Professional Documents
Culture Documents
seizures (convulsions) are the result of uncontrolled electrical discharges from the nerve cells of the cerebral cortex and
are characterized by sudden, brief attacks of altered consciousness, motor activity, and/or sensory phenomena. seizures
can be associated with a variety of cerebral or systemic disorders as a focal or generalized disturbance of cortical
function. sensory symptoms arise from the parietal lobe; motor symptoms arise from the frontal lobe.
the phases of seizure activity are prodromal, aural, ictal, and postictal. the prodromal phase involves mood or
behavior changes that may precede a seizure by hours or days. the aura is a premonition of impending seizure activity
and may be visual, auditory, or gustatory. the ictal stage is characterized by seizure activity, usually musculoskeletal.
the postictal stage is a period of confusion/somnolence/irritability that occurs after the seizure.
the main causes for seizures can be divided into six categories:
toxic agents: poisons, alcohol, overdoses of prescription/nonprescription drugs (with drugs the leading cause).
chemical imbalances: hyperkalemia, hypoglycemia, and acidosis.
fever: acute infections, heatstroke.
cerebral pathology: resulting from head injury, infections, hypoxia, expanding brain lesions, increased intracranial
pressure.
eclampsia: prenatal hypertension/toxemia of pregnancy.
idiopathic: unknown origin.
seizures can be divided into two major classifications (generalized and partial). generalized seizure types include
tonic-clonic, myoclonic, clonic, tonic, atonic, and absence seizures. partial (focal) seizures are the most common type
and are categorized as either (1) simple (partial motor, partial sensory) or (2) complex.
CARE SETTING
community; however, may require brief inpatient care on a medical or subacute unit for stabilization/treatment of status
epilepticus.
RELATED CONCERNS
cerebrovascular accident (cva)/stroke
craniocerebral trauma (acute rehabilitative phase)
psychosocial aspects of care
substance dependence/abuse rehabilitation
CIRCULATION
may exhibit: ictal: hypertension, increased pulse, cyanosis
postictal: vital signs normal or depressed with decreased pulse and respiration
EGO INTEGRITY
may report: internal/external stressors related to condition and/or treatment
irritability; sense of helplessness/hopelessness
changes in relationships
may exhibit: wide range of emotional responses
ELIMINATION
may report: episodic incontinence
may exhibit: ictal: increased bladder pressure and sphincter tone
postictal : muscles relaxed, resulting in incontinence (urinary/fecal)
FOOD/FLUID
may report: food sensitivity nausea/vomiting correlating with seizure activity
may exhibit: dental/soft-tissue damage (injury during seizure)
gingival hyperplasia (side effect of long-term phenytoin [dilantin] use)
NEUROSENSORY
may report: history of headaches, recurring seizure activity, fainting, dizziness
history of head trauma, anoxia, cerebral infections
prodromal phase: vague changes in emotional reactivity or affective response preceding
aura in some cases and lasting minutes to hours
presence of aura (stimulation of visual, auditory, hallucinogenic areas)
postictal: weakness, muscle pain, areas of paresthesia/paralysis
may exhibit: seizure characteristics: (ictal, postictal)
generalized seizures:
tonic-clonic (grand mal): rigidity and jerking posturing, vocalization, loss of consciousness,
dilated pupils, stertorous respiration, excessive salivation (froth), fecal/urinary
incontinence, and biting of the tongue may occur and last 2–5 min. postictal
phase: patient sleeps 30 min to several hours, then may be weak, confused, and
amnesic concerning the episode, with nausea and stiff, sore muscles
myoclonic: short abrupt muscle contractions of arms, legs, torso; may not be symmetrical;
lasts seconds
clonic: muscle contraction with relaxation resembling myoclonic movements but with
slower repetitions; may last several minutes
tonic: abrupt increase in muscle tone of torso/face, flexion of arms, extension of legs; lasts
seconds
atonic: abrupt loss of muscle tone; lasts seconds; patient may fall
absence (petit mal): periods of altered awareness or consciousness (staring, fluttering of
eyes) lasting 5–30 sec, which may occur as many as 100 times a day; minor
motor seizures may be akinetic (loss of movement), myoclonic (repetitive motor
contractions), or atonic (loss of muscle tone). postictal phase: amnesia for
seizure events, no confusion, able to resume activity
status epilepticus: defined as 30 or more minutes of continuous generalized seizure activity
or two or more sequential seizures without full recovery of consciousness in
between, possibly related to abrupt withdrawal of anticonvulsants and other
metabolic phenomena. if absence seizures are the pattern, problem may go
undetected for a period of time because patient does not lose consciousness
partial seizures:
complex (psychomotor/temporal lobe): patient generally remains conscious, with reactions
such as dream state, staring, wandering, irritability, hallucinations, hostility, or
fear. may display involuntary motor symptoms (lip smacking) and behaviors
that appear purposeful but are inappropriate (automatism) and include impaired
judgment and, on occasion, antisocial acts; lasts 1–3 min. postictal phase:
absence of memory for these events, mild to moderate confusion
simple (focal-motor/jacksonian): often preceded by aura (may report deja vu or fearful
feeling); no loss of consciousness (unilateral) or loss of consciousness
(bilateral); convulsive movements and temporary disturbance in part controlled
by the brain region involved (e.g., frontal lobe [motor dysfunction], parietal
[numbness, tingling], occipital [bright, flashing lights], posterotemporal
[difficulty speaking]). convulsions may march along limb or side of body in
orderly progression. if restrained during seizure, patient may exhibit combative
and uncooperative behavior; lasts seconds to minutes
PAIN/DISCOMFORT
may report: headache, muscle/back soreness postictally
paroxysmal abdominal pain during ictal phase (may occur during some partial/focal
seizures without loss of consciousness)
may exhibit: guarding behavior
alteration in muscle tone
distraction behavior/restlessness
RESPIRATION
may exhibit: ictal: clenched teeth, cyanosis, decreased or rapid respirations; increased mucous secretions
postictal: apnea
SAFETY
may report: history of accidental falls/injuries, fractures
presence of allergies
may exhibit: soft-tissue injury/ecchymosis
decreased general strength/muscle tone
SOCIAL INTERACTION
may report: problems with interpersonal relationships within family/socially
limitation/avoidance of social contacts
TEACHING/LEARNING
may report: familial history of epilepsy
drug (including alcohol) use/misuse
increased frequency of episodes/failure to improve
discharge plan drg projected mean length of inpatient stay: 4.4 days
considerations: may require changes in medications, assistance with some homemaker/maintenance tasks
relative to issues of safety, and transportation
refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
electrolytes: imbalances may affect/predispose to seizure activity.
glucose: hypoglycemia may precipitate seizure activity.
blood urea nitrogen (bun): elevation may potentiate seizure activity or may indicate nephrotoxicity related to
medication regimen.
complete blood count (cbc): aplastic anemia may result from drug therapy.
serum drug levels: to verify therapeutic range of antiepileptic drugs (aeds).
toxicology screen: determines potentiating factors such as alcohol or other drug use.
skull x-rays: identifies presence of space-occupying lesions, fractures.
electroencephalogram (eeg) may be done serially: locates area of cerebral dysfunction; measures brain activity. brain
waves take on characteristic spikes in each type of seizure activity; however, up to 40% of seizure patients have
normal eegs because the paroxysmal abnormalities occur intermittently.
video-eeg monitoring, 24 hours (video picture obtained at same time as eeg): may identify exact focus of seizure
activity (advantage of repeated viewing of event with eeg recording).
computed tomography (ct) scan: identifies localized cerebral lesions, infarcts, hematomas, cerebral edema, trauma,
abscesses, tumor; can be done with or without contrast medium.
magnetic resonance imaging (mri): localizes focal lesions.
positron emission tomography (pet): demonstrates metabolic alterations, e.g., decreased metabolism of glucose at site
of lesion.
single photon emission computed tomography (spect): may show local areas of brain dysfunction when ct and mri are
normal.
magnetoencephalogram: maps the electrical impulses/potential of brain for abnormal discharge patterns.
lumbar puncture: detects abnormal cerebrospinal fluid (csf) pressure, signs of infections or bleeding (i.e.,
subarachnoid, subdural hemorrhage) as a cause of seizure activity (rarely done).
wada’s test: determines hemispheric dominance (done as a presurgical evaluation before temporal lobectomy).
NURSING PRIORITIES
1. prevent/control seizure activity.
2. protect patient from injury.
3. maintain airway/respiratory function.
4. promote positive self-esteem.
5. provide information about disease process, prognosis, and treatment needs.
DISCHARGE GOALS
ACTIONS/INTERVENTIONS RATIONALE
independent
explore with patient the various stimuli that may alcohol, various drugs, and other stimuli (e.g., loss of
precipitate seizure activity. sleep, flashing lights, prolonged television viewing) may
increase brain activity, thereby increasing the potential for
seizure activity.
ACTIONS/INTERVENTIONS RATIONALE
seizure precautions (nic)
independent
discuss seizure warning signs (if appropriate) and usual enables patient to protect self from injury and recognize
seizure pattern. teach so to recognize warning signs and changes that require notification of physician/further
how to care for patient during and after seizure. intervention. knowing what to do when seizure occurs can
prevent injury/complications and decreases so’s feelings
of helplessness.
keep padded side rails up with bed in lowest position, or minimizes injury should seizures (frequent/generalized)
place bed up against wall and pad floor if rails not occur while patient is in bed. note: most individuals seize
available/appropriate. in place and if in the middle of the bed, individual is
unlikely to fall out of bed.
encourage patient not to smoke except while supervised. may cause burns if cigarette is accidentally dropped
during aura/seizure activity.
evaluate need for/provide protective headgear. use of helmet may provide added protection for
individuals who suffer recurrent/severe seizures.
use tympanic thermometer when necessary to take reduces risk of patient biting and breaking glass
temperature. thermometer or suffering injury if sudden seizure activity
should occur.
maintain strict bedrest if prodromal signs/aura patient may feel restless/need to ambulate or even
experienced. explain necessity for these actions. defecate during aural phase, thereby inadvertently
removing self from safe environment and easy
observation. understanding importance of providing for
own safety needs may enhance patient cooperation.
turn head to side/suction airway as indicated. insert plastic helps maintain airway and reduces risk of oral trauma but
bite block only if jaw relaxed. should not be “forced” or inserted when teeth are
clenched because dental and soft-tissue damage may
result. note: wooden tongue blades should not be used
because they may splinter and break in patient’s mouth.
(refer to nd: airway clearance/breathing pattern,
ineffective, risk for)
cradle head, place on soft area, or assist to floor if out of gentle guiding of extremities reduces risk of physical
bed. do not attempt to restrain. injury when patient lacks voluntary muscle control. note:
if attempt is made to restrain patient during seizure,
erratic movements may increase, and patient may injure
self or others.
document preseizure activity, presence of aura or unusual helps localize the cerebral area of involvement.
behavior, type of seizure activity (e.g., location/duration
of motor activity, loss of consciousness, incontinence, eye
activity, respiratory impairment/cyanosis), and
frequency/recurrence. note whether patient fell, expressed
vocalizations, drooled, or had automatisms (e.g., lip-
smacking, chewing, picking at clothes).
ACTIONS/INTERVENTIONS RATIONALE
seizure management (nic)
independent
perform neurological/vital sign check after seizure, e.g.,
level of consciousness, orientation, ability to comply with
simple commands, ability to speak; memory of incident;
weakness/motor deficits; blood pressure (bp), documents postictal state and time/completeness of
pulse/respiratory rate. recovery to normal state. may identify additional safety
concerns to be addressed.
reorient patient following seizure activity.
ACTIONS/INTERVENTIONS RATIONALE
seizure management (nic)
collaborative
topiramate (topamax), ethosuximide (zarontin), adjunctive therapy for partial seizures or an alternative for
lamotrigine (lamictal), gabapentin (neurontin); patients when seizures are not adequately controlled by
other drugs.
diazepam (valium, diastat rectal gel); may be used alone (or in combination with phenobarbital)
to suppress status seizure activity. diastat, a gel, may be
administered rectally, even in the home setting, to reduce
frequency of seizures and need for additional medical
care.
monitor/document aed drug levels, corresponding side standard therapeutic level may not be optimal for
effects, and frequency of seizure activity. individual patient if untoward side effects develop or
seizures are not controlled.
monitor cbc, electrolytes, glucose levels. identifies factors that aggravate/decrease seizure
threshold.
prepare for surgery/electrode implantation as indicated. vagal nerve stimulator, magnetic beam therapy, or other
surgical intervention (e.g., temporal lobectomy) may be
done for intractable seizures or well-localized
epileptogenic lesions when patient is disabled and at high
risk for serious injury. success has been reported with
gamma ray radio surgery for the treatment of multiple
seizure activity that has otherwise been difficult to
control.
ACTIONS/INTERVENTIONS RATIONALE
airway management (nic)
independent
encourage patient to empty mouth of dentures/foreign
objects if aura occurs and to avoid chewing gum/sucking
lozenges if seizures occur without warning.
reduces risk of aspiration/foreign bodies lodging in
place in lying position, flat surface; turn head to side pharynx.
during seizure activity.
loosen clothing from neck/chest and abdominal areas. promotes drainage of secretions; prevents tongue from
obstructing airway.
insert plastic airway or soft roll as indicated and only if
jaw is relaxed. facilitates breathing/chest expansion.
ACTIONS/INTERVENTIONS RATIONALE
independent
discuss feelings about diagnosis, perception of threat to reactions vary among individuals, and previous
self. encourage expression of feelings. knowledge/experience with this condition affects
acceptance of therapeutic regimen. verbalization of fears,
anger, and concerns about future implications can help
patient begin to accept/deal with situation.
identify possible/anticipated public reaction to condition. provides opportunity to problem-solve response, and
encourage patient to refrain from concealing problem. provides measure of control over situation. concealment is
destructive to self-esteem (potentiates denial), blocking
progress in dealing with problem, and may actually
increase risk of injury/negative response when seizure
does occur.
explore with patient current/past successes and strengths. focusing on positive aspects can help alleviate feelings of
guilt/self-consciousness and help patient begin to accept
manageability of condition.
avoid overprotecting patient; encourage activities, participation in as many experiences as possible can
providing supervision/monitoring when indicated. lessen depression about limitations.
observation/supervision may need to be provided for such
activities as gymnastics, climbing, and water sports.
determine attitudes/capabilities of so. help individual negative expectations from so may affect patient’s sense
realize that his/her feelings are normal; however, guilt and of competency/self-esteem and interfere with support
blame are not helpful. received from so, limiting potential for optimal
management/personal growth.
ACTIONS/INTERVENTIONS RATIONALE
self-esteem enhancement (nic)
independent
stress importance of staff/so remaining calm during
seizure activity.
independent
review pathology/prognosis of condition and lifelong provides opportunity to clarify/dispel misconceptions and
need for treatments as indicated. discuss patient’s present condition as something that is manageable within
particular trigger factors (e.g., flashing lights, a normal lifestyle.
hyperventilation, loud noises,video games, tv viewing).
review possible effects of hormonal changes. alterations in hormonal levels that occur during
menstruation and pregnancy may increase risk of seizures.
discuss significance of maintaining good general health, regularity and moderation in activities may aid in
e.g., adequate diet, rest, moderate exercise, and avoidance reducing/controlling precipitating factors, enhancing
of exhaustion, alcohol, caffeine, and stimulant drugs. sense of general well-being, and strengthening coping
ability and self-esteem. note: too little sleep or too much
alcohol can precipitate seizure activity in some people.
review importance of good oral hygiene and regular reduces risk of oral infections and gingival hyperplasia.
dental care.
identify necessity/promote acceptance of actual reduces risk of injury to self or others, especially if
limitations; discuss safety measures regarding driving, seizures occur without warning.
using mechanical equipment, climbing ladders,
swimming, and hobbies.
discuss local laws/restrictions pertaining to persons with although legal/civil rights of persons with epilepsy have
epilepsy/seizure disorder. encourage awareness but not improved during the past decade, restrictions still exist in
necessarily acceptance of these policies. some states pertaining to obtaining a driver’s license,
sterilization, workers’ compensation, and required
reportability to state agencies.
review medication regimen, necessity of taking drugs as lack of cooperation with medication regimen is a leading
ordered, and not discontinuing therapy without physician cause of seizure breakthrough. patient needs to know risks
supervision. include directions for missed dose. of status epilepticus resulting from abrupt withdrawal of
anticonvulsants. depending on the drug dose and
frequency, patient may be instructed to take missed dose
if remembered within a predetermined time frame.
ACTIONS/INTERVENTIONS RATIONALE
teaching: prescribed medication (nic)
independent
provide information about potential drug interactions and
necessity of notifying other healthcare providers of drug
regimen.
knowledge of anticonvulsant use reduces risk of
prescribing drugs that may interact, thus altering seizure
threshold or therapeutic effect. for example, phenytoin
(dilantin) potentiates anticoagulant effect of warfarin
(coumadin), whereas isoniazid (inh) and chloramphenicol
(chloromycetin) increase the effect of phenytoin
(dilantin), and some antibiotics (e.g., erythromycin) can
review proper use of diazepam rectal gel (diastat) with cause elevation of serum level of carbamazepine
patient and so/caregiver as appropriate. (tegretol), possibly to toxic levels.
stress need for routine follow-up care/laboratory testing as expedites treatment and diagnosis in emergency
indicated, e.g., cbc should be monitored biannually and in situations.
presence of sore throat/fever, signs of other infection.
therapeutic needs may change and/or serious drug side
effects (e.g., agranulocytosis or toxicity) may develop.