SEIZURE DISORDERS

SEIZURES

Seizures are episodes of abnormal motor,sensory,autonomic and psychic activity(or a combination of these )that results from sudden excessive discharge from cerebral neurones. A part or all of the brain is involved. The international classification of seizures differentiates between two main types., partial seizures that begin in one part of the brain and generalized seizures that involve electrical discharge in the whole brain.

INTERNATIONAL CLASSIFICATION OF SEIZURES

Partial seizures(seizures beginning locally)

Simple partial seizures (with elementary symptoms, generally without impairment of consciousness)

With motor symptoms With special sensory or somatosensory symptoms With autonomic symptoms Compound forms

Complex partial seizures (with complex symptoms, generally with impairment of consciousness)

With impairment of consciousness only. With cognitive symptoms With affective symptoms With psycho sensory symptoms With psychomotor symptoms(automatisms) Compound forms

Partial seizures secondarily generalized

Generalized seizures(Convulsive or non convulsive, bilaterally symmetric,without local onset)

Tonic clonic seizures Tonic seizures Clonic seizures Absence(Petitmal) seizures Atonic seizures Myoclonic seizures(Bilaterally massive epileptic)

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Unclassified seizures

ETIOLOGY

The underlying cause is an electrical disturbance (Dysrrhythmia)in the nerve cells in one section of the brain., these cells emits abnormal,recurring,uncontrolled,electrical discharges.

Idiopathic causes(Genetic or developmental causes) Acquired causes which includes

1. Cerebrovascular disorders.2. Hypoxemia of any cause including vascular insufficiency.3. Fever(childhood).4. Head injury.5. Hypertension’.6. Central nervous system infections.7. Metabolicandtoxicconditions(eg..renalfailure,hypernatremia,hypocalcemia,h

ypoglycaemia).8. Drug and alcoholic withdrawal.9. Allergies.

NURSING MANAGEMENT(DURING A SEIZURE )

The circumstances before the seizure(visual, auditory or olfactory stimuli, tactile stimuli, emotional or psychological disturbances,sleep,hyperventilation)

The occurrence of an aura(premonitory or warning sensation that can be visual, auditory or olfactory)

The first thing the patient does in the seizure where the movements or the stiffness begins, conjugate gaze position, position of the head at the beginning of the seizure. This information gives clue to the location of the seizure lesion in the brain.(In recording it is important to record whether the beginning of the seizure is observed or not)

Observe the areas in the body involved during seizure and the type of movements involved.

The size of both the pupils and whether both the eyes are open or closed. Whether the eyes or head is turned to one side The presence or absence of automatisms(involuntary motor activity, such as

lip smacking or repeated swallowing. Incontinence of urine or stool Unconsciousness if present and the duration. Any obvious paralysis or weakness of arms or legs after any seizure. Inability to speak after the seizure.

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.Whether or not the patient speaks afterwards. Cognitive status(confused or not confused after the seizure. Protect the patient both physically and psychologically. Provide privacy and protect the patient from curious onlookers Ease the patient to the floor if possible. Protect the head with a pad to prevent injury(from striking a hard surface) Loosen constrictive clothing Push aside any furniture that may injure the patient during seizure. If the patient is on bed put side rails If an aura preceded insert an oral airway to reduce the possibility of the

patient from biting the tongue or cheeks. Do not attempt to open the jaws that are clenched in a spasm or to insert

anything. Broken teeth and an injury to the tongue and lips may result from such an action

Do not restrain the patient during a seizure episode. Place the patient in side lying position and the suction apparatus and the

oxygen cylinder should be nearby the patient.

NURSING CARE AFTER THE SEIZURE

Keep the patient on one side to prevent aspiration. Make sure that the airway is patent.

There is usually a period of confusion after an episode of grandmal seizure. A short apnoeic period may occur during or immediately after a generalized seizure.

EPILEPSY

Epilepsy is a group of syndromes characterized by unprovoked recurring seizures.Epileptic syndromes are classified by patterns of clinical features including age of onset,family history,and seizure type.The improved treatments of cerebrovascular disorders,head injuries,brain tumors,meningitis and meningitis has decreased the number of patients who are susceptible to seizures and epilepsy.

ETIOLOGY

Seizures may be heridiatry,but the cause is usually idiopathic. Birth trauma,asphyxia or injuries Infectious diseases(bacterial,viral or parasitic) Toxicity(carbon monoxide and lead poisoning) Circulatory problems Metabolic problems and nutritional disorders Drug or alcohol intoxication

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Brain tumors,abscess,congenital malformations

PATHOPHYSIOLOGY

Messages of the body are carried by the neurones of the brain by means of discharge of electrochemical energy.Some times these cells or group of cells continue firing after a task is finished

Due to the unwanted discharges parts of the body performs irratically

If this uncontrolled abnormal discharges occurs repeatedly the patient is said to have epileptic syndrome

CLINICAL MANIFESTATIONS In simple partial seizures - Only a finger or a hand may shake but the mouth jerks

uncontrollably.Patient talks unintelligibly.Patient may be dizzy and may experience unusual or unintelligent sites.

In complex partial seizures - The patient either remains motionless or moves automatically,but inappropriately for time and place.

In generalized seizures/Grandmal seizures - Intense rigidity of the entire body occurs.Alternative muscle relaxation and contraction occurs.The simultaneous contraction of the diaphragm and the chest muscles produces an epileptic cry.The tongue is chewed and the patient is incontinent to urine and feces.

ASSESSMENT AND DIAGNOSTIC FINDINGS

Assessment is aimed at determining the type of seizures,frequency and severity of the factors that precipitate them.A developmental history is taken including the events of pregnancy and child birth.Patient is asked for any history of head injuries.Physical and neurological examination is done.Biochemical,haematological and serological studies are done.

CT Scan and MRI Electroencephalogram Microelectrodes(Electrodes can be inserted deep into the brain to probe the action

of single brain cells.) Telemetry and computerized equipments are used to monitor electrical brain

activity. Videorecording of the seizures to rule out the type of seizure. SPECT

EPILEPSY IN WOMENWomen with epilepsy often note an increase in seizure frequency mainly during their menses time due to the elevation in sex hormones.Women of child bearing age who has epilepsy requires more care during and after the pregnancy.The risk for congenital anomalies in fetus is 2-3 times more in mothers with epilepsy.The effect of

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maternal seizures and antiseizure medications contributes to malformation.The pregnant women with seizure should carefully monitor blood studies to detect the level of antiseizure medications.Because of the bone loss associated with long term use of antiseizure medications ,patients should be assessed forlow bone mass and osteoporosis.

PREVENTION

Head injury is the main cause of epilepsy. Through highway safety programmes and occupational safety precautions life can be saved.

MANAGEMEN T management depends on the condition of the patient.

Pharmacological therapy

Medications controls the seizures but not cures. Selection of the medication is done depending on the type of seizure. If medications are taken properly it will control seizures to about 70-80%of the cases. Treatment usually starts with a single medication. The starting dose and the rate is adjusted depending on the side effects. The medication levels of the blood should be carefully monitored. Change to another medication is done if the treatment regimen is in appropriate. side effects of the medications can be divided into three groups. Idiosyncratic or allergic disorders that manifests primarily as skin reactions ,Acute toxicity which occurs when the medication is primarily prescribed .Chronic toxicity in the late course of the therapy.

Common medications are Carbamezapine,Clonazepam,Lamotrigine,Phenobarbital,Valporate etc...

SURGICAL MANAGEMENT

Surgery is indicated if the epilepsy is as a result of abscess,cyst or vascular anomalies.

NURSING PROCESS

ASSESSMENT

The patient is asked about the factors or events that may precipitate the seizures.The nurse determines whether the patient has an aura before an epileptic seizure,which may indicate the origin of the seizure.(eg..seeing flashing light may indicate seizure originated in the temporal lobe.The effect of seizure on the patients lifestyle is also assessed.

NURSING DIAGNOSIS

Risk for injury related to seizure activity. Fear related to possibility of seizures. Ineffective individual coping related to stresses imposed.

E major complications are status epilepticus and medication effects.

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NURSING INTERVENTIONS

Preventing injury

The patient is managed to be on the floor to prevent further injury. Potentially harmful items like furniture should be avoided. Patient should never be restrained or shouldnot force anything into the patients

mouth once the seizure episode has begun Pads should be applied to the side rails to prevent injury to the patient

Reducing fear of seizures

Psychological support should be given to the patient and family. Instruct the patient about the importance of taking antiseizure medications on time

and on a continuing basis,it should be of the prescribed dose and shoulnot stop the medication until the physician recommends

Periodic monitoring is essential to ensure adequacy of the treatment and monitor for side effects.

Assess the factors which precipitate the seizures in an attempt to control(Factors includes environmental factors,onset of menstruation in female patients or fever)

The patient is instructed to maintain a regular lifestyle(avoid excessive stimulants)exercise and rest(sleep deprivation may lower the seizure threshold),avoid excessive activity,

Diet is recommended,ketogenic diet is recommended.This is high protein low carbohydrate diet which is used in controlling seizures in children whose seizure is not controlled with two antiepileptics.

Photic stimulation(flickering of light)stimulates seizure activity. Instruct the patient to wear dark glasses,covering one eye is also effective. Stress management classes are recommended. Instruct the patient to avoid alcohol and beverage intake.

Improving coping mechanism

Psychological support should be given and adequate counselling is recommended. Teach the family members as well as the patient regarding the symptoms and its

management.

Providing patient and family education

Ongoing education and psychological support should be given to the patient to overcome the reactions loke anxiety, hostility,secrecy.humiliation and shame.

The patient with epilepsy should carry an emergency medical identification cardor wear a medical information bracelet.

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The patient and the family members should be educated regarding the medication intake as well as the care during seizures.

Managing and monitoring potential complications

The patient and the family members should be instructed about the side effects and the signs and symptoms that indicates medication overdose.

The serum drug levels should be assessed in periodic intervals.

Promoting home and community based care

Teaching patient about self care and continuing care

Thorough oral hygiene after each meal,gum massage,daily flossing and regular interval to prevent or to control gingival hyperplasia in patients receiving dilantin.

Dilantin has drug interaction.Inform the patient regarding this. Written instructions should be given at the patients level of understanding regarding

the treatment regimen. State vocational rehabilitation agencies provides information about job training. People with uncontrollable seizures accompanied by psychological and social

difficulties can be referred to comprehensive epilepsy centres where continuous audio-video and ECG monitoring,specialized treatment and rehabilitation services are available.

EXPECTED OUTCOMES

Sustains no injury during the seizure activity. Indicates decrease in fear. Displays effective individual coping. Exibits knowledge and understanding of epilepsy. Absence of complications.

STATUS EPILEPTICUS

Status epilepticus(acute prolonged seizure activity)is a series of generalized seizures that occur without full recovery of consciousness between the attacks.Vigorous muscular contractions impose a very high metabolic demand and can interfere with respiration.Respiratory arrest at the height of each seizure produces venous congestion and hypoxia of the brain.repeated episodes of cerebral hypoxia and edema can lead to irreversible fatal brain damage.Factors that precipitate status epilepticus includes withdrawal of the antiseizure medication,fever and concurrent infection.

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MEDICAL MANAGEMENT

The goal of the medical management is to stop the seizures as early as possible to ensure adequate cerebral oxygenation and to maintain the patient in a seizure free state.

An airway and adequate oxygenation is established.If the patient remains unresponsive a cuffed endotracheal tube is inserted.

Intravenous Diazepam(Valium),Lorazepam(Ativan),or phosphenytoin(Cerebyx),Is administered slowly.

ECG Monitoring to determine the seizure activity. Vital signs and neurological signs are monitored on a continuous basis. An IV Infusion of dextrose if there is hypoglycaemia. The serum values of the medication is measured because low dose indicates that the

patient is not taking the medication on aregular basis

NURSING MANAGEMENT

The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function because of the risk for delayed depression of the respiration and blood pressure secondary to the administration of the anti seizure medications and sedatives to halt the seizures.

The patient is usually kept in side lying position.Suction apparatus should be available.

Cardiac monitoring and recording of the seizure activity. IV Line should be closely monitored. A patient at long term seizure therapy is at risk for fracture resulting from bone

disease(Osteoporosis,Osteomalacia and hyperparathyroidism) So precautions should be taken to prevent injury.

The nurses must protect themselves from injury

NURSING DIAGNOSIS

Ineffective airway clearance related to loss of consciousness,apnea,excessive secretions, jaw clenching, or airway occlusion by the tongue or foreign body

Turning the patient to the side promotes drainage of saliva from the mouth and reduces the risk of aspiration.

Attempts to force the jaw open or insert objects during a seizure may cause damage to the teeth.

If the airway becomes occluded during the tonic phase ,significant hypoxia may ensure, so maintaining an open airway is essential

Suction the oropharynx,as needed. Provide supplemental oxygen via nasal canula.

If seizure is persistent, endotracheal intubation is needed.

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After the seizure, insert a nasogastric tube and connect to the low suction Supplemental oxygen is given if there is risk of aspiration. Emptying the stomach prevents accidental risk of aspiration.

Risk for status epilepticus related to inadequate pharmacological control or misidentification of the underlying cause.

Administer IV antiseizure medication as ordered.Commonly used antiseizure medications are:

Diazepam(Valium)5-10mg IV may repeat every 10 to 15 minutes,shouldnot exceed 30mg an hour.Observe the patient curiously for respiratory depression.Monitor for drug interactions if the patient is taking phenothiazines,barbiturates,narcotics or monoamine oxidase inhibitors.

Phenobarbital(Luminal)and other barbiturate convulsants.The usual dose of phenobarbiatal ranges from 60-400 mg/day.Observe the patient closely for respiratory depression especially if the patient has also received diazepam.Monitor for drug interactions if the patient is receivingPhenothiazines,Warfarin(Coumadin),digoxin(Lanoxin) etc...

Phenytoin(Dilantin)the usual loading dose is 10 to 15 mg/kg followed by 100 mg every6 to 8 hours.Administer phenytoin slowly in normal saline solution giving not more than 50mg/min.Monitor the ECG and monitor for adverse reactions toxicity,elevated serum glucose levelsdiplopia etc...

Consider the possible underlying cause of the seizure If the seizure doesnot respond to medications general anaesthesia with

mechanical ventilation has to be initiated Risk for injury related to excessive uncontrolled muscle activity

Ensure safe patient positioning,place pillows or padding around the patient and raise the side rails

Maintain the bed in low position During the seizure activity stay with the patient. Maintain a patent airway and suction the secretions if needed. Provide privcacy as possible As the motor activity stops place the patient in sidelying position to prevent

the risk of aspiration Avoid excessive environmental stimulation If the seizure is prolonged monitor for myoglobinuria,indicated by a red or

cola colour Knowledge deficit(seizure management)related to lack of exposure to information

Assess the patient s level of understaning. Instruct the patient and family about the disorder and the need to adhere to

a medical regimen Instruct the patient and family about medications and causes of seizures

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