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Care of the Patient with Seizures
At the end of this session the participant will:
• Describe convulsive seizures
• Describe non-convulsive seizures
• List 3 nursing actions for a patient having a
convulsive seizure
• Describe nursing considerations for select antiseizure medications.
1
SEIZURES
• Definition
• An abnormal electro-physiologic phenomenon of the brain
resulting in abnormal synchronization of neuronal activity
manifested as altered mental state, tonic or clonic
movements, convulsions, or various psychic symptoms.
• Incidence
• <20 >60 yrs old, occurs before age 20 in >75% of
cases.
• Epilepsy versus Seizure Disorder
• Seizure Disorder-usually an underlying cause
• Epilepsy-multiple, recurrent unprovoked
2
Seizures
Terms:
Aura-occurs before seizure activity, may be
depression, irritability, or unusual sensations.
Ictus-the period of seizure activity.
Postictus (post-ictal)-period after the seizure, pt. may
or may not be conscious. If conscious, may be
confused, disoriented, tired, lethargic, nauseated.
3
Precipitating Factors
Metabolic
• Hypoxia
• Hypoglycemia
• Structural
• Trauma
• Toxic metabolites
• Tumors
• Acidosis
• Infection
• Electrolyte imbalances (Na) • Hemorrhage
• Pregnancy
• Stroke, new and old
• (eclampsia/cerebral edema)
• Abrupt withdrawal of drugs/ETOH
• Drugs that alter seizure threshold
4
Age-related Precipitating Factors
Neonate-may have a brain defect, birth injury, meningitis,
hypoglycemia, or hypocalcemia.
Children-febrile illness is a common cause, lead toxicity (lead
encephalopathy), or head trauma.
Adult-head trauma, alcohol withdrawal, metabolic disorders,
tumor, abscesses, meningitis, or encephalitis
5
Generalized, convulsive seizures
•
Generalized, convulsive
• Tonic-Clonic
• Grand mal - “classic seizure”
• Tonic - contraction of voluntary
muscles, stiffening, usually
lasts 10-30 seconds.
• Clonic - rhythmic contraction,
jerking, frothing, seldom lasts
longer than 2 minutes.
• Usually associated with loss of
consciousness. Post-ictal phase
lasts 30 min. to several hours.
6
Generalized non convulsive seizures
• Absence Seizure (Petit mal)
• Rare, more common in children
• Blank stare, eye fluttering, lip smacking- begins
and ends abruptly (approx. 10 seconds), brief
7
Generalized non convulsive seizures
• Atonic Seizure (akinetic, astatic, “drop attack”)
• Sudden collapse of individual, lasts only a few
seconds
• The person either doesn’t lose consciousness or
regains it before hitting the ground.
8
Partial Seizures
• Arise from a localized portion of the brain or
foci
• Consciousness may or may not be impaired
• Types of partial seizures:
• Simple partial
• Partial sensory
• Complex partial
9
Partial Seizures
• Simple partial
• jerking may begin in one area
of body
• no loss of consciousness
• cannot control movements
• can spread to become
generalized seizure
10
Partial Seizures
• Partial Sensory
• may not be obvious
• experiences distorted environment
• hallucinations
• unexplained feelings
11
Partial Seizures
• Complex Partial
• starts with blank stare, progresses to chewing,
then other random activity
• Patient is unaware of surroundings
EEG during
seizure
12
SEIZURES
• Treatment
• Airway Protection
• PREVENT INJURY
• Medical Management
• Evaluate for Cause
• Describe/document
what is seen including
duration
13
Nursing Management
Consider
• IV access, oxygen readiness, available suction
• Pad siderails (not a restraint if patient has a convulsive
disorder)
• If convulsive seizure occurs
• Protect from harm - pt and staff
• Do not restrain patient during seizure
• Be prepared to intubate
• Don’t put anything in mouth
• Evaluate for underlying cause
14
Medication Management
Fosphenytoin (Cerebryx)Dosage: Load 20mg PE/kg at a rate up to 150mg
PE/minute. Converts to phenytoin in the body.
Therapeutic Level: Monitored with phenytoin level and
should be 10-20mg/dl. Level to be drawn 2 hours
after infusion is completed.
Side Effects: Hypotension.
Instructions: May be diluted with equal volume of D5W
or NS and given on a syringe pump or mixed in a bag
and given as an infusion at 150mgPE/minute.
After mixing, must be refrigerated (max 7days), but
can be kept at room temp. for 24 hours.
15
Medication Management
Levetiracetam (Keppra)
Dosage:
Subarachnoid Hemorrhage: 500mg IV/PO x 3 days
then discontinue.
Traumatic Brain Injury: 500mg IV/PO x 7 days then
discontinue.
Therapeutic Level: 5-65mg/dl, how to clinically
interpret this data is unknown yet.
Side Effects: Agitation, fatigue, GI.
Instructions: Must be diluted with NS, D5W, or LR.
Infuse over 15 minutes. Oral and IV doses are
equivalent. Use IV ONLY for patients who cannot
tolerate PO for first dose.
16
Status Epilepticus
Definition: one continuous unremitting seizure
lasting longer than 30 minutes or recurrent
seizures without regaining consciousness between
seizures for greater than 30 minutes.
• Emergency!
• Monitor airway, prepare to intubate
• Medical treatment includes benzodiazepines,
primarily Lorazepam (Ativan®)
17
Seizure Mapping
• For patients with medically
intractable seizures
(unresponsive to medications)
• Small electrodes, are placed
over the surface of the brain or
skull/face
• Goal: identify areas causing
seizures for possible surgical
removal
18
References
•
•
19
http://en.wikipedia.org/wiki/Status_epilepticus
http://emedicine.medscape.com/article/793708-overview