This document discusses seizure disorders and epilepsy. It begins by differentiating between types of seizures, such as partial and generalized seizures. Diagnostic tests for seizures are outlined, along with the assessment and management of seizures. Various anti-seizure medications are discussed, along with goals of drug therapy and patient education. Nursing priorities for patients with seizures include maintaining a patent airway, providing oxygenation, obtaining vascular access, using seizure precautions, administering appropriate medications, and assessing therapeutic drug levels.

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