Transcript Chapter_059_Seizure_Disorders

Focus on
Seizure Disorders

(Relates to Chapter 59,
“Nursing Management:
Chronic Neurologic Problems,”
in the textbook)
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Seizure
 Paroxysmal, uncontrolled electrical
discharge of neurons in brain,
interrupting normal function
 Often symptom of underlying illness
 May accompany other disorders or
occur spontaneously without apparent
cause
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Seizure
 Seizures resulting from metabolic
disturbances are not considered
epilepsy if seizures cease when
underlying condition is treated.
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Seizure
 Origin possibly related to metabolic
disturbances
 Acidosis
 Electrolyte imbalances
 Hypoglycemia
 Hypoxemia
 Alcohol or barbiturate withdrawal
 Dehydration or water intoxication
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Seizure
 Origin possibly related to extracranial
disorders
 Heart
 Hypertension
 Lung
 Kidneys
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Seizure
 Origin possibly related to extracranial
disorders
 Liver
 Systemic lupus erythematosus
 Diabetes mellitus
 Septicemia
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Epilepsy
 Condition in which a person has
spontaneously recurring seizures
caused by underlying chronic
condition
 In United States, 3 million people with
epilepsy
 Higher incidence in those >60 years of
age
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Etiology and Pathophysiology
 Common causes during first 6 months
of life
 Severe birth injury
 Congenital birth defects involving CNS
 Infections
 Inborn errors of metabolism
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Etiology and Pathophysiology
 Common causes from ages 2 to 20
 Birth injury
 Infection
 Trauma
 Genetic factors
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Etiology and Pathophysiology
 Common causes between ages
20 and 30
 Structural lesions
 Trauma
 Brain tumor
 Vascular disease
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Etiology and Pathophysiology
 Common causes after 50
 Cerebrovascular lesions
 Metastatic brain tumors
 75% of seizure disorders are
considered idiopathic.
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Etiology and Pathophysiology
 Role of heredity in seizure disorders is
difficult to determine.
 Some families carry predisposition in
the form of low threshold to seizureproducing stimuli.
 Trauma
 Disease
 High fever
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Etiology and Pathophysiology
 In epilepsy, abnormal neurons
undergo spontaneous firing.
 Cause of abnormal firing is unclear.
 Firing spreads to adjacent or distant
areas of the brain.
 If activity involves whole brain,
generalized seizure occurs.
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Etiology and Pathophysiology
 Often area of brain from which
epileptic activity arises is found to
have gliosis.
 Thought to interfere with normal
chemical and structural environment of
neurons
 Therefore making them more likely to fire
abnormally
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Etiology and Pathophysiology
 Astrocytes are now believed to play a
key role in recurring seizures.
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Clinical Manifestations
 Determined by site of electrical
disturbance
 Divided into two major classes:
generalized and partial
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Algorithm for Classification of Seizures
Fig. 59-2. Algorithm for classification of seizures.
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Clinical Manifestations
 May progress through several phases
 Prodromal phase
 Aural phase
 Ictal phase
 Postictal phase
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Clinical Manifestations
Generalized Seizures
 Characterized by bilateral
synchronous epileptic discharges in
brain from seizure onset
 No warning or aura as entire brain is
affected
 Loss of consciousness from seconds to
minutes
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Clinical Manifestations
Generalized Seizures
 Tonic-clonic seizures (grand mal)
 Characterized by loss of consciousness
and falling
 Body stiffens (tonic) with subsequent
jerking of extremities (clonic).
 Cyanosis, excessive salivation, and
tongue or cheek biting may occur.
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Clinical Manifestations
Generalized Seizures
 Tonic-clonic seizures (grand mal)
(cont’d)
 Postictal phase for tonic-clonic
characterized by muscle soreness,
fatigue; patient may sleep for hours
 May not feel normal for days
 No memory of seizure
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Clinical Manifestations
Generalized Seizures
 Typical absence seizures (petit mal)
 Occurs only in children and rarely into
adolescence
 May cease or develop into another type
 Typical symptom is staring spell for only a
few seconds and usually goes unnoticed
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Clinical Manifestations
Generalized Seizures
 Typical absence seizures (petit mal)
(cont’d)
 Brief loss of consciousness
 May occur up to 100 times/day if
untreated
 EEG demonstrates pattern unique to this
type of seizure.
 Often precipitated by hyperventilation
and flashing lights
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Clinical Manifestations
Generalized Seizures
 Atypical absence seizures
characterized by staring spell with
other signs and symptoms
 Brief warnings
 Peculiar behavior during seizure
 Confusion after
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Clinical Manifestations
Generalized Seizures
 Myoclonic seizure
 Characterized by sudden, excessive jerk
of body and extremities
 Can be forceful enough to cause fall
 Brief and may occur in clusters
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Clinical Manifestations
Generalized Seizures
 Atonic seizure involves tonic episode
or paroxysmal loss of muscle tone and
person falls
 Consciousness usually returns by time
person hits ground and can resume
normal activity
 Great risk for head injury
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Clinical Manifestations
Generalized Seizures
 Tonic seizures involve sudden onset of
decreased exterior muscle tone.
 Patients often fall.
 Clonic seizures begin with loss of
consciousness and sudden loss of
muscle tone.
 Followed by limb jerking
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Clinical Manifestations
Partial Seizures
 Partial seizures are referred to as
partial focal seizures.
 Caused by focal irritations
 Begin in specific region of cortex
 May be confined to one side of brain
and remain partial or focal in nature
 May involve entire brain, accumulating
in tonic-clonic
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Clinical Manifestations
Partial Seizures
 Divided into simple and complex
partial seizures
 Simple: simple motor or sensory
phenomena with elementary symptoms
with no loss of consciousness and lasting
less than 1 minute
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Clinical Manifestations
Partial Seizures
 Any tonic-clonic seizure preceded by
aura or warning is a partial seizure that
generalizes secondarily.
 Second generalized seizure may result
in transient residual neurologic deficit
postictally (Todd’s paralysis).
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Clinical Manifestations
Partial Seizures
 Divided into simple and complex
partial seizures
 Complex: involve behavioral, emotional,
affective, and cognitive function
 Alteration in consciousness
 Followed by period of postictal confusion
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Clinical Manifestations
Partial Seizures
 Most common complex partial seizure
involves lip smacking and
automatisms.
 Called psychomotor seizures
 No memory of activity during seizure
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Clinical Manifestations
Partial Seizures
 Psychosensory symptoms that may
occur during complex partial seizures
 Distortions of visual or auditory
sensations
 Vertigo
 Alterations in memory
 Alterations in thought processes
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Clinical Manifestations
Partial Seizures
 Alterations in sexual function
 May experience sexual sensations during
seizure
 Antiseizure drugs can ↓ sexual drive or
erectile dysfunction
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Complications
 Status epilepticus is state of constant
seizure or condition when seizures
recur in rapid succession without
return to consciousness between
seizures.
 Neurologic emergency
 Can involve any type of seizure
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Complications
 Status epilepticus causes the brain to
use more energy than is supplied.
 Neurons become exhausted and cease to
function.
 Permanent brain damage can result.
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Complications
 Tonic-clonic status epilepticus most
dangerous as it can cause ventilatory
insufficiency, hypoxemia, cardiac
arrhythmias, hyperthermia, and
systemic acidosis
 Trauma during seizures can cause
severe injury and death.
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Complications
 Social stigma
 Interferes with values of self-control,
conformity, and independence
 Discrimination in employment and
education
 Driving sanctions
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Diagnostic Studies
 Accurate, comprehensive description
of seizures with patient’s health
history
 EEG
 Only small percentage of patients with
seizure disorders have abnormal findings
with first test.
 Continuous monitoring may be needed.
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Diagnostic Studies
 Magnetoencephalography in
conjunction with EEG
 Greater sensitivity for detecting small
magnetic fields generated by neuronal
activity
 CBC, serum chemistries, liver and
kidney function, UA to rule out
metabolic disorders
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Diagnostic Studies
 CT or MRI in new-onset seizure to rule
out structural lesion
 Cerebral angiography, SPECT, MRS,
MRA, and PET in selected situations
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Algorithm for Classification of
Seizures
Fig. 59-2. Algorithm for classification of seizures.
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Collaborative Care
 Drug therapy aimed at prevention
 Stabilize nerve cell membranes and
prevent spread of epileptic discharge.
 70% of patients controlled with
medication
 Monitor drug serum levels.
 Serum levels of medication should be
monitored.
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Collaborative Care
 Primary drugs for treatment of
generalized tonic-clonic and partial
seizures
 Older
 phenytoin (Dilantin)
 carbamazepine (Tegretol)
 phenobarbital
 divalproex (Depakote)
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Collaborative Care
 Primary drugs for generalized tonicclonic and partial seizures
 Newer
 gabapentin (Neurontin)
 lamotrigine (Lamictal)
 topiramate (Topamax)
 tiagabine (Gabitril)
 levetiracetam (Keppra)
 zonisamide (Zonegran)
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Collaborative Care
 Felbamate (Felbatol) may be used to
treat patients whose seizure disorders
are refractory to other drugs.
 Pregabalin (Lyrica) is used as an “addon” for control of partial seizures that
are not successfully managed with a
single medication.
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Collaborative Care
 For absence, akinetic, and myoclonic
 Ethosuximide (Zarontin), divalproex
(Depakote), and clonazepam (Klonopin)
 Status epilepticus treated with IV
lorazepam (Ativan) and diazepam
(Valium)
 Must be followed with long-acting drugs
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Collaborative Care
 Antiseizure drugs should not be
discontinued abruptly as this can
precipitate seizures.
 Side effects include diplopia, drowsiness,
ataxia, and mental slowing.
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Collaborative Care
 Neurologic assessment involves
testing for
 Nystagmus
 Hand and gait coordination
 Cognitive functioning
 General alertness
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Collaborative Care
 Side effects outside of CNS include
 Rashes
 Hyperplasia of gingiva
 Blood dyscrasias
 Effects on liver and kidneys
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Collaborative Care
 Gerontologic considerations
 Phenytoin may be problematic for older
adults with compromised liver function.
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Collaborative Care
 Gerontologic considerations (cont’d)
 Newer antiseizure medications offer
better treatment for older adults.
 Gabapentin
 Levetiracetam
 Lamotrigine
 Trileptal
 Topiramate
 Zonisamide
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Collaborative Care
 Surgical removal of epileptic focus to
prevent spread of epileptic activity in
brain
 Removal of one lobe (usually temporal) or
cortex, or separation of two hemispheres
(corpus callosotomy)
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Collaborative Care
 Benefits of surgery include reduction
or cessation in frequency of seizures.
 Not all types benefit from surgery.
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Collaborative Care
 Requirements for surgery
 Diagnosis of epilepsy confirmed
 Adequate trial with drug therapy without
satisfactory results
 Electroclinical syndrome defined
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Collaborative Care
 Vagal nerve stimulation gives
intermittent stimulation to brain to
reduce frequency and intensity of
seizures.
 Biofeedback to control seizures
teaches patient to maintain a certain
brain wave frequency that is refractory
to seizure activity.
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Nursing Assessment
 Birth defects or injuries at birth
 Anoxic episodes
 CNS trauma
 Tumors
 Metabolic disorders
 Alcoholism
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Nursing Assessment
 Exposure to metals or carbon
monoxide
 Hepatic or renal failure
 Compliance with antiseizure
medications, barbiturate or alcohol
withdrawal, cocaine/amphetamines
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Nursing Assessment
 Family history
 Headaches, aura, mood or behavioral
changes before seizure
 Anxiety, depression, loss of selfesteem, social isolation
 Decreased sexual drive, erectile
dysfunction
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Nursing Assessment
 Metabolic acidosis or alkalosis
 Hyperkalemia
 Hypoglycemia
 Dehydration
 Water intoxication
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Nursing Assessment
 Bitten tongue, soft tissue damage,
cyanosis
 Abnormal respiratory rate
 Apnea (ictal)
 Absent or abnormal breath sounds
 Airway occlusion
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Nursing Assessment
 Hypertension, tachy/bradycardia
 Bowel/urinary incontinence, excessive
salivation
 Weakness, paralysis, ataxia (postictal)
 Abnormal CT, MRI, EEG
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Nursing Assessment
 Tonic-clonic: loss of consciousness,
muscle tightening then jerking,
dilated pupils, hyperventilation then
apnea, postictal somnolence
 Absence: altered consciousness, minor
facial motor activity
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Nursing Assessment
 Simple: aura; focal sensory, motor,
cognitive, or emotional phenomena;
unilateral “marching”; motor seizure
 Complex: altered consciousness with
inappropriate behaviors, amnesia of
event
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Nursing Diagnoses
 Ineffective breathing pattern
 Risk for injury
 Ineffective coping
 Ineffective self-health management
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Planning
 Overall goals are that patient will
 Be free from injury during seizure
 Have optimal mental and physical
functioning while taking antiseizure
medications
 Have satisfactory psychosocial
functioning
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Nursing Implementation
Prevention
 Wear helmet if risk for head injury.
 General health habits (diet, exercise)
 Assist to identify events or situations
precipitating seizures, and avoid if
possible.
 Instruct to avoid excessive alcohol,
fatigue, and loss of sleep.
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Nursing Implementation
Acute Intervention
 Observation and treatment of seizure
 Maintain patent airway, support head,
turn to side, loosen constrictive clothing,
ease to floor
 May require suctioning or oxygen after
seizure
 Assessment of level of understanding
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Nursing Implementation
Ambulatory and Home Care
 Instruct on importance of adherence
to medication, not to adjust dose
without physician
 Keep regular appointments.
 Teach family members emergency
management.
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Nursing Implementation
Ambulatory and Home Care
 Emotional support and identification
of coping mechanisms
 Medical alert bracelets
 Referrals to agencies and
organizations
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Evaluation
 Appropriate HR/rhythm, depth of
respirations
 No injury
 Verbalization of knowledge of
potential injury
 Arrangement of environment to
minimize injury
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Evaluation
 Acceptance of disorder
 Acknowledgment seizure has occurred
 Therapeutic drug levels
 Compliance with therapeutic regimen
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Audience Response Question
The nurse is called to the patient’s room by the patient’s
spouse when the patient experiences a seizure. Upon finding
the patient in a clonic reaction, the nurse should:
1. Turn the patient to the side.
2. Start oxygen by mask at 6 L/min.
3. Restrain the patient’s arms and legs to prevent injury.
4. Record the time sequence of the patient’s movements and
responses as they occur.
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Case Study
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Case Study
 54-year-old man began to experience
periods of feeling suddenly
disoriented.
 He did not personally know this was
happening.
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Case Study
 His co-worker told him that on several
occasions, she observed he was
behaving inappropriately.
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Case Study
 This behavior consisted of lipsmacking and facial grimacing lasting
a couple of minutes, followed by
disorientation and confusion.
 Fearing he had Alzheimer’s disease, he
made an appointment with a
neurologist.
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Discussion Questions
1. What type of seizure is he most likely
experiencing?
2. What is the hallmark of this type of
seizure?
3. What patient teaching should you do
with him?
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