seizures

1. SEIZURE
DISORDERS
Linda H. Warren
EdD RN MSN CCRN
NUR 335

2. OBJECTIVES
Differentiate different types of seizures.
Demonstrate knowledge of diagnostic testing.
Demonstrate knowledge of assessment & management of seizures.
Discuss various pharmacological agents used in the treatment of
seizure disorders.
Demonstrate knowledge of patient & family teaching.

3. WHAT IS A SEIZURE?...
Abnormal electrical discharges
in the cerebral cortex.
Repetitive depolarization of
hyperactive, hypersensitive cells
at a rate of 300 – 1000 per sec.
Alteration in sensation, behavior,
movement, perception, or LOC.
• Seen at different levels r/t type of seizure.

7. EPILEPSY IS A
SPECTRUM OF
DISORDERS!!!

8. INTERNATIONAL CLASSIFICATION OF EPILEPTIC SEIZURES
Elementary (Simple) Partial:
• No impairment of consciousness.
• Motor or sensory
• Autonomic (repetitive)
• Psychic (déjà vu)
Complex Partial:
• Simple partial at onset
• Some impaired consciousness
PARTIAL: Activation of a restricted part of one hemisphere.

9. MOTOR:
• Myoclonic
• Clonic
• Tonic
• Tonic-Clonic
• Atonic
• Status Epilepticus
NONMOTOR:
• Absence Attacks
- Simple / typical
- Atypical
• Eyelid myoclonia
GENERALIZED: both hemispheres affected
INTERNATIONAL CLASSIFICATION OF EPILEPTIC SEIZURES

11. PHASES OF
SEIZURE ACTIVITY:
Prodromal:
 Changes in mood or behavior seen before a seizure.
Aural: signals the start of seizure activity.
 Lasts seconds to minutes
 Dreamlike, déjà vu, lightheaded, fear, smells (subjective)
Ictal: duration of seizure activity
 May be convulsive or non-convulsive
 Depends on seizure type & part of brain affected
Post-ictal: period after seizure, ”recovery stage”
 Can last minutes to hours
 Pt may not remember the seizure
 Pt may be confused, tired, weak, uncoordinated

15. PARTIAL SEIZURES:
Simple:
• Motor
• Sensory (visual, auditory, smell)
• Autonomic
- Hypotension / HTN
- Tachy/bradycardia
- Pallor, sweating
• Psychic
Complex:
• Automatisms:
- Lip smacking, pill rolling

16. PARTIAL SEIZURES:

17. GENERALIZED SEIZURES:
TONIC / CLONIC
TONIC PHASE: stiffening
• Rigid muscles
• Extremities extended
• Neck hyperextension
• Breathing ceases / Cyanosis
CLONIC PHASE: jerking
• Return of Breathing / Hyperventilation
• Muscles contract and relax
• Phase gradually subsides
“Grand Mal”
Loss of Consciousness

19. GENERALIZED SEIZURES:
ABSENCE SEIZURES
• “Petit Mal”
• Non-Convulsive
• Usually occurs in children:
- Blank Stare
- Impaired Consciousness (briefly)
- Cessation of movement (briefly)

20. STATUS EPILEPTICUS:
 Seizure activity lasts >30 mins.
 Sequential seizures without regaining
consciousness btwn seizures.
Frequent Causes / Precipitating Factors:
• Non-compliance taking anticonvulsants
• ETOH withdrawal (MI, stroke)
• Electrolyte imbalances
• Head trauma
• Brain tumor
• Azotemia (waste accumulation r.t renal failure)
MEDICAL EMERGENCY!!!

21. PHASE ONE:
• ↑ cerebral metabolism
• Hyperglycemia (release of glucose from brain)
• HTN (↑ cerebral blood flow)
• Hyperpyrexia / fever (r.t catecholamine release)
• Lactic acidosis (anaerobic metabolism)
• Cardiac dysrhythmias (↑ epi/NE)
• Autonomic dysfunction
PHASE TWO: 30-60 mins after phase one
• Decompensation r/t ↑ metabolic demands
• Metabolic / Respiratory acidosis
• Hypoglycemia (depleted energy stores)
• Electrolyte imbalances (sweating, dehydration)
• Pulmonary edema
• Aspiration (esp. if vomiting)
• Renal Failure (hyperkalemia, hyponatremia)
• Death!!

23. DOCUMENTATION
• Time seizure began & ended, duration of seizure
• Status before seizure
• Description of the seizure
• Type of motor movement
• Parts of the body involved, where did it start?
• LOC: Before, during & after seizure?
• Pupil Response: Deviation (deviates to side the focus initiated)
• Incontinence / Diaphoresis
• Complications during the seizure: injury, fractures, etc.
• Vital Signs including Pulse-Ox: may be apneic for a period of time
• Post-ictal status
• Motor / Sensory / neuro status (GCS, can they follow commands or talk)
• Behavior: Confusion , Headache, Drowsiness

24. EPILEPSY
• Seizure Disorder
• A condition of recurring seizures
• Occur over days, weeks or years
• Primary: Idiopathic
• Secondary: Symptom of an underlying condition
(tumor, facial injury, previous brain injury)

25. HISTORY & PHYSICAL
• Birth and developmental history (forceps? Difficult labor?)
• Illnesses or injuries
• Family history
• Febrile seizures as children
• Neurological Assessment: GCS (best eye opening, verbal, mvmt)
• Seizure History
• Precipitating Factors (a certain smell/taste/sensory experience?)
• Antecedent Event (what happened before seizure began?)
• Seizure Description

26. DIAGNOSTIC TESTS
• Labs
- BMP, electrolytes, BUN/creatinine r/t azotemia, glucose, LFT
- Monitor for therapeutic serum levels of anticonvulsant
• Lumbar Puncture (meningitis?)
• CT Scan (tumors, lesions)
• MRI / MRA
• PET Scan (tumors)
• EEG

27. ASSESSMENT
• Neurological
• Respiratory
• Precipitating Factors
• Cardiac Monitoring

28. MANAGEMENT
Airway: ensure adequate oxygenation
• Be prepared to intubate
• Meds to TX can also cause respiratory depression
Vascular Access
Seizure precautions: pad side rails, low bed, lower to floor

30. MEDICAL MANAGEMENT
 Lorazepam (Ativan): drug of choice (1-2mg, consecutive doses)
• Benzodiazepines (Lorazepam, midazolam, diazepam)
• Dilantin (phenytoin): anticonvulsant
- ONLY given with NS.
- <50mg/min bc it can cause cardiac arrest (apply cardiac monitor).
- Requires a filter added to IV tubing if given as a gtt.
- NEVER mixed w dextrose (precipitates & clogs up tubing).
• Phenobarbital: anticonvulsant
• takes a while to reach therapeutic levels, given as maintenance dose.
• Propofol: mg/kg when used for seizure activities (not mcg/kg)
- Assess for hypotension & respiratory depression.

31. COLLABORATIVE MANAGEMENT
Drug Therapy
Surgery
Vagal Nerve Stimulation

32. GOALS OF DRUG THERAPY
Reduce number of seizures.
Return to normal ADLs with minimal restrictions.
• Significant lifestyle changes
• May not be able to drive
• May not be able to participate in contact sports

33. ANTI-SEIZURE MEDICATIONS
• Carbamazepine (Tegretol)
• Divalproex (Depakote)  also an antipsychotic
• Gabapentin (Neurontin)  also used for neuropathy
• Phenytoin (Dilantin) not used as much bc side effects
• Causes dental decay…ensure pt has frequent dental visits.
• Valproic Acid (Depakane)
• Lorazapam (Ativan)
• Diprivan (Propofol)

34. ANTI-SEIZURE MEDS:
ABSENCE & MYOCLONIC SEIZURES
• Clonazepam (Klonapin)
• Divalproex (Depakote)
• Ethosuzimide (Zarontin)
• Phenobarbitol
• Valproic Acid (Depakene)
EEG helps to determine if pt is seizing when it can’t be
visually observed (when pt is on anticonvulsants)

35. NURSING DIAGNOSIS
• Risk for Injury
• Risk for Ineffective Breathing Pattern
• Risk for Ineffective Airway Clearance
• Risk for Altered Tissue Perfusion
• Risk for Volume Excess
• Altered Thought Process
• Impaired Verbal Communication
• Risk for Ineffective Family Coping
• Knowledge Deficit
• Self-Esteem Disturbance / Anxiety

36. PRIORITIES:
• Maintain Patent Airway
• Provide Adequate Oxygenation
• Maintain / Obtain Vascular Access
• Maintain Seizure Precautions
• Preparation / Administration of Appropriate Medications
• Assess for therapeutic drug levels

37. PATIENT & FAMILY
EDUCATION
• Medications need to be taken as
prescribed to maintain therapeutic
levels & prevent complications.
• Use of non-drug techniques
• Medic alert bracelet
• Community resources
AVOID:
• Alcohol
• Elicit drug use
• Fatigue
• Sleep deprivation