Clinical Manifestations
Clinical manifestations of absence seizures?
Typical absence seizures:
usually occurs in children and rarely beyond adolescence
may cease as child matures or develop into another type
can be precipitated by flashing lights and hyperventilation
typical symptoms is staring spell "daydreaming": lasts only a few seconds; often goes unnoticed, may occur up to 100 times/day when untreated
EEG demonstrates pattern unique to this type of seizure
ATYPICAL ABSENCE SEIZURES:
characterized by staring spell with other manifestations: eye blinking, jerking movements of lips, lasts more than 10 seconds, usually continue into adulthood
Safety alert: During a seizure you should: ?
Maintain a patent airway for the patient
protect the patient's head, turn the patient to the side, loosen constrictive clothing, ease patient to the floor (if seated)
Do not restrain the patient
do not place any objects in the patient's mouth!
What are the most common medications used to treat tonic-clonic and focal-onset seizures?
Phenytoin (Dilantin), Carbamazepine (Tegretol), divalproex (Depakote)
What kind of teaching would you alert the patient of in regards to medication regimen importance?
Abrupt withdrawal after long-term use may cause seizures
if weaning is to occur, the patient must be seizure free for a prolonged period (ex: 2-5 years) and have a normal neurologic assessment and EEG.
Most treatments are life long use.
What is the most useful diagnostic tool when diagnosing seizures?
An accurate, comprehensive description of seizures and the patient's health history!!
Clinical manifestations of tonic-clonic seizures?
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
postictal phase for tonic-clonic characterized by muscle soreness, fatigue: patient may sleep for hours, may not feel normal for hours or days, no memory of seizure
What are some common nursing interventions for acute intervention for hospitalized patients in regards to seizure precautions?
2. Suction as needed; assist ventilation if patient does not breathe spontaneously after seizure
3. Never force an airway of padded tongue blade into patients mouth
4. DO NOT RESTRAIN: carefully observe and record details
5. Ensure patient safety; turn patient on side
6. Loosen tight clothing and lower to floor if not already down
7. Establish IV access
8. Stay with patient until seizure has passed
9. Anticipate administration of phenobarbital, phenytoin (Dilantin) or benzodiazepines (Valium, Versed, Ativan) to control seizures
10. Monitor VS, O2 sat, pupil size and reactivity
11. Reassure and orient patient
12. Often postictal 5-30 minutes after seizure
What are some drugs commonly used specifically for focal seizures?
Carbamazepine, Lamotrigine (Lamictal), or Levetiracetam (Keppra)
What kind of complications would you teach the patient to be aware of for seizure disorders and epilepsy?
Subclinical seizures: a form of SE (status epilepticus) in which a sedated patient seizes but there are no external signs because of sedative use. Example: a patient under sedation for ventilatory support in the ICU could have a seizure without physical movements and we miss the seizure occurrence.
Severe injury and death from trauma during a seizure (patients who lose consciousness are at greatest risk)
Persons with epilepsy have a mortality rate 2-3 times the rate of the general population
SUDEP: most cases occur during or right after a seizure. It is most often from tonic-clonic seizures. SUDEP is more common at night, in those taking multiple anti seizure drugs, and in patients with poorly managed seizure activity. There is no known exact cause!
Effect on lifestyle is most common complication of seizure disorder: depression, social stigma still exists, discrimination in employment and education, driving sanctions
What is a test indicated for patients with focal seizures who have been using at least two antiepileptic medications with no success?
RNS!
Responsive Neurostimulation System: electrodes are surgically implanted to sense, record, and interrupt seizure activity in the brain
Characteristic manifestations of status epilepticus (SE)?
State of continuous seizure activity or condition when seizures recur in rapid succession without return to consciousness between seizures
any seizure lasting more than 5 minutes
neurologic emergency!
can occur with any type of seizure
status epilepticus causes brain to use more energy than is supplied (neurons become exhausted and cease to function; permanent brain damage can result)
What is done for ongoing monitoring for patient's that undergo seizure activity?
Monitor vital signs, level of consciousness, O2 saturation, Glasgow Coma Scale results, pupil size, and reactivity
Reassure and orient patient after seizure
Give IV dextrose for hypoglycemia
Maintain NPO till awake with gag reflex!
What are the most common medications used to treat generalized onset nonmotor and myoclonic seizures?
Ethosuximide (Zarontin), Divalproex (Depakote), and Clonazepam (Klonopin)
Generalized safety measures: wearing helmets
Improved perinatal, labor, delivery care have reduced fetal trauma and hypoxia
What are some common diagnostic testing that can be anticipated to confirm/diagnose/manage seizure activity?
CBC, UA (urinalysis), electrolytes (COMP), creatinine, FBG (Fasting blood glucose)
Lumbar puncture (CSF for analysis)
CT, MRI (magnetic resonance imaging), MRA (magnetic resonance angiography), PET scan (positron emission tomography)
What are the different classifications of seizures?
Generalized seizures -- involve both sides of the brain; these include: Tonic-clonic seizures, absence seizure, atypical absence seizure
Focal Seizures (partial seizures) -- these include: simple focal seizures (conscious), and complex focal seizures (change or loss of consciousness)
psychogenic seizures (pseudo seizures)
What are some common collaborating care interventions for seizure disorders and epilepsy?
Drug therapy: (Anti-seizure drugs) Lewis Table 59-9
Goal of drug therapy: to prevent recurrence of seizures, minimum of side effects
observation
surgical therapy (Lewis table 59-10) -- removal of epileptic focus
vagal nerve stimulation (interrupt brain wave activity and stop excessive discharge of neurons; surgically implanted electrode in the neck)
side effects of vagal nerve stimulation include: coughing, hoarseness, dyspnea, tingling in the neck
other interventions: Ketogenic diet; biofeedback
What are some common side effects for anti-seizure drugs?
Neurologic assessment for dose-related toxicity involves testing for nystagmus and evaluating hand and gait coordination, cognitive function, and general alertness
What are some home care teachings for seizures and epilepsy?
2. Help patient understand treatment regime
3. Encourage client to eat well, get plenty of rest, understand events that may precipitate seizures
4. DO NOT STIGMATIZE!! support, support, support!
Include focal resection or temporal lobe resection -- indicated for focal seizures and generalized seizures
What are the different phases included with clinical manifestations that occur with seizure activity?
Aural phase -- partial seizure or sensation, may be auditory, visual, or gustatory (taste) - can be a funny feeling
Prodromal Phase -- early manifestations -- malaise, headache, depression
Ictal phase -- seizure activity
postictal phase -- period following seizure
Common triggers for seizures?
increased physical activity, excessive stress, hyperventilation, overwhelming fatigue, acute alcohol ingestion, excessive caffeine intake, exposure to flashing lights (mainly for epilepsy), substances such as cocaine, aerosols, and inhaled glue products, illness
What are some common contraindications related to anti-seizure drugs?
Oral contraceptives: can interact with phenytoin, medications can decrease effectiveness of the contraceptive
Warfarin: phenytoin can decrease absorption and increase metabolism of the oral anticoagulants
What education should be provided to patients in regards to a ketogenic diet?
Special high-fat, low-carbohydrate diet that helps controls seizures in some people
meals are carefully planned to restrict the amount of protein and carbohydrate
patients who are taking anti-coagulants need close monitoring for bleeding when on this diet
seizures may worsen if the diet is stopped abruptly.
What is a vagal nerve stimulator and what education would you provide the patient if they are undergoing this procedure?
Is a device surgically implanted into the left chest wall and connected to an electrode placed on the left vague nerve - programmed to administer intermittent stimulation of the brain via stimulation of the vagal nerve at a rate specific to the patient's needs
Education: Avoid diagnostic procedures such as MRI and ultrasound diathermy, and the use of microwave ovens and shortwave radios - can interfere with the device and place patient in danger.