Download PowerPoint - NC-NET

SEIZURE DISORDERS
Joyce Estes RN, MSN
Objectives
• By the end of this module, the student will be
able to:
• Explain what a seizure is and the incidence of
patients who have seizures.
• Differentiate between seizures and epilepsy.
• Discuss the causes of seizure activity.
• Discuss the types of seizures based on the
type of movement presented with each.
Objectives (cont.)
• Discuss the stages of a seizure and apply to the
assessment and document of seizure activity.
• Compare types and activity of childhood seizures
with the adult seizure.
• Discuss the various diagnosis, treatments and
medications used to manage seizure disorders.
• Describe the appropriate nursing diagnosis and
interventions for the management of seizures.
Seizures in History and FYI
• 400 AD-The Greek physician Hippocrates writes the first book
on epilepsy.
• Seizures were known as “convulsions or fits”
• 1494-women with seizures were thought to be witches
• Some people known to have seizures and epilepsy:
– Socrates
– Charles Dickens
– Vincent Van Gogh
– Alfred Nobel
– Richard Burton
– Agatha Christie
Notice those people with seizures/epilepsy are gifted writers, thinkers,
painters.
What is a seizure?
What is epilepsy?
• A seizure is the clinical event that result from
abnormal nerve cell (neuronal) activity.
– Excessive bursts of disorganized electrical
impulses from neurons in the cerebral cortex.
– Epilepsy is two or more unprovoked seizures.
– Thought to be an imbalance of neurotransmitters,
or abnormal neuronal, or both.
Incidence of seizures
• According to the Epilepsy Foundation®, more
than 2 million people in the United States and
about 65 million worldwide suffer from
epilepsy.
• In the United States, about 150,000 new cases
are diagnosed each year,
• About 300,000 people with epilepsy are under
the age of 14
• 500,000 are over the age of 65.
• One in ten people will have a seizure at some
point during their life. http://www.epilepsyfoundation.org/
Epilepsy
• Epilepsy is a generic term used to define a
variety of disorders characterized by recurring
seizures.
• Epilepsy means that a person has an
underlying condition that affects the delicate
systems which govern how electrical energy
behaves in the brain, making it susceptible to
recurring seizures.
Seizures
• A seizure is a brief, temporary disturbance in
the electrical activity of the brain.
• Seizures are a symptom of epilepsy.
• Having a seizure does not necessarily mean
that a person has epilepsy.
• People can experience different types of
seizures.
What Causes Epilepsy?
• In about 70% of people with epilepsy, the
cause is not known (idiopathic)
• In the remaining 30%, the most common
causes are:
-
Head trauma
Infection of brain tissue
Brain tumor and stroke
Heredity
Lead poisoning
Prenatal disturbance of brain development
Medical Causes of Seizures
•
•
•
•
•
•
•
•
Heart disease
Heat illness (or heat intolerance)
High fever
Illicit drugs, such as angel dust (PCP), cocaine,
amphetamines
Kidney or liver failure
Low blood sugar
Phenylketonuria (PKU), which can cause seizures
in infants
Poisoning
Medical Causes of Seizures
• Stroke
• Toxemia of pregnancy
• Uremia related to kidney failure
• Very high blood pressure (malignant hypertension)
• Venomous bites and stings (see snake bite)
• Withdrawal from alcohol after drinking a lot on most
days
• Withdrawal from certain drugs, including some
painkillers and sleeping pills
• Withdrawal from benzodiazepines (such as Valium)
Seizure Causes
• Sometimes no cause can be identified, called
idiopathic seizures.
• Usually are seen in children and young adults
but can occur at any age.
• There may be a family history of epilepsy or
seizures.
What happens during a seizure?
• The kind of seizure a person has depends on
where in his brain the abnormal electrical
activity starts and where it spreads.
• The seizure may be classified according to the
movement that is experienced.
What Happens During a Seizure
• Generalized seizure
– Involve the whole brain and loss of consciousness
• Absence: characterized by brief loss of consciousness
• Tonic-clonic: characterized by rhythmic jerking of muscles
• Partial seizure
– Involve only part of the brain; may or may not
include loss of consciousness
• Symptoms relate to the part of the brain affected
2007
14
Types of Generalized
• 1. "Grand Mal" or Generalized tonic-clonicUnconsciousness, convulsions, muscle rigidity
• 2. Absence-Brief loss of consciousness
• 3. Myoclonic-Sporadic (isolated), jerking
movements
• 4. Clonic-Repetitive, jerking movements
• 5. Tonic-Muscle stiffness, rigidity
• 6. Atonic -Loss of muscle tone
Generalized Seizures
• Tonic-Clonic-involves the whole brain at once.
– More commonly known.
– The muscles contract simultaneously, becoming
very rigid and the person may cry out as breath is
forced out of the lungs when the diaphragm
contracts.
– Person loses consciousness and will fall down if
standing.
– Rhythmic jerking of the head, legs, and arms may
occur as massive signals from the brain stimulate
the muscles to alternately tense and relax.
Tonic-Clonic
• Injuries and accidents may occur, such as
tongue biting and urinary incontinence.
• http://www.youtube.com/watch?v=dZwFhSL1
bK0
(please remove the word neurology from the screen after starting this video. )
• This tonic-clonic seizure shows a good example of the
movement and the tonic-clonic movement that disrupts
the diaphragm. Notice the sucking and blowing out of air.
Generalized Seizures
• ABSENCE (formerly known as petit-mal)
– generalized seizure a brief loss of consciousness,
which usually lasts no more than a few seconds.
– The person is essentially “absent.”
– Frequently overlooked, often being mistaken for
daydreaming.
– Autonomic phenomena
– Behavioral phenomena
– Motor phenomena
Absence Seizures
• These seizures begin and end abruptly and
may occur several times a day. Patients are
usually not aware that they are having a
seizure, except that they may be aware of
"losing time."
• http://www.youtube.com/watch?v=BzIs8YeafZM
http://www.ieaecell.org/epilepsy-03.html
Partial Seizures
The symptoms of a partial seizure relate to the
normal function of the brain area that is
involved. The person may experience
involuntary movements or tingling, light flashes,
or other symptoms. You may hear these called
focal seizures. There are two forms of partial
seizures, simple and complex.
Simple Partial Seizures
• Simple partial seizures are generally brief and
do not involve loss of consciousness.
• Simple partial seizures may cause jerking
motions or hallucinations, but the person
often remains aware of what is happening
• http://www.youtube.com/watch?v=dKItDS30nvc
• Although the child is having simple partial, she also
looks as if she my be having some complex there at
the end. Her eyes have become dysconjugate .
Complex Partial
• A person having this type of seizure will be
unaware of his surroundings during the
seizure, may wander aimlessly, run, do a series
of repetitive movements (automatisms), pick
at clothes, chew, mumble and, to a casual
onlooker, appear to be drunk.
• http://www.youtube.com/watch?v=XGzpD1u42Bc
(from vanumu.com)
Prodromal Phase
• Some patients may experience a Prodromal
phase which can occur hours or days before
the seizure begins.
• Some symptoms are:
– Sleep disturbances
– Lightheadedness
– Feelings of being uncomfortable
Stages and Care
• Stage 1-Aura is also known as “Pre-ictal”
– This stage is a beginning. Not every patient has an
aura, but it is considered the “warning stage” .
Auras are usually visual, auditory or a strange
feeling or smell. Some may have tingling or the
feeling of déjà vu.
– Nausea and vomiting are a common aura for some
patients who experience seizures
– “Feeling butterflies” is a common aura.
– There are as many auras as there are seizures.
Each patient has their own descriptions.
Nursing Care During an Aura
• When with a patient who has an aura, you
have the opportunity to get them to a safe
place.
• Once they are safely positioned, you will have
the opportunity to watch them during the
seizures and take the appropriate actions.
• Documentation should include the time the
aura started and the symptoms. Important is
to note if the patient was cognitive at during
the aura.
The Ictal Stage
• Stage 2-The ictal stage is the actual event.
• The goal is to protect the patient from injury
– Turn the patient on their side to keep the airway clear.
Maintain the airway; use oxygen and suction as needed.
– Loosen any restrictive clothing.
– Do not restrain the patient or stop movement. Guide the
movement if necessary. Especially those patients who
want to walk around.
– Note the time the seizure began and ended.
– NEVER FORCE ANYTHING INTO THE
PATIENT’S MOUTH!!
Post-ictal stage
• Stage 3-During the post-ictal stage, the brain is
in a state of recovery.
– Patient may become confused or disoriented.
– With tonic-clonic seizures or some complexpartial, the patient will become extremely drowsy
and fall to sleep. This can last from 5-30 minutes.
•
•
•
•
Take the patient’s vital signs.
Perform neurological checks.
Allow the patient to rest.
Keep the patient on their side.
Post-ictal
• Assess the patient for any bleeding inside the
mouth when awake. (Do not put your fingers
into their mouth).
• Many seizure patient will bite and chew their
tongues or cheeks.
• Patient may need oxygen at this time.
Focused Assessment
• When observing and documenting the seizure,
the following is important:
– Date, time and duration of the seizure, was there more than one.
– Description of the seizure: movement, staring, blinking, automatisms,
– Was there more than one type of seizure? If you are not sure of the
type, document the movements of the seizure.
– Which body part was first involved?
– How long did the seizure last?
– Was there an aura?
• What was involved in the aura? Visual, Auditory, GI disturbances?
• What did the patient do after the seizure (post-ictal)?
– Drowsy, weak?
– Did the patient resume normal behavior?
– Was the patient aware the seizure took place?
– How long did it take for the patient to return to pre-seizure status
Observations during the seizure
• Observations and documentation during the
seizure:
– Was there any eye deviations or changes in the
pupil size, eye fluttering.
– Level of Consciousness, was the patient able to
follow commands
– Presence of apnea, cyanosis, salivation
– Movement and progression of motor activity; was
a side more active during the seizure? (R vs. L)
– Lip smacking or other automatisms
– Biting of tongue or lip.
Diagnosis of seizure/epilepsy
• With first seizure, patient should go to the
Emergency Room.
• Did they or did they experience a seizure?
• First-a thorough past and present medical
history!!!
• Alcohol or drug use, medications
• Detailed information regarding the seizure:
aura, movement, LOC, any injuries associated
with the seizure.
Diagnostics
• Laboratory studies
– CBC, Metabolic Package,
– Drug screen, Urine drug screen
– Other labs to rule out medical conditions:
• Lumbar puncture (Meningitis)
• Prolactin-will increase 3x’s the normal after seizure for
12 hours after seizures.
Diagnostics
• Head CT Scan-r/o stroke, head injury, tumors
• MRI-can identify possible epilepsy lesions
• Electroencephalogram-EEG-electrical signals
of the brain are recorded.
– This electrical activity is detected by electrodes, or
sensors, placed on the patient's scalp and
transmitted to a machine that records the activity
NORMAL
Epileptic spikes and waves
Electrodes connected to scalp.
The EEG shows the abnormal
“waves” that are associated with
the seizure.
The brain waves consist of
Beta
Alpha
Theta
Delta
See the next slide for what these
waves are associated with.
http://www.angelfire.com/journal/ldps/SleepingDisorders
Treatments for Seizures
• Antiepileptic drugs (AED)
The drug should be:
– 1. highly effective, but exhibit a low incidence of toxicity.
– 2. effective against more than one type of seizure and for
mixed seizures.
– 3. long acting and nonsedative so that the client is not
incapacitated with sleep or excessive drowsiness.
– 4. tolerated by the client and inexpensive, since the client
may have to take it for years or the rest of his/her life.
– 5. control seizures and permit a client to function
effectively in any environment.
– 6. Tolerance to the therapeutic effects of the drug should
not develop.
Main Pharmacologic effects are:
• (1) to increase motor cortex threshold to
reduce its response to incoming electric or
chemical stimulation.
• (2) to depress or reduce the spread of a
seizure discharge from its focus (origin) by
depressing synaptic transport or decreasing
nerve conduction
Common medications
• Barbiturates – phenobarbital. One of the first
anticonvulsants used.
• Benzodiazepine- To suppress the propagation of
diazepam (Valium) seizure activity produced by foci
in the cortex, thalamus, and limbic areas.
• Hydantoins - Inhibit spread of seizure.
– Phenytoin (Dilantin).
• Blurred vision, gingival hyperplasia
• Elevated incidence of birth defects in children of
mothers taking phenytoin.
AEDs
• divalproex (Depakote). Derived from valproaic acid. Has been
used during pregnancy but has been associated with spina
bifida, fatal hepatic problems in infants
• www.drugs.com/pregnancy/divalproex-sodium.html
•Carboxamides (Oxazolidinediones)
Carbamazepine (Carbatrol, Tegretol)
Oxcarbazepine (Trileptal)
•GABA Analogues
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Tiagabine (Gabitril)
Surgical Management
• About 20% of patients with epilepsy do not respond
well to drug therapy. (Intractable seizures) These
patients may undergo procedures to remove the foci
of the seizures or to stop the progression of the
seizures.
• The presurgical work-up is comprehensive and is
directed at the identification of the seizures and the
area of the brain it is located.
Vagus Nerve Stimulation
• Was approved for use in adults and children
over 12 with partial-onset seizures and cannot
be controlled by AEDs
– An implantable programmed signal generator is
placed in the left upper chest. A bipolar VNS lead
connects the lead to the left vagus nerve in the
neck.
– This sends stimulation to the brain stem which
sends info to othe rest of the brain and
interrupting the seizure.
Vagus Nerve Stimulator
Approved since 1997
Ketogenic Diet
• One of the oldest treatments for epilepsy
• It is intended to maintain starvation or fasting
metabolism over a long period of time. In a
fasting state, it creates ketones, a by-product
of fat-burning metabolism.
• The diet is very high in fat and low in
carbohydrates. High fats=ketones.
• It has been found that seizures often lessen or
disappear during periods of fasting in some
individuals with epilepsy.
Ketogenic Diet
• Diet has been used mostly in children with
difficult-to-control, generalized epilepsies –
• Recommended for children ages 2 through 12
who have been diagnosed with a generalized
type of epilepsy and are not responding to
drugs.
• Initiation of the diet usually takes place in the
hospital
• Patient should be monitored for potential side
effects such as vomiting, low blood sugar,
dehydration, and seizures.
Status Epilepticus
• Continuous seizures that last at least 5
minutes, or there are 2 or more seizures
together with no recovery between the
seizures.
• Usually a tonic-clonic seizure, in 50% of
patients it is usually their first seizure. (Hickey,
2009).
• Although there are many types of status
epilepticus, this information is based on the
tonic-clonic seizure the most common and
constitutes a medical emergency.
Status Epilepticus
• Initial nursing management:
– ABCs
– Position for airway clearance, suction to maintain
patency.
– Oxygen at 100% via nasal cannula. (turn it up!)
Monitor with pulse oximetry. Severe status can
cause extreme cerebral hypoxia and can result in
severe irreversible neurological deficits.
– Secure IV access with frequent vital sign
monitoring.
– Protect the patient from injury
– Provide information to to the family.
Status Epilepticus (SE)
• Medications used for SE are:
– Benzodiazepines
•
•
•
•
Valium
Lorazepam
These are ordered by mg per kg.
The dose is usually given every 5 minutes until the
seizure stops.
Seizure Precautions
• Each medical facility has its own policy for the
safety of patients with seizures. Most
protocols or standards of care include:
– Safety concerns• Side rails up, padded.
• Call bell at bedside, within patient’s reach
• O2 and suction at bedside, check function at the
beginning of each shift
• Bed in low position
• Remove glasses, sharp objects when seizing
• Maintain IV access
Nursing Diagnosis
• Ineffective Breathing Pattern related to
neuromuscular dysfunction during seizure.
• Ineffective airway clearance related to inability
to control secretions during seizure.
• Risk for injury related to seizure activity
• Fear related to the possibility of seizures
• Deficient knowledge related to epilepsy and
its control
Patient Education
• Educate patient and family on:
– Recognition of seizures and their safety
– Compliance with medications
– Driving and seizure activity
– Medical ID bracelet
– Family Support
– Community Resources
Epilepsy Syndromes and Childhood
Seizures
• A major advance in recent epileptology is the recognition of
epileptic syndromes that allows an accurate diagnosis and
management of seizure disorders.
• Important clinical features include
–
–
–
–
–
–
–
–
–
–
the type of seizures
their localization
frequency
sequence of events
circadian distribution
precipitating factors
age at onset
mode of inheritance
physical or mental symptoms and signs
prognosis, and response to treatment (epilepsy.com/professionals)
Childhood Seizures
• Children are more likely to experience seizures
than adults.
• Newborns and young children have seizures
most frequently. Their seizures are often
caused by problems around the time of birth,
including injuries during birth or infections.
• The types of seizures that children experience
are different from those in adults and may be
associated with an epileptic syndrome.
Infantile Spasms
• Infantile spasms are an age-specific disorder
beginning during the first 2 years of life.
– Peak age of onset is between 4 and 6 months.
Approximately 90% of infantile spasms begin
before 12 months of age.
– Rare for infantile spasms to begin during the first 2
weeks of life or after 18 months.
Febrile Seizures
• Febrile seizures involve contractions in the
child’s muscles—either mild (such as stiffening
of the child’s limbs) or severe (tonic-clonic).
– Triggered by fever.
– Fairly common: About 2 to 5 percent of children in
the United States experience a febrile seizure.
– Usually happen in children between 6 months and
5 years of age. Children who have febrile seizures
often have a family history of this type of seizure.
***Neonatal Seizures***
• Neonatal period is the most vulnerable period of
life for developing seizures.
• Neonatal epileptic seizures often constitute a
neurological emergency demanding urgent
diagnosis and management.
• Neonatal seizures are paroxysmal, repetitive, and
stereotyped events. They are usually clinically
subtle.
• There is no recognizable post-ictal state.
• Generalized tonic-clonic seizures probably do not
occur.
Benign Familial Neonatal Seizures
• The diagnosis of this syndrome in a child with
seizures is based on five criteria:
– normal neurologic examination
– negative evaluation for another etiology of the
seizures
– normal developmental and intellectual outcome
– positive family history of newborn or infantile seizures
with benign outcome
– onset of seizures during the neonatal or early infantile
period)
Neonatal Seizures
•
•
•
•
•
•
There are 5 main types of neonatal seizures:
Subtle seizures (50%)
Tonic seizures (5%)
Clonic seizures (25%)
Myoclonic seizures (20%)
Non-paroxysmal repetitive behaviors
Neonatal Seizures
• Severe causes are usually the cause.
• Hypoxic-ischemic encephalopathy is the most
common cause (80% of all seizures in the first
2 days of life).
• Previously common acute metabolic
disturbances such as electrolyte and glucose
abnormalities are now unusual causes.
Benign Rolandic Epilepsy
Classified as an idiopathic, localization-related epileptic
syndrome. It is characterized by:
– nocturnal generalized seizures, probable focal onset
– diurnal partial seizures arising from the lower rolandic area
Both daytime and nighttime seizures may occur, although in
most children the seizures usually occur during sleep.
• The disorder always begins during childhood.
• Age range is from 3 to 13 years, with the peak incidence
occurring between the 7th and 8th year of life.
• Somewhat more common in boys than in girls.
• Most affected children have normal intelligence and normal
findings on the neurologic examination.
• The disorder is usually familial.
(http://professionals.epilepsy.com/page/syndromes_benign.html 2013)
Benign childhood focal seizures
• The most common pediatric seizure.
• 25% of children with non-febrile seizures.
Seizures are infrequent, usually nocturnal, and
remit within 1 to 3 years from onset.
• Brief or prolonged seizures, even status
epilepticus, may be the only clinical event of the
patient’s lifetime.
• Ictal autonomic manifestations are frequent and
may occasionally appear in isolation as in pure
autonomic seizures.
Nursing Care for pediatrics
• Nursing care for children is the same but
should include:
– Safety should include the rails of the crib, or bed
so the child does not roll out.
– Children’s brain cannot recover from status well.
Medications should be given ASAP.
– Rectal benzodiazepines may be used for seizure
control.
• For school age and adolescents, the school
should know the type of seizure and what to
expect from the child.
• Parental/Caregiver support is a must!
• Some young girls may experience seizures in
conjunction with puberty and their menstrual
cycle. Hormones play a large part in seizure
activity.
Questions
• 1. In teaching family members how to care for
a patient during a seizure, the nurse should
include which of these measures?
a. Begin cardiac compressions
b. Sit the client in an upright position
c. Do not force anything into the patient’s mouth
d. Hold the patient down so not to injure himself
Question #2
• An ictal assessment should include the
following: (Select all that apply)
a.
b.
c.
d.
e.
Name, address
Time the event started
Movement of extremities
Vocalizations
Cognition during the event
Question #3
• One out of ten people will experience a
seizure at least once in their life.
– True
– False
Question #4
• Upon entering the patient’s room at the end
of the seizure, the patient can tell the nurse
everything that happened during the seizure.
The nurse realizes that this patient
experienced a:
a. Complex Partial Seizure
b. Generalized Tonic-Clonic
c. Myoclonic Seizure
d. Simple Partial Seizure
Question #5
• Status Epilepticus is a: (select all that apply)
a. an medical emergency
b. Name for a generalized seizure
c. Continuous seizure lasting for longer that 5
minutes
d. A possible fatal condition
References
• Epilepsy Foundation www.epilepsyfoundation.org
• Ignatavicius, Donna (2010) Medical-Surgical Nursing,
Patient-Centered Collaborative Care. Elsevier St.
Louis, Missouri.
• Hickey, Joanne (2009) The Clinical Practice of
Neurological and Neurosurgical Nursing 6th ed. ,
Lippincott, Williams, & Wilkins, Philadelphia, PA.
• KSA competencies for pre-licensure (2013) qsen.org.
• EEG, Vagus Nerve Stimulator
http://www.nlm.nih.gov/medlineplus/seizures.html