care prescriber.

MANAGEMENT3. Trends and changes in seizure activity (type and/or frequency) should be

documented in the nursing notes and reported to the primary care prescriber.4. Seizure records should be reviewed on a regular basis for accuracy and

completeness.

DIET5. A well balanced diet should be eaten at regular times.6. Coffee and other caffeinated beverages should be limited to a moderate amount.7. Fluid intake should be between 1,000 to 1,500 ml per day (depending on the

weather).8. Alcoholic beverages should be avoided.