NU 428 Seizures

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1

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.

2

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

3

What are some types of seizures? What are seizure classifications based on?

Generalized

  • Tonic-Clonic
  • Typical Absence
  • Atypical Absence
  • Myoclonic
  • Atonic
  • Tonic
  • Clonic

Partial /Focal

  • Simple Partial/Focal
  • Complex Partial/Focal

Psychogenic

Based on how the seizure affects LOC

4

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.

Incontinence

Post- I ctal phase:

Soreness

Fatigue

Loss of memory- No memory of seizure

5

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

Atypical Absence

  • Brief staring spell
  • Warnings
  • Peculiar behavior
  • Confusion after seizure
6

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

7

What are the types and clinical manifestations of partial seizures?

Partial /Focal Seizures

  • Focal irritations
  • May be unilateral

Simple Partial/Focal

  • Stay conscious
  • < 1 minute

Complex Partial

  • > 1 minute
  • Postictal confusion
  • Some alteration in consciousness
  • Automatisms (don’t remember)
  • Déjà vu
8

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:

Abuse

Neglect

Traumatic episodes

9

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

Labs

  • 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
10

What must a nurse know about a CT scan?

With Contrast

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

11

What does a nurse need to know about an MRI?

Physicians Order

Signed Consent

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.

12

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.

13

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.

14

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.

15

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)
  • phenobarbital
  • divalproex (Depakote)

Absence/Myoclonic

  • clonazepam (Klonopin)
  • divalproex (Depakote)
  • phenobarbital
  • valproic acid(Depakene)
16

What medications are used for short-acting effects? What should a nurse know about them?

Benzodiazepines- lorazepam (Ativan) diazepam (Valium)

  • CNS Depression
  • Hypotension
  • Especially when given IV
  • Confusion
  • Don’t mix with other meds in syringe
  • Antidote for all benzos is flumazenil (Romazecon)
17

What are some long-acting medications for seizures and what should a nurse know about them?

Phenytoin (Dilantin)

  • 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

Phenytoin toxicity:

  • CNS Effects
  • Sedation
  • Diplopia
  • Nystagmus
  • Confusion
  • Ataxia
  • 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

Phenobarbital

  • Barbiturate
  • CNS depression: Assess LOC
  • Resp depression: Assess vital signs
  • Nystagmus (Toxicity)
  • Give slowly (IV)
18

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

19

What assessment data would the nurse anticipate in a client with seizures?

Precipitating factors

Cyanosis

Diaphoresis

Abnormal rate and rhythm

Apnea or airway occlusion (tongue or vomit)

Tachycardia

Elevated BP

Incontinence

LOC changes

Stiffening and jerking of the extremities or no tone at all. Depends on type of seizure.

Muscle fatigue

Rigid or flaccid muscles

20

What things would a nurse want a seizure patient to do?

ID triggers and precipitating factors of seizures

Verbalize s/s

Maintain adequate O2 sat

21

What health promotion techniques should a nurse implement?

Prevent head injuries

Pre, peri, & post-natal care

Healthy lifestyle

Identify precipitating factors

Coping strategies

Home Care

  • 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
22

What can the RN delegate to the NAP and LPN? What can only the RN perform?

RN

  • Client Education
  • Assess & Document Seizure
  • Airway Mgmt
  • IV Medications
  • Referrals
  • Family Education

LPN

  • Administer Oral Meds
  • Homecare monitoring of med compliance
  • Home Care Evaluation

NAP

  • 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
23

What are some more serious seizures than normal?

Acute Seizures

  • Differ from client’s baseline seizure activity
  • Greater intensity, number, or length

Status Epilepticus

  • State of continuous seizure activity
  • Rapid succession of seizures without return to consciousness in between
  • NEUROLOGIC EMERGENCY!!!!!!!!!!
  • Seizures >10 minutes can cause death!!!!!

Subclinical Seizures

  • Status epilepticus in sedated clients
  • Fail to exhibit symptoms due to sedation
24

What are some causes of status epilepticus?

Seizures

Trauma

Illicit drug or alcohol use/withdrawal

Sudden stopping of anti-seizure meds

Infections

Cerebral edema

Metabolic disturbances

Anoxia

25

What are the principles of emergency managment of status epilepticus?

AIRWAY

  • 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.

Ongoing:

Vital Signs

Resp Status

  • O2 sat
  • RR/ Effort

Neuro Status

  • LOC
  • Glasgow Coma Scale

Orient client after seizure

Correct cause if possible

  • Check labs
  • Check blood sugar

Place on seizure precautions

26

What are general seizure precautions?

Provide Privacy

Pad side-rails

AVOID placing anything in client’s mouth

Maintain airway

Don’t restrain client, just protect from injury

Ensure O2, suction equipment are at bedside

Bed in lowest position

Loosen clothing