Focus on Seizure Disorders  (Relates to Chapter 59, “Nursing Management: Chronic Neurologic Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Seizure  Paroxysmal, uncontrolled electrical discharge of neurons in brain, interrupting normal function  Often symptom of underlying illness  May accompany other disorders or occur spontaneously without apparent cause Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Seizure  Seizures resulting from metabolic disturbances are not considered epilepsy if seizures cease when underlying condition is treated. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Seizure  Origin possibly related to metabolic disturbances  Acidosis  Electrolyte imbalances  Hypoglycemia  Hypoxemia  Alcohol or barbiturate withdrawal  Dehydration or water intoxication Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Seizure  Origin possibly related to extracranial disorders  Heart  Hypertension  Lung  Kidneys Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Seizure  Origin possibly related to extracranial disorders  Liver  Systemic lupus erythematosus  Diabetes mellitus  Septicemia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Epilepsy  Condition in which a person has spontaneously recurring seizures caused by underlying chronic condition  In United States, 3 million people with epilepsy  Higher incidence in those >60 years of age Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Etiology and Pathophysiology  Common causes during first 6 months of life  Severe birth injury  Congenital birth defects involving CNS  Infections  Inborn errors of metabolism Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Etiology and Pathophysiology  Common causes from ages 2 to 20  Birth injury  Infection  Trauma  Genetic factors Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Etiology and Pathophysiology  Common causes between ages 20 and 30  Structural lesions  Trauma  Brain tumor  Vascular disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Etiology and Pathophysiology  Common causes after 50  Cerebrovascular lesions  Metastatic brain tumors  75% of seizure disorders are considered idiopathic. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Etiology and Pathophysiology  Role of heredity in seizure disorders is difficult to determine.  Some families carry predisposition in the form of low threshold to seizure- producing stimuli.  Trauma  Disease  High fever Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Etiology and Pathophysiology  In epilepsy, abnormal neurons undergo spontaneous firing.  Cause of abnormal firing is unclear.  Firing spreads to adjacent or distant areas of the brain.  If activity involves whole brain, generalized seizure occurs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Etiology and Pathophysiology  Often area of brain from which epileptic activity arises is found to have gliosis.  Thought to interfere with normal chemical and structural environment of neurons  Therefore making them more likely to fire abnormally Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Etiology and Pathophysiology  Astrocytes are now believed to play a key role in recurring seizures. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Clinical Manifestations  Determined by site of electrical disturbance  Divided into two major classes: generalized and partial Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Algorithm for Classification of Seizures Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Fig Algorithm for classification of seizures.

Clinical Manifestations  May progress through several phases  Prodromal phase  Aural phase  Ictal phase  Postictal phase Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Clinical Manifestations Generalized Seizures  Characterized by bilateral synchronous epileptic discharges in brain from seizure onset  No warning or aura as entire brain is affected  Loss of consciousness from seconds to minutes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Clinical Manifestations Generalized Seizures  Tonic-clonic seizures (grand mal)  Characterized by loss of consciousness and falling  Body stiffens (tonic) with subsequent jerking of extremities (clonic).  Cyanosis, excessive salivation, and tongue or cheek biting may occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Clinical Manifestations Generalized Seizures  Tonic-clonic seizures (grand mal) (cont’d)  Postictal phase for tonic-clonic characterized by muscle soreness, fatigue; patient may sleep for hours  May not feel normal for days  No memory of seizure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Clinical Manifestations Generalized Seizures  Typical absence seizures (petit mal)  Occurs only in children and rarely into adolescence  May cease or develop into another type  Typical symptom is staring spell for only a few seconds and usually goes unnoticed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Clinical Manifestations Generalized Seizures  Typical absence seizures (petit mal) (cont’d)  Brief loss of consciousness  May occur up to 100 times/day if untreated  EEG demonstrates pattern unique to this type of seizure.  Often precipitated by hyperventilation and flashing lights Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Clinical Manifestations Generalized Seizures  Atypical absence seizures characterized by staring spell with other signs and symptoms  Brief warnings  Peculiar behavior during seizure  Confusion after Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Clinical Manifestations Generalized Seizures  Myoclonic seizure  Characterized by sudden, excessive jerk of body and extremities  Can be forceful enough to cause fall  Brief and may occur in clusters Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Clinical Manifestations Generalized Seizures  Atonic seizure involves tonic episode or paroxysmal loss of muscle tone and person falls  Consciousness usually returns by time person hits ground and can resume normal activity  Great risk for head injury Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Clinical Manifestations Generalized Seizures  Tonic seizures involve sudden onset of decreased exterior muscle tone.  Patients often fall.  Clonic seizures begin with loss of consciousness and sudden loss of muscle tone.  Followed by limb jerking Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Clinical Manifestations Partial Seizures  Partial seizures are referred to as partial focal seizures.  Caused by focal irritations  Begin in specific region of cortex  May be confined to one side of brain and remain partial or focal in nature  May involve entire brain, accumulating in tonic-clonic Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Clinical Manifestations Partial Seizures  Divided into simple and complex partial seizures  Simple: simple motor or sensory phenomena with elementary symptoms with no loss of consciousness and lasting less than 1 minute Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Clinical Manifestations Partial Seizures  Any tonic-clonic seizure preceded by aura or warning is a partial seizure that generalizes secondarily.  Second generalized seizure may result in transient residual neurologic deficit postictally (Todd’s paralysis). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Clinical Manifestations Partial Seizures  Divided into simple and complex partial seizures  Complex: involve behavioral, emotional, affective, and cognitive function  Alteration in consciousness  Followed by period of postictal confusion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Clinical Manifestations Partial Seizures  Most common complex partial seizure involves lip smacking and automatisms.  Called psychomotor seizures  No memory of activity during seizure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Clinical Manifestations Partial Seizures  Psychosensory symptoms that may occur during complex partial seizures  Distortions of visual or auditory sensations  Vertigo  Alterations in memory  Alterations in thought processes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

Clinical Manifestations Partial Seizures  Alterations in sexual function  May experience sexual sensations during seizure  Antiseizure drugs can ↓ sexual drive or erectile dysfunction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Complications  Status epilepticus is state of constant seizure or condition when seizures recur in rapid succession without return to consciousness between seizures.  Neurologic emergency  Can involve any type of seizure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

Complications  Status epilepticus causes the brain to use more energy than is supplied.  Neurons become exhausted and cease to function.  Permanent brain damage can result. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Complications  Tonic-clonic status epilepticus most dangerous as it can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and systemic acidosis  Trauma during seizures can cause severe injury and death. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

Complications  Social stigma  Interferes with values of self-control, conformity, and independence  Discrimination in employment and education  Driving sanctions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

Diagnostic Studies  Accurate, comprehensive description of seizures with patient’s health history  EEG  Only small percentage of patients with seizure disorders have abnormal findings with first test.  Continuous monitoring may be needed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

Diagnostic Studies  Magnetoencephalography in conjunction with EEG  Greater sensitivity for detecting small magnetic fields generated by neuronal activity  CBC, serum chemistries, liver and kidney function, UA to rule out metabolic disorders Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

Diagnostic Studies  CT or MRI in new-onset seizure to rule out structural lesion  Cerebral angiography, SPECT, MRS, MRA, and PET in selected situations Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

Algorithm for Classification of Seizures Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43 Fig Algorithm for classification of seizures.

Collaborative Care  Drug therapy aimed at prevention  Stabilize nerve cell membranes and prevent spread of epileptic discharge.  70% of patients controlled with medication  Monitor drug serum levels.  Serum levels of medication should be monitored. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

Collaborative Care  Primary drugs for treatment of generalized tonic-clonic and partial seizures  Older  phenytoin (Dilantin)  carbamazepine (Tegretol)  phenobarbital  divalproex (Depakote) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45

Collaborative Care  Primary drugs for generalized tonic- clonic and partial seizures  Newer  gabapentin (Neurontin)  lamotrigine (Lamictal)  topiramate (Topamax)  tiagabine (Gabitril)  levetiracetam (Keppra)  zonisamide (Zonegran) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

Collaborative Care  Felbamate (Felbatol) may be used to treat patients whose seizure disorders are refractory to other drugs.  Pregabalin (Lyrica) is used as an “add- on” for control of partial seizures that are not successfully managed with a single medication. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

Collaborative Care  For absence, akinetic, and myoclonic  Ethosuximide (Zarontin), divalproex (Depakote), and clonazepam (Klonopin)  Status epilepticus treated with IV lorazepam (Ativan) and diazepam (Valium)  Must be followed with long-acting drugs Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

Collaborative Care  Antiseizure drugs should not be discontinued abruptly as this can precipitate seizures.  Side effects include diplopia, drowsiness, ataxia, and mental slowing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Collaborative Care  Neurologic assessment involves testing for  Nystagmus  Hand and gait coordination  Cognitive functioning  General alertness Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

Collaborative Care  Side effects outside of CNS include  Rashes  Hyperplasia of gingiva  Blood dyscrasias  Effects on liver and kidneys Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51

Collaborative Care  Gerontologic considerations  Phenytoin may be problematic for older adults with compromised liver function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52

Collaborative Care  Gerontologic considerations (cont’d)  Newer antiseizure medications offer better treatment for older adults.  Gabapentin  Levetiracetam  Lamotrigine  Trileptal  Topiramate  Zonisamide Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53

Collaborative Care  Surgical removal of epileptic focus to prevent spread of epileptic activity in brain  Removal of one lobe (usually temporal) or cortex, or separation of two hemispheres (corpus callosotomy) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 54

Collaborative Care  Benefits of surgery include reduction or cessation in frequency of seizures.  Not all types benefit from surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55

Collaborative Care  Requirements for surgery  Diagnosis of epilepsy confirmed  Adequate trial with drug therapy without satisfactory results  Electroclinical syndrome defined Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 56

Collaborative Care  Vagal nerve stimulation gives intermittent stimulation to brain to reduce frequency and intensity of seizures.  Biofeedback to control seizures teaches patient to maintain a certain brain wave frequency that is refractory to seizure activity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 57

Nursing Assessment  Birth defects or injuries at birth  Anoxic episodes  CNS trauma  Tumors  Metabolic disorders  Alcoholism Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 58

Nursing Assessment  Exposure to metals or carbon monoxide  Hepatic or renal failure  Compliance with antiseizure medications, barbiturate or alcohol withdrawal, cocaine/amphetamines Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 59

Nursing Assessment  Family history  Headaches, aura, mood or behavioral changes before seizure  Anxiety, depression, loss of self- esteem, social isolation  Decreased sexual drive, erectile dysfunction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 60

Nursing Assessment  Metabolic acidosis or alkalosis  Hyperkalemia  Hypoglycemia  Dehydration  Water intoxication Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 61

Nursing Assessment  Bitten tongue, soft tissue damage, cyanosis  Abnormal respiratory rate  Apnea (ictal)  Absent or abnormal breath sounds  Airway occlusion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 62

Nursing Assessment  Hypertension, tachy/bradycardia  Bowel/urinary incontinence, excessive salivation  Weakness, paralysis, ataxia (postictal)  Abnormal CT, MRI, EEG Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63

Nursing Assessment  Tonic-clonic: loss of consciousness, muscle tightening then jerking, dilated pupils, hyperventilation then apnea, postictal somnolence  Absence: altered consciousness, minor facial motor activity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 64

Nursing Assessment  Simple: aura; focal sensory, motor, cognitive, or emotional phenomena; unilateral “marching”; motor seizure  Complex: altered consciousness with inappropriate behaviors, amnesia of event Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 65

Nursing Diagnoses  Ineffective breathing pattern  Risk for injury  Ineffective coping  Ineffective self-health management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 66

Planning  Overall goals are that patient will  Be free from injury during seizure  Have optimal mental and physical functioning while taking antiseizure medications  Have satisfactory psychosocial functioning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 67

Nursing Implementation Prevention  Wear helmet if risk for head injury.  General health habits (diet, exercise)  Assist to identify events or situations precipitating seizures, and avoid if possible.  Instruct to avoid excessive alcohol, fatigue, and loss of sleep. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 68

Nursing Implementation Acute Intervention  Observation and treatment of seizure  Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor  May require suctioning or oxygen after seizure  Assessment of level of understanding Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 69

Nursing Implementation Ambulatory and Home Care  Instruct on importance of adherence to medication, not to adjust dose without physician  Keep regular appointments.  Teach family members emergency management. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 70

Nursing Implementation Ambulatory and Home Care  Emotional support and identification of coping mechanisms  Medical alert bracelets  Referrals to agencies and organizations Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 71

Evaluation  Appropriate HR/rhythm, depth of respirations  No injury  Verbalization of knowledge of potential injury  Arrangement of environment to minimize injury Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 72

Evaluation  Acceptance of disorder  Acknowledgment seizure has occurred  Therapeutic drug levels  Compliance with therapeutic regimen Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 73

The nurse is called to the patient’s room by the patient’s spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, the nurse should: 1. Turn the patient to the side. 2. Start oxygen by mask at 6 L/min. 3. Restrain the patient’s arms and legs to prevent injury. 4. Record the time sequence of the patient’s movements and responses as they occur. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 74

Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 75

Case Study  54-year-old man began to experience periods of feeling suddenly disoriented.  He did not personally know this was happening. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 76

Case Study  His co-worker told him that on several occasions, she observed he was behaving inappropriately. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 77

Case Study  This behavior consisted of lip- smacking and facial grimacing lasting a couple of minutes, followed by disorientation and confusion.  Fearing he had Alzheimer’s disease, he made an appointment with a neurologist. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 78

Discussion Questions 1. What type of seizure is he most likely experiencing? 2. What is the hallmark of this type of seizure? 3. What patient teaching should you do with him? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 79