NU 428 Seizures
What are seizures? What is epilepsy? What are some causes of seizures?
Definition: Uncontrolled electrical discharge of neurons, interrupts normal function, cannot talk to you while having a seizure.
Difference in epilepsy and seizure: Epilepsy is the underlying condition of recurring seizures.
Causes: Sodium abnormalities, fever, trauma to the head, stroke, hypoxia, hypoglycemia, withdrawal from drugs or alcohol. Can be in a small area of the brain or generalized over the whole brain.
What are the phases of seizures?
Prodromal phase- signs/activity preceding seizure
Aural phase-sensory warning, smell or dots/lights in vision, tells person seizure is about to occur
Ictal phase-during the full seizure
Postictal phase-recovery, will have confusion and fatigue
What are some types of seizures? What are seizure classifications based on?
- Typical Absence
- Atypical Absence
- Simple Partial/Focal
- Complex Partial/Focal
Based on how the seizure affects LOC
What are the clinical manifestations of tonic-clonic seizures?
LOSS OF CONSCIOUSNESS
Stiffening of body (Tonic) then jerking of extremities (Clonic)
Cyanosis – late sign of hypoxia
Tongue/cheek biting – don’t stick anything in their mouth.
Post- I ctal phase:
Loss of memory- No memory of seizure
What are the clinical manifestations of typical and atypical absence seizures?
Typical Absence - may be mistaken for attention lapses in school
- Usually only in children
- May cease with maturity or evolve
- Brief staring spells for few seconds
- May occur up to 100 times/day
- Brief staring spell
- Peculiar behavior
- Confusion after seizure
What are myoclonic, atonic, tonic, and clonic seizures?
Myoclonic: Sudden, excessive jerking of body or extremities, at risk for falling
Atonic: Sudden loss of muscle tone
Tonic: Sudden onset of increased muscle tone
Clonic: Loss of consciousness and sudden loss of tone, limb jerking
What are the types and clinical manifestations of partial seizures?
Partial /Focal Seizures
- Focal irritations
- May be unilateral
- Stay conscious
- < 1 minute
- > 1 minute
- Postictal confusion
- Some alteration in consciousness
- Automatisms (don’t remember)
- Déjà vu
What are psychogenic seizures?
Psychiatric in origin, but not produced bc the pt is trying to gain attention e.g. not fake seizures
Not caused by abnormal brain activity
Not “purposely” produced by client
Symptoms often precipitated by an event
More frequent in clients with history of:
What are some diagnostic studies used for seizures?
History & Physical: Any hx seizures? Any trauma to the head? Any drugs and alcohol?
Electroencephalography (EEG): shows electrical activity of the brain
- Not always positive on first EEG
- Within 24 hours of seizure
- Sometimes not the best indicator of seizure unless constantly on EEG
- CBC: Checks O2 through H&H, WBCs to look for possible infection
- CMP: Electrolytes, especially sodium
- LFP: If liver isn't functioning, will have a build up of ammonia or bilirubin (increased levels cause seizures)
- UA: Just to tell you if they have a UTI, spilling protein, or if they have another infection. Just another diagnostic to r/o other diseases
- Toxicology: Drugs or alcohol
What must a nurse know about a CT scan?
What do we need prior to this testing?
- Physician Order
- BUN/Crea Levels: Contrast for CT will worsen kidney problems if already damaged or in failure.
- Assess Allergies to iodine and shellfish
- Tell client they may feel warm, like they're going to pee themselves
- Need at least a 20 g IV in the AC for contrast
- Might be NPO. If diabetic and NPO, never give insulin
Need to push fluid after the procedure to flush the dye through the kidney with a large amount of fluids if it's not contraindicated
What does a nurse need to know about an MRI?
With hx of claustrophobia, might need some sedation to get them through it.
Contraindications: Metallic fragments or implants, aneurysm clips, pacemakers, pregnancy, on titrated IV drip medicine in CCU.
In the event of a cardiac or resp arrest, client must be removed from MRI machine and room. Then start procedures/CPR if needed. Usually have a code cart outside of the room.
What does a nurse need to know about a lumbar puncture?
Might do a lumbar to see if meningitis if the cause of seizures.
Must have doctor's order
Pre-procedure: Need to look at CBC for platelets. Must do baseline neuro assessment before test to establish baseline.
Contraindications: Low platelets, anticoagulants, skin infection near puncture site.
Post-procedure: Must lay flat 2-4 hours, HA is common bc of release of cerebrospinal fluid (may need mild analgesic like Tylenol), increase fluids to replace cerebrospinal fluid, frequently assess neuro status, check dressing on pucture site to see if they’re bleeding or leaking CS fluid, avoid NSAIDs and anticoagulants 48 hours.
What should a nurse know about an EEG?
Pre-procedure: client should no skip meals, need to eat before procedure, caffeine containing food or beverages are prohibited within 8 hours prior to test, shampoo hair night before, avoid conditioners or oils in the hair, withhold anything that would cause CNS depression for 24 hours prior to test (sedatives).
Post-procedure: Wash their hair to get the gook out, monitor for safety and seizure precautions.
What is a PET scan and what should a nurse know to teach the client?
Shows hot spots where tumors may be. Could be in the brain causing seizures.
Typically can’t have any kind of food or drink except for water 6 hours before the exam.
What are some general guidelines to drug therapy for seizures?
Prevention of seizures (Not curable)
Drugs act to stabilize nerve cell membranes & prevent spread of discharge
Begin with single drug and increase until controlled or toxic effects occur
Many have therapeutic serum drug ranges
Tonic- Clonic / Partial
- phenytoin (Dilantin)
- carbamazepine (Tegretol)
- divalproex (Depakote)
- clonazepam (Klonopin)
- divalproex (Depakote)
- valproic acid(Depakene)
What medications are used for short-acting effects? What should a nurse know about them?
Benzodiazepines- lorazepam (Ativan) diazepam (Valium)
- CNS Depression
- Especially when given IV
- Don’t mix with other meds in syringe
- Antidote for all benzos is flumazenil (Romazecon)
What are some long-acting medications for seizures and what should a nurse know about them?
- Interacts with tube-feeding & many medications
- Gingival Hyperplasia: Teach oral care and have good oral assessments
- Therapeutic level: 10-20mcg/mL (Dial at ten)
- Blood Dyscrasias: Assess CBC
- Give slowly ( 50mg/min)
- Only with normal saline!
- Give through “good” IV site: if it extravasates, will cause necrosis
- CNS Effects
- Slurred speech
- Stevens- Johnson Syndrome: red rash and blisters all over skin
Carbamezepine ( Tegretol )
- Therapeutic level: 4-12mcg/mL
- Avoid GRAPEFRUIT juice
- Give with milk or food
- Report Visual abnormalities
- Watch for Stevens Johnson Syndrome
- Interacts with many medications
- Watch for tardive dyskinesia
- Bone marrow suppression: Agranulocytosis, Watch CBC
- DO NOT ABRUPTLY STOP! Will cause status epilepticus
- CNS depression: Assess LOC
- Resp depression: Assess vital signs
- Nystagmus (Toxicity)
- Give slowly (IV)
What are some other treatments for seizures?
Surgical therapy: Remove the epileptic focus and prevent the spread of activity
Vagal Nerve stimulation: Interrupts the epileptic discharge inside the brain
What assessment data would the nurse anticipate in a client with seizures?
Abnormal rate and rhythm
Apnea or airway occlusion (tongue or vomit)
Stiffening and jerking of the extremities or no tone at all. Depends on type of seizure.
Rigid or flaccid muscles
What things would a nurse want a seizure patient to do?
ID triggers and precipitating factors of seizures
Maintain adequate O2 sat
What health promotion techniques should a nurse implement?
Prevent head injuries
Pre, peri, & post-natal care
Identify precipitating factors
- Teach medication compliance/regimen
- Teach about medication side-effects
- Relaxation techniques
- Community resources
- Importance of medical-alert bracelet
- Avoid excessive alcohol & fatigue
- Eat regular meals
What can the RN delegate to the NAP and LPN? What can only the RN perform?
- Client Education
- Assess & Document Seizure
- Airway Mgmt
- IV Medications
- Family Education
- Administer Oral Meds
- Homecare monitoring of med compliance
- Home Care Evaluation
- Place Equipment at bedside
- Remove harmful objects
- Immediately report seizure activity to RN
- Observe/report events of seizure to RN
- Obtain postictal vitals
- Provide oral suction after seizure event
What are some more serious seizures than normal?
- Differ from client’s baseline seizure activity
- Greater intensity, number, or length
- State of continuous seizure activity
- Rapid succession of seizures without return to consciousness in between
- NEUROLOGIC EMERGENCY!!!!!!!!!!
- Seizures >10 minutes can cause death!!!!!
- Status epilepticus in sedated clients
- Fail to exhibit symptoms due to sedation
What are some causes of status epilepticus?
Illicit drug or alcohol use/withdrawal
Sudden stopping of anti-seizure meds
What are the principles of emergency managment of status epilepticus?
- Place on side
- Suction as needed
- Anticipate intubation
Assist with ventilations
Protect from injury
Remove/loosen tight clothing
Establish large bore IV access
Stay with client until seizure activity subsides
Prepare to administer fast-acting Benzodiazepines (lorazepam, diazepam) 1st
May have to administer D50 for hypoglycemia
Then anticipate longer acting anti-seizure meds (phenytoin, fosphenytoin, phenobarbital, divalproex)
Document seizure- precipitating events, assessments, duration, etc.
- O2 sat
- RR/ Effort
- Glasgow Coma Scale
Orient client after seizure
Correct cause if possible
- Check labs
- Check blood sugar
Place on seizure precautions
What are general seizure precautions?
AVOID placing anything in client’s mouth
Don’t restrain client, just protect from injury
Ensure O2, suction equipment are at bedside
Bed in lowest position