for School Nurses - NWESD 189 Guide/Sectio… · for School Nurses This product was made possible...

Second EditionA Quick Reference Guide

for School Nurses

This product was made possible through a grant from the national Centers for Disease Control and Prevention (CDC), Grant # U58/CCU322073.Its content is solely the responsibility of the authors and do not necessarily represent the views of the CDC.

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©2006, 2009 by the Epilepsy Foundation. All rights reserved.

This publication is protected by copyright. Unless specifically noted, no part of itmay be reproduced, stored or maintained in a retrieval system or transmitted in

any form or by any means, electronic, mechanical, photocopying, recording or oth-erwise, without the prior written permission of the Epilepsy Foundation.

Printed in the United States of America

This guide is intended to provide school nurses with information on epilepsy.Laypersons who read this material are warned against making any changes in theirtreatment approaches without consulting their healthcare providers. Approaches fordiagnosing and treating epilepsy are improving constantly. For more information,

visit the Epilepsy Foundation’s Web site at www.epilepsyfoundation.org.

Great care has been taken to maintain the accuracy of the information containedwithin this volume. However, the Epilepsy Foundation cannot be held responsible

for errors or for any consequences arising from the use of the information con-tained herein.

800-332-1000www.epilepsyfoundation.org

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A school nurse can have a significant impact on the wellbeing of students with epilepsy. This guide is aninvaluable tool to help school nurses manage students’ seizure conditions in school. It is easy to use, providescurrent findings and recommendations on the treatment and management of students with seizures and dis-cusses school nursing best practices. By applying the practices discussed in this guide the school nurse can sup-port positive treatment outcomes, maximize educational and developmental oppor tunities, and create a safeand supportive environment for the student with seizures.

Although research has advanced our understanding and treatment of epilepsy, there are still unfounded prej-udices that negatively impact students. The school nurse can play a pivotal role in changing these attitudes.Through positive example and educational efforts, the school nurse helps to demystify epilepsy and positive-ly influence the attitudes of others toward those with this condition.

The care of children with epilepsy is a mutual concern of many parents, educators, health care pro viders,health organizations and students. There fore, a collaborative effort between school nurses, epilepsy specialists,and other vested partners is vital to ensure accurate and up-to-date information is available to support thework of school nursing.

The Epilepsy Foundation continues to provide educational opportunities for school nurses and current med-ical information about epilepsy. For additional information on further educational opportunities please con-tact the Epilepsy Foundation or your state school nurse organization.

We gratefully acknowledge all the contributions to this manual. The clinical expertise and professional com-mitment dedicated to the delivery of quality, specialized school health services is a commendable legacy forthe health and safety of our children.

Marcia Buckminster, APRN, BC, PNP, CSNDirector of School Health, Framingham Public SchoolsFellow, National Association of School NursesProfessional Advisory Board, Epilepsy Foundation of

Massachusetts and Rhode Island

FOREWARD

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The Epilepsy Foundation wishes to extend its appreciation to the following experts for their contributions in the development of this publication:

Joan K. Austin, DNS, RN, FAANDistinguished Professor of NursingSchool of NursingIndiana UniversityIndianapolis, IN

Mary Alice Bare, RN, MSPHEpilepsy SpecialistDepartment of NeurologyChildren’s Hospital Medical CenterCincinnati, OH

Elisabeth Barclay, RN, BSN, MA EdIllinois Certified School NurseMcLean County Unit District No. 5 Normal, IL

Marcia Buckminster, APRN, BC, PNP, CSNDirector of School Health ServicesFramingham Public SchoolsFramingham, MA

Patricia K. Crumrine, MDDirector, Pediatric Epilepsy ProgramChildren’s Hospital of PittsburghPittsburgh, PA

Patricia Dean, ARNP, MSN Clinical CoordinatorComprehensive Epilepsy CenterMiami Children’s HospitalMiami, FL

Sandra Dewar, RN, MSPatient Care CoordinatorDepartment of NeurologyUCLA Medical CenterLos Angeles, CA

Colleen DiIorio, PhD, RN, FAANProfessorDepartment of Behavioral Sciences and Health EducationRollins School of Public HealthEmory UniversityAtlanta, GA

Stephanie Dubinsky, RN, MPHProgram CoordinatorKelsey Research FoundationBob and Vivian Smith Epilepsy ProgramHouston, TX

Christine L. O’Dell, RN, MSNClinical Nurse SpecialistMontefiore Medical CenterAlbert Einstein College of MedicineEpilepsy Management CenterBronx, NY

Patricia Osborne Shafer, RN, MNEpilepsy Nurse SpecialistBeth Israel Deaconess Medical CenterCoordinator, Comprehensive Epilepsy CenterBoston, MA

In addition, we acknowledge the EpilepsyFoundation St. Louis Region for its contributionsto this publication and its pioneering work intraining school nurses throughout Missouri.

ACKNOWLEDGMENTS

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Table o

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TABLE OF CONTENTS

FOREWARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SECTION 1: SEIZURE AND EPILEPSY BASICS . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Epilepsy Etiology and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Risk of Epilepsy in Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Classifying Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Partial Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Simple Partial Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Complex Partial Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Generalized Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Absence Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Atypical Absence Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Atonic Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Clonic Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Myoclonic Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Tonic Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Tonic-Clonic Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Epileptic Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Benign Rolandic Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Childhood Absence Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Juvenile Myoclonic Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Lennox-Gastaut Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Temporal Lobe Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Frontal Lobe Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Progressive Myoclonic Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Landau-Kleffner Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Reflex Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Seizure-Like Phenomena: Medical Conditions that Mimic Epilepsy . . . . . . . . . 21

Psychogenic Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Intractable Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Status Epilepticus: Prolonged or Serial Seizures . . . . . . . . . . . . . . . . . . . . . . 23

Nonconvulsive Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Epilepsy in Female Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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SECTION 2: THE IMPACT OF EPILEPSY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Impact of Epilepsy on Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Assessing Learning and Behavioral Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Impact of Epilepsy on the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Impact of Epilepsy on Social Development and Quality of Life . . . . . . . . . . . 27

Assessing the Impact of Epilepsy: The Spectrum of Severity. . . . . . . . . . . . . 28

Uncomplicated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Compromised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Devastated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

SECTION 3: FIRST AID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Basic First Aid: Care and Comfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Care of Students with No Change in Consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Care of Students with Altered Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Care of Students with Seizures that Cause Loss of Consciousness . . . . . . . . . . . . . . . . . . . . . 31

After a Seizure Episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Acute Interventions and Emergency Response . . . . . . . . . . . . . . . . . . . . . . . 32

When is a Seizure Considered an Emergency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Use of Medications for Prolonged or Cluster Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Vagus Nerve Stimulation and Magnet Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Delegation of Acute Intervention Responsibilities . . . . . . . . . . . . . . . . . . . . . 33

SECTION 4: TREATMENT FOR SEIZURE PREVENTION . . . . . . . . . . . . . . . . . . . 35

Antiepileptic Drugs (AEDs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Initiating Drug Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Antiepileptic Drugs in Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

PRN Medications for Prolonged or Acute Repetitive Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . 37

The Cognitive and Behavioral Effects of Antiepileptic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Discontinuing Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Ketogenic Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Vagus Nerve Stimulator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Alternative Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Advances in Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39


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SECTION 5: SEIZURE ACTION PLANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Assessing the Student’s Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Medication Documentation and Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Documenting Seizures and Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Behaviors Before a Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Is There a Pattern? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

What Happens to the Student During a Seizure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

What Was the Length of the Seizure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Behavior After the Seizure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Observing Responses to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Assessing Learning and Psychosocial Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Customizing an Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Educational Accommodations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Special Circumstances and Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Teaching and Tailoring Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Supportive Counseling and Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

When to Refer to a Specialist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

SECTION 6: TRAINING TEACHERS AND OTHER SCHOOL PERSONNEL . . . . . . 49

General Curriculum for Training Others in the School Setting . . . . . . . . . . . . 50

Training Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Considerations in Curriculum Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Dispelling Myths and Reducing Fears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Teaching About the Impact of Epilepsy on Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Managing Seizures in the Classroom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Managing Seizures Under Special Circumstances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

On the School Bus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

For a Student in a Wheelchair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

When Seizures Occur in Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

In Non-Classroom Areas of the School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

SECTION 7: EPILEPSY RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Community Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Internet Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Books, Kits, Pamphlets and Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55


Materials for Training Teachers and Other School Personnel. . . . . . . . . . . . . 55

Fact Sheets on Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Driving and Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

APPENDICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Appendix A: Seizure Action Planning Forms. . . . . . . . . . . . . . . . . . . . . . . . . . 61

Appendix B: Seizure Recognition and First-Aid Chart . . . . . . . . . . . . . . . . . . 69

Appendix C: Antiepileptic Medications Chart . . . . . . . . . . . . . . . . . . . . . . . . . 73

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

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11

As parents, grandparents and healthcare profession-als, we can agree that all children should be afford-ed every opportunity to learn and to play, exploringlife both at home and at school. This is how young-sters acquire both the cognitive and social skills, inconjunction with neurodevelopmental growth,needed to function in today’s increasingly complexand demanding society. As William Wordsworthnoted, “The child is father of the man,” so the lega-cy of lessons learned in childhood — both positiveand negative — play a pivotal role in the quality oflife each child will eventually enjoy as an adult.

While most seizures last from a few seconds to aminute or two, the child who experiences them inschool is often compromised on several levels.Cognitive function is often affected. But it is notthe only complicating factor. These students mustoften cope with added challenges related to theadverse effects of drug therapy. There can be emo-tional and behavioral consequences as well. Thismultiplicity of issues adds to the complexity ofmanaging the student’s needs and safeguarding thestudent both physically and emotionally in theschool setting.

For those working with students with epilepsy, thereare many challenges. These include coping with theunpredictability of seizures and learning how torespond to a seizure.

Perhaps most importantly, however, is the schoolnurse’s ability to help create a positive atmosphereamong teachers, staff and fellow students withrespect to the student with seizures. This helps tominimize stigmatizing behaviors and to support apositive self-image for the student. The school nursecan facilitate this understanding and enhanceawareness and sensitivity by educating everyone inthe school setting about the nature and manage-ment of seizures. By example, the school nurse canreinforce the need for compassion, patience andunderstanding for the student who has seizures.

While the school nurse is clearly important in influencing positive societal attitudes that we hopewill prevail in the future, his/her intervention isespecially crucial for the here and now. All of theschool nurse’s activities assist the student withepilepsy in achieving success in school life and insocial relationships. The school nurse can help edu-cators recognize the causes of behavior problems, ifthese occur, and can help diminish the educationaland social impacts often associated with childhoodepilepsy. The school nurse can also assist in earlydiagnosis by alerting parents and healthcareproviders about possible seizure-related behaviorsand offer guidance on obtaining information andservices that will benefit students and their families.

INTRODUCTION

“ ”The school nurse’s role is multifaceted.It means being a caregiver, advocate,

fact-finder and communicator.


”“Epilepsy is a

chronic disorder,the hallmark of

which is recurrent,unprovoked

seizures.

Section 1SEIZURE AND EPILEPSY BASICS


Epilepsy is clinically defined as two or more unpro-voked seizures occurring more than 24 hours apartin someone older than one month of age. It is themost common treatable serious neurological disor-der in children and is the third most common of allserious neurological disorders in childhood, withmental retardation and cerebral palsy being the mostcommon (Shinnar and Pellock, 2002). It affectsfrom four to ten school-aged children per 1,000.

A seizure is the clinical manifestation of an abnormaland excessive synchronized discharge of cerebralneurons. It is sudden and transient and can includea wide variety of motor, psychic and sensory phen -omena. There may or may not be an alteration inconsciousness or awareness. The location of the initialelectrical disruption, the extent of its spread withinthe brain and its duration determine the clinicalmanifestations of the seizure and its impact on thestudent.

A seizure can include jerking movements of thelimbs, falling down, staring, automatisms (purpose-less repetitive actions) such as lip smacking or handwringing or even strange feelings in one’s stomach.Seizures are usually unprovoked and unpredictable.The child can’t control his or her behavior during aseizure.

About 10 percent of all individuals will experience aseizure during their lifetimes. These seizures may berelated to acute medical, neurological or neurosur-gical conditions and do not recur once the underly-ing cause is resolved. Some children have a singleseizure, the cause of which is never identified. Theseacute episodes are not considered to be epilepsy.

Epilepsy Etiology and Prognosis Epilepsy is a brain disorder characterized by the ten-dency to have recurrent unprovoked seizures. It mayor may not be associated with damage in brain struc-ture. In some cases, usually the more benign forms,genetics seem to play a role. Sometimes epilepsy isrelated to a congenital malformation in brain struc-ture or an inborn error in brain metabolism. About30 percent of cases of epilepsy can be attributed totrauma, infection, postnatal vascular lesions or CNSdegenerative conditions. About 20 percent of cases areassociated with neurological conditions presumed tobe present from birth, such as mental retardationand/or cerebral palsy (see Table 3). About 70 percentof all new cases in children are considered idiopathic(assumed to be genetic) or cryptogenic (see Table 2)and have no apparent cause (Hauser, 2001).

14 MANAGING STUDENTS WITH SEIZURES

Section 1SEIZURE AND EPILEPSY BASICS

TABLE 1: Epilepsy Statistics

• Epilepsy affects up to 1 percent of all children age 16 or younger.

• As many as 325,000 school-aged children (ages 5 to 14) have epilepsy (Shinnar and Pellock, 2002).

• Up to 45,000 new cases of epilepsy are diagnosed annually in children (200,000 total new cases arediagnosed annually in the United States).

• Incidence is highest in those under age 2 and over age 65.

• In children, the median age of onset is between 5 and 6 years old.

• Incidence is greater in African-American and socially-disadvantaged populations.

• In more than 70 percent of those with epilepsy, no specific cause for the disorder can be identified.


In general, those who experience idiopathic seizureshave a better prognosis in terms of both seizure con-trol and eventual remission than do those withepilepsy symptomatic of underlying brain damageor disease. About 70 percent of those children whoare otherwise normal will outgrow epilepsy and beseizure-free as adults (Shinnar and Pellock, 2002).

In childhood, the majority of seizures are partial innature, with specific epileptic syndromes, such asbenign rolandic epilepsy and childhood absenceepilepsy, accounting for a large proportion of cases(Shinnar and Pellock, 2002).

Some forms of childhood epilepsy are defined asbenign. They are self-limiting and often remit byadolescence. The child’s development and intellectwill most likely be normal. In other cases, althoughdevelopment and intellect do not appear to be affect-ed, seizures persist despite treatment. Others aremore serious and can be associated with developmen-tal delay or cognitive impairment and persistentseizures. The prognosis depends upon a variety offactors as listed in Tables 4 and 5.

Risk of Epilepsy in Special PopulationsThe basic underlying risk of developing epilepsy isabout 1 percent. Individuals in certain populationsare, however, at greater risk. Epilepsy can be expect-ed to develop in:

• 10 to 15 percent of children with mental retardation

• 13 percent of people with Cerebral Palsy(McDermott, 2005)

• 8.7 percent of children of mothers with epilepsy

• Up to 50 percent of children with both mentalretardation and cerebral palsy

• 2.4 percent of children of fathers with epilepsy • 33 percent of children who have had a single

seizure(Hauser, 1990)

Classifying SeizuresSeizures are classified by their clinical symptoms,supplemented by electroencephalographic (EEG)data. Accurate classification of seizures has beengreatly improved by the simultaneous use of EEGand videotape recordings. However, since most chil-dren experience seizures in a non-medical setting,the most important basis for classification is still aneyewitness account.

The International League Against Epilepsy (ILAE)Commission on Classification and Terminology firstproposed a classification system for epileptic seizuresin 1981. Today, it is the most widely used classifi -cation system. It divides seizures into two majorgroups — partial and generalized (see Table 6).

Partial SeizuresPartial seizures are the most common type of seizureexperienced by children with epilepsy. Virtually anymovement, sensory or emotional symptom canoccur as part of a partial seizure, including complexvisual, auditory or olfactory hallucinations.

SECTION 1: SEIZURE AND EPILEPSY BASICS 15

TABLE 3: Causes of Symptomatic Seizures

• Brain trauma (auto accidents are #1)

• Brain lesions (e.g. tumors, tubers)

• Brain injury at birth

• Congenital malformations

• Infections of the brain (e.g. meningitis,encephalitis)

• High fever

• Metabolic abnormalities (e.g. hypoglycemia,hypocalcemia, hyponatremia)

• Poisoning

TABLE 2: Causes of Epilepsy

For approximately 70 percent of children diagnosed with epilepsy the cause is determined to be either:

• Cryptogenic (of unknown cause)

• Idiopathic (presumed to be genetic)

For the remaining 30 percent the causes aregenerally the same as those for symptomaticseizures.


In partial seizures the electrical disturbance is limit-ed to a specific area of one cerebral hemisphere (sideof the brain). Partial seizures are subdivided intosimple partial seizures (in which consciousness isretained) and complex partial seizures (in whichconsciousness is impaired or lost). Partial seizurescan spread to cause a generalized seizure, in whichcase the classification category is partial seizures secondarily generalized.

Simple Partial Seizures Simple partial seizures result from abnormal neu-ronal activity in specific, limited areas of the brainthat affect movement, sensation or emotion. Partialseizures can progress through several stages thatreflect spread of the abnormal neuronal firing todifferent areas of the brain. For example, a seizurethat begins in a motor area can cause focal twitch-ing of the hand or the face.

This explains why simple partial seizures do notaffect consciousness. The child remains aware of theenvironment, remembers the seizure experience,but may be limited in how he or she can interactwhile it is in progress. Speech, for example, may bearrested.

A simple partial seizure can also be manifested astingling in the hand or face, visual distortions or

hallucinations, a feeling of sudden fear, a sense ofunexpected familiarity (déjà vu) or unfamiliarity(jamais vu), a breeze on the skin, a sudden risingfeeling in the stomach or sudden unexplained pain.Simple partial seizures of this type are also referredto as auras, internal experiences that may heraldmore extensive seizures to come and serve as warn-ings to the affected individual.

Complex Partial Seizures Complex partial seizures, like simple partialseizures, begin in one area of the brain, but usuallyinvolve larger portions of the brain and are associat-ed with an alteration in consciousness. In practicalterms, this means that the person experiencing theseizure cannot interact normally with his environ-ment, has impaired responsiveness and usually doesnot remember what happened during the episode.

Automatisms are a common characteristic of com-plex partial seizures. These are repetitive, complexmovements that are purposeless, undirected andinappropriate. Common examples of automatismsinclude lip smacking, repetitious swallowing orchewing, fidgeting with fingers or hands and repeat-ed clumsy movements of a preceding motor act.Automatisms are likely to be stereotyped — that is,the same type of movement occurs each time thestudent has a complex partial seizure.

In some cases, complex partial seizures generateactivities that cause social distress — disrobing, run-ning, screaming, flailing and exhibiting excessivefear. These phenomena, while far less common thanthe facial and fumbling automatisms describedabove, nevertheless create major social difficulties forchildren who experience them and for their families.


TABLE 4: Factors Predictive of Good Prognosis

• Normal neurological exam

• Normal intellectual functioning

• Absence of brain lesions

• Late onset of seizures (child is older than 3 or 4 years)

• Normal EEG

• Infrequent seizures

• Only one type of seizure

• Early response to a single medication

• No tonic and/or atonic seizures

• No status epilepticus

TABLE 5: Factors Predictive of Seizure Persistence

• Abnormal neurological exam

• Brain abnormality

• Abnormal EEG

• Multiple seizure types

• Frequent seizures


TABLE 6: Classification of Epileptic Seizures

I. Generalized Seizures (Convulsive or nonconvulsive)

a. Absenceb. Atonic/akineticc. Myoclonicd. Tonic, clonic and tonic-clonic

II. Partial (Focal Seizures)

a. Simple partial seizures (consciousness is not impaired) i. With motor symptoms ii. With sensory symptoms (including vision changes, bodily sensations, dizziness and imagined sounds,

smells and tastes)iii. With autonomic symptomsiv. With psychic symptoms (including dysphasia, dysmnesia, hallucinatory and affective changes)v. Compound (i.e., mixed) forms

b. Complex partial seizures (consciousness is impaired) i. Simple partial seizures followed by loss of consciousnessii. With impairment of consciousness at the outsetiii. With automatisms

III. Unclassified

IV. Prolonged or repetitive seizures (status epilepticus)

Summarized from the International Classification of Epileptic Syndromes, 1981

Generalized SeizuresGeneralized seizures affect both cerebral hemi-spheres (sides of the brain) from the beginning ofthe seizure. They produce loss of consciousness,either briefly or for a longer period of time.

Absence Seizures Absence seizures typically last just several seconds.There is no warning before the seizure and the childtypically resumes whatever activity he or she wasinvolved in before the seizure occurred. For exam-ple, if a student is reading he or she will stop. Thechild will usually blink his eyes a few times and theeyes may even roll up a bit. They may also haveassociated automatisms. When the seizure is overthe student will continue to read. These seizures areextremely brief in duration and are typically notassociated with the risk of injury. These seizures canoccur many times a day or in clusters, both of whichinterfere with a child’s ability to learn and function.

Atypical Absence Seizures Atypical absence seizures are different from typicalabsence seizures. They last longer, onset is not asabrupt and incomplete loss of awareness and mus-cle tone changes are more severe. There may beassociated head drops (atonic seizures) or myclonicseizures (see below). Atypical absence seizures usual-ly occur as part of a mixed seizure disorder.

Atonic Seizures Atonic seizures produce an abrupt loss of muscletone. Other names for this type of seizure includedrop attacks, astatic or akinetic seizures. They pro-duce head drops, loss of posture or sudden collapse.Because they occur abruptly without warning, andbecause those who experience them fall with force,atonic seizures can result in injuries to the head andface. Children with this type of seizure sometimeswear protective headgear to avoid injury. Theseseizures tend to be resistant to drug therapy.



Clonic SeizuresClonic seizures are always symptomatic of underly-ing brain disease. They involve rhythmic jerkingmovements of the arms and legs, sometimes onboth sides of the body. They are uncommon andoccur most frequently in neonates, infants andyounger children.

Myoclonic SeizuresMyoclonic seizures are characterized by rapid, briefmuscle contractions that usually occur at the sametime on both sides of the body. Occasionally, theyinvolve one arm or foot. Observers usually see themas sudden jerks or clumsiness. A variant of the expe-rience, common to many individuals who do nothave epilepsy, is the sudden jerk of a foot duringsleep (sleep myoclonus).

Tonic SeizuresTonic seizures are particularly common in childrenwho have Lennox-Gastaut syndrome, but they canoccur in anyone. They involve tensing or stiffeningof muscles in the body, arms or legs. The limbs mayextend and maintain this posture for seconds to aminute or so. Consciousness is usually preserved.

These seizures occur most often during sleep.However, because they usually involve all or most of the brain and affect both sides of the body, achild who is standing when the seizure starts willoften fall.

Tonic-Clonic SeizuresThese seizures are the most common and bestknown type of generalized seizure. They begin withstiffening of the limbs (the tonic phase), followedby jerking of the limbs and face (the clonic phase).

During the tonic phase, breathing may decrease orcease altogether, producing cyanosis (bluing) of thelips, fingernail beds and face. Breathing typicallyreturns during the clonic (jerking) phase, but it maybe irregular. The clonic phase usually lasts less thana minute. Incontinence can occur. The child maybite his/her tongue or inside of the mouth duringthe episode. Breathing afterward may be noisy andappear to be labored.

Contrary to popular belief, nothing should beplaced in the student’s mouth during a seizure. It isbest to turn the student on one side to help preventchoking and keep the airway clear. Following theseizure, the student will be lethargic, possibly con-fused, and want to sleep. Headaches sometimesoccur. Full recovery takes minutes to hours, depend-ing on the individual.

Epileptic SyndromesUsing seizure type alone to classify the type ofepilepsy often overlooks other important informa-tion about the student and the seizure episodes.Classifying into syndromes takes a number of theseidentifying characteristics and symptoms intoaccount, including the following:

• Seizure type

• Typical EEG recordings

• Clinical features such as behavior during theseizure

• The expected course of the disorder

• Precipitating features

• Expected response to treatment

• Genetic factors

Epileptic syndromes can be either idiopathic orsymptomatic of underlying brain damage or dis-ease. In general, idiopathic forms have a betterprognosis in terms of both seizure control andeventual remission than do symptomatic forms.

Benign Rolandic Epilepsy Benign rolandic epilepsy is the most commonepilepsy syndrome in children. It usually beginsbetween ages three and thirteen in neurologicallynormal children. Also known as benign partialepilepsy of childhood, it accounts for more thanone-third of all cases of epilepsy that begin in mid-dle childhood. There is a family history of this syndrome in 18 percent of cases and the conditionis thought to be genetically determined.

Seizure episodes begin as simple partial seizures,usually with twitching in the face, tongue, pharynx



and larynx. Most of the seizures are nocturnal,occurring within a few hours after falling asleep.Seizures are usually accompanied by gurglingsounds, profuse drooling and temporary inability tospeak. Consciousness is generally preserved, unlessthe seizure generalizes to tonic-clonic seizure, whichhappens often. If the child experiences these seizuresonly during sleep, the decision is often made not totreat with medication.

The child’s neurological and other functioning isusually normal. However the EEG readings mostoften show a dramatic focal spike in the centrotem-poral regions of the brain. Most children are seizure-free five years after onset and 95 percent ofthem will have undergone permanent remission byage 14 (see Table 7).

Childhood Absence EpilepsyAbsence seizures account for 2 to 4 percent of allcases of epilepsy in children. These seizures are non-convulsive and tend to occur in clusters.

Seizure onset usually occurs between ages four andeight.

Children with this syndrome are otherwise normal.About 40 percent outgrow the seizures. The syn-drome has a strong genetic component which is notwell understood at this time. Despite its overallbenign nature, approximately half of the childrenwith absence epilepsy can expect to have a general-ized tonic-clonic seizure during adolescence. Therisk is reduced if seizures are quickly controlled withmedication.

The prospects for remission of childhood absenceepilepsy are more likely when the child is younger atonset, the seizures are easily controlled with medica-tion, the child does not have generalized tonic-clonic seizures and there are no other neurologicalproblems (see Table 8).

Juvenile Myoclonic EpilepsyJuvenile myoclonic epilepsy is also called Janz’s syn-drome and myoclonic epilepsy of adolescence. It ischaracterized by myoclonic, tonic-clonic andabsence seizures. These seizures often occur uponawakening.

Juvenile myoclonic epilepsy generally appears atpuberty (between ages 10 and 20), but may haveexisted prior to that time. Seizures may be precipi-tated by sleep deprivation, early awakening, alcoholand drug use, stress, strong emotion, photic stimu-lation and menstruation. This is often a lifelongcondition (see Table 9).


TABLE 7: Benign Rolandic Epilepsy

• Onset usually before age 15

• Characterized by partial seizures resulting intemporary inability to speak

• Seizure often generalizes to tonic-clonic

• Most seizures are nocturnal

• 95 percent of children experience remissionby age 14

TABLE 8: Childhood Absence Seizures

• 40 percent outgrow seizures

• Probably inherited

• Half of these children also experience generalized tonic-clonic seizures

TABLE 9: Juvenile Myoclonic Epilepsy

• Appears at or around puberty

• Is characterized by generalized tonic-clonic,myoclonic and absence seizures

• Seizures are primarily jerking of arms and legs


Lennox-Gastaut SyndromeThe Lennox-Gastaut syndrome (also known asmyoclonic astatic epilepsy) is characterized by acombination of factors, usually including atypicalabsence seizures, tonic seizures, atonic seizures andmental retardation with a distinctive slow spike-and-wave EEG. Students with this syndrome areprone to convulsive and nonconvulsive statusepilepticus both requiring a medical intervention.Onset is usually between ages one and five.

Some children with this epilepsy syndrome aredevelopmentally normal when the syndromebegins, but then lose ground, sometimes dramati-cally. Episodes of status epilepticus contribute tothis decline. By age six most of these children havesome degree of mental retardation.

Children with Lennox-Gastaut syndrome typicallyexperience more than one type of seizure. The atonicastatic (drop attack) seizures are potentially the mosttroubling because of injuries caused by repeated falls.As a result, many children with this syndrome mustwear protective helmets. The tonic seizures are mostcommon during sleep, including nap time, whereasgeneralized tonic-clonic seizures occur most oftenon awakening. As children with the Lennox-Gastautsyndrome grow older, the types of seizures change.Among teenagers with Lennox-Gastaut, complexpartial seizures are the most-common form.

Temporal Lobe EpilepsyThe temporal lobes, one on each side of the head,just above the ears, are the sites of one of the most-common forms of epilepsy. Complex partial seizureswith automatisms, such as lip smacking or rubbingthe hands together, are the most-common seizuresin temporal lobe epilepsy.

Seventy-five percent of patients with this form ofepilepsy also experience simple partial seizureswhich may include features such as: a mixture ofthoughts, emotions and feelings that are hard todescribe; sudden emergence of old memories orfeelings of strangeness in familiar surroundings; hal-lucinations of voices, music, smells or tastes and

feelings of unusual fear or joy and; gastric sensations(e.g. pain, nausea, emesis). While partial seizuresdominate, approximately half the people with tem-poral lobe epilepsy have generalized tonic-clonicseizures as well.

The seizures characteristic of temporal lobe epilep-sy often begin in the deeper parts of the temporallobe (part of the limbic system) which control emo-tions and memory. Memory problems may developover time in people with this syndrome.

Frontal Lobe EpilepsyPartial seizures beginning in the frontal lobe mayproduce weakness or the inability to use certainmuscles, including the muscles that make it possibleto talk. Sudden thrashing movements during sleepare also characteristic of frontal lobe epilepsy, as isposturing with the head jerking to one side and thearm rising with it into a brief, frozen state. Some -times a generalized convulsion follows the slow marchof these movements.

Complex partial seizures in the frontal lobe havesome distinct features in contrast to those in thetemporal lobes. They usually last less than a minute,are less likely to be followed by confusion or fatigueand often occur in a series or cluster. They oftenoccur during sleep and may occur many times dur-ing the night and disrupt the normal sleep cycle.This can result in daytime sleepiness, behavioralproblems and poor school performance.

Frontal lobe epilepsy has significant social effectsbecause the seizures it generates are more likely toinvolve brief episodes of screaming, bicycling move-ments or even movements suggestive of sexualactivity.

Progressive Myoclonic EpilepsyProgressive myoclonic epilepsy is a rare, geneticallybased form of epilepsy marked by myoclonic andtonic-clonic seizures. People with this disorder alsoexperience difficulties with balance, muscle rigidityand progressive loss of mental abilities. A gene asso-ciated with this disorder has recently been identified.



Landau-Kleffner SyndromeLandau-Kleffner syndrome, also a rare disorder,causes the sudden or gradual loss of the ability tounderstand spoken language in addition to a seizuredisorder. Speech in children with this syndromeslowly declines over time. There are always epilepsy-related abnormalities on the EEG, even thoughsome children with this syndrome do not haveseizures. Parents often think that the child is devel-oping a hearing problem or has become suddenlydeaf. Hearing tests, however, show normal hearing.Children may also be initially diagnosed as autisticor developmentally delayed.

The syndrome typically begins between ages threeand seven. Seizures generally occur while the childis asleep and may be quite infrequent. Simple par-tial and tonic-clonic seizures may occur. Treatmentwith standard antiepileptic drugs is not very effec-tive, but treatment with steroids has been tried withsome success.

Reflex EpilepsyReflex epilepsy is the name given to seizures whichare triggered by individual sensitivity to sensorystimulation in the environment. The most-commonform is photosensitive epilepsy — seizures caused byexposure to intense or fluctuating levels of light.

Seizures in photosensitive people may be triggeredby exposure to television screen flicker or rollingimages, certain video games, computer monitors,alternating patterns of different colors or the intensestrobe lights in fire alarms. Also, some people havereported having seizures triggered by natural light,such as sunlight flickering through trees, light glancingoff water or through the slats of Venetian blinds.The condition usually begins in childhood and maybe outgrown by adulthood.

The reflex response is usually absence seizures butmay generalize to myoclonic seizures or generalizedtonic-clonic seizures. Wearing polarized sunglasseswith blue lenses has been cited as good protectionagainst photosensitive reflex seizures.

While flashing or flickering light is the most com-mon trigger for reflex epilepsy, rare triggers include

certain sounds, music, tone of voice, reading, immer-sion in hot water or even eating.

Seizure-Like Phenomena: Medical Conditions thatMimic Epilepsy Differential diagnosis of epilepsy is sometimes confounded by a variety of medical conditions thatproduce sudden symptoms resembling epilepticseizures. Some of these episodes can be caused byother medical conditions that mimic epilepsy.These include:

• Migraine and transient ischemic attacks thatproduce visual disturbances

• Hyperventilation, which produces tingling,lightheadedness and occasionally loss ofconsciousness

• Syncope (see Table 10)

• Breath-holding spells that lead to cyanosis(bluing) of the lips and jerking (usually inchildren under age five)

• Tics that produce jerking

• Sleepwalking and other sleep disturbances thatmimic seizure symptoms

• Episodic dyscontrol syndrome (rage attacks) thatare erroneously identified as epileptic seizures

• Narcolepsy, characterized by intermittent,uncontrollable episodes of falling asleep duringthe daytime which can produce cataplexy(short-lived intermittent muscle weakness) andsleep paralysis (paralysis while falling asleep orwaking)

• Certain paroxysmal movement disorder —with chorea or dystonia


“”

About 70 percent of thosechildren who are otherwise

normal will outgrowepilepsy and be

seizure-free as adults.


TABLE 10: Differentiating Syncope from Epileptic Seizures

CLINICAL DATA SYNCOPE SEIZURES

Precipitating factors Almost always Occasional

Warning Lightheaded, dizzy, queasy May have aura

Fall Often slumps to the floor May be violent

Motor component Rare Frequent

Incontinence Rare Occasional

Self-injury Rare Common

Appearance Pale, clammy Rubor, cyanosis, diaphoresis

Pulse Decreased, irregular Usually increased

Degree of postictal Mild Often marked

Family history Often positive for syncope Often positive for seizures

Interictal EEG Usually normal Often abnormal

TABLE 11: Differentiating Epileptic Seizures from Psychogenic Seizures

CLINICAL DATA PSYCHOGENIC GENERALIZED COMPLEX PARTIAL SEIZURES TONIC-CLONIC SEIZURES SEIZURES

Changes in seizure frequency Rare Common Commonwith medication change

Increased seizure Frequent Occasional Occasionalfrequency with stress

Combativeness Common Rare Rare

Vulgar language Frequent Rare Rare

Self-injury Rare Occasional Rare

Incontinence Rare Common Rare

Tongue biting Rare Common Rare

Nocturnal occurrence Rare Common Occasional

Stereotype Often variable Little variation Not identical but usuallyof attacks have similar patterns

Postictal confusion, Rare Always Frequentlethargy, sleepiness

EEG, Interictal Often normal Frequently abnormal Frequently abnormal

EEG, During attack Normal Always abnormal Usually abnormal

Psychogenic SeizuresPsychogenic seizures, also called pseudoseizures, arenon-epileptic, episodic, paroxysmal events not relat-ed to abnormal electrical activity in the brain.Considered to be of psychological rather than phys-ical origin, they offer a major challenge to diagnoseand treat.

While these episodes do resemble true epilepticseizures, they are different from them in severalimportant ways:

• Students have repeatedly normal EEG readingsduring seizure-like events.

• There is a lack of any response to therapeuticlevels of antiepileptic drugs.



• The seizures may be marked by violent thrash-ing of all four limbs, with typically asynchro-nous and arrhythmic movement, without los-ing consciousness. It is unusual in epilepsy forsomeone to remain conscious in the presence ofsustained motor activity of the arms and legs.

Psychogenic seizures are best dealt with on an indi-vidual basis. Once identified through video-EEGmonitoring, the problem can be addressed throughindividual and family counseling and psychotherapy.Occasionally treatment may include psychiatric med-ication. Sometimes the seizures abate when the per-son is informed that they are psychological in nature.

Intractable Epilepsy Students with intractable epilepsy fail to respond tostandard antiepileptic drug therapy. Often, theyhave underlying structural brain or neurologicalconditions, head injury or cognitive problems.These children continue to experience seizures andare usually on large amounts of multiple antiepilep-tic medications. They must endure not only theongoing seizures but also the side effects of the drugtherapy. Of the 326,000 children under age 15 withepilepsy, approximately 90,000 have severe seizuresthat cannot be adequately treated.

Students with intractable epilepsy are the greatestchallenge for school nurses. They are more likely toexperience seizures during school and, therefore,require more time and attention. They may requireonsite emergency interventions by the nurse or atrained designee.

Although single seizures do not permanently impairintellectual or behavioral functions, multiple anduncontrolled seizures can have significant conse-quences. The long-term effects of numerous orrecurrent seizures are the subject of studies and con-troversy and should never be underestimated.

Intractable seizures also significantly impact thestudent’s quality of life, with limitations onparticipation in sports, schoolyard games and classoutings. Students with more severe seizures may needan aide with them at all times and/or must wear a

protective helmet. This can further stigmatize andshame the student and have deleterious effects onthe student’s self esteem.

These students are at high risk of becoming isolatedand withdrawn. The school nurse should facilitatethe student’s ability to participate safely in schoolactivities and counsel the family whenever there areconcerns about the student’s emotional well-being.

Status Epilepticus: Prolonged or Serial SeizuresMost seizures end after a few seconds or a fewminutes. If they are prolonged or occur in a series,there is an increased risk of status epilepticus.Traditionally, status epilepticus is medically defined as30 minutes or more of uninterrupted seizure activityor more than one seizure without regaining baselinewithin 30 minutes. Many believe, however, thatmuch shorter periods of continuous seizure activitymay cause neuronal injury and that seizure self-termination is unlikely after as few as five minutes.More recent medical definitions consider 10 minutes,rather than 30 minutes, as the defining time. TheEpilepsy Foundation advises calling for emergencyassistance whenever a convulsive seizure continues formore than five minutes without signs of stopping.

Although rare, death or brain damage can occur as aresult of status epilepticus. During status seizuresproblems can arise if there is pulmonary or cardiacarrest that is not promptly treated. More often, how-ever, serious negative consequences occur hours ordays after the onset of status as a result of prolongedstress, oxygen deprivation and systemic complica-tions such as organ failure.


TABLE 12: Status Epilepticus Facts

• 10 percent of patients who develop epilepsyhave status as their first seizure

• Of all of those who experience status, 25 percent are individuals with epilepsy

• 15 percent of persons with epilepsy experience an episode of status epilepticus


In children, the most common precipitating factorsfor status epilepticus are fever/infection and with-drawal from medication or noncompliance with theprescribed regimen (DeLorenzo, 1992). There may,however, be no obvious cause for the episode. Tenpercent of children who later progress to epilepsyhave experienced their first seizure as a statusepisode.

In all cases, prompt treatment is the key to prevent-ing serious negative outcomes. The goal of treatmentis to stop the seizure activity as quickly as possibleand treat any underlying precipitant (Delorenzo,1992). Mortality in children and adults is minimizedwhen status lasts less than one hour. After an hour,however, mortality increases slightly in children butjumps dramatically to close to 38 percent in adults.

Any type of epileptic seizure can progress to statusepilepticus, but convulsive status has the greatestpotential for causing long-term damage.

Treatment of convulsive status epilepticus generallyincludes use of such drugs as diazepam, lorazepam,phenytoin and phenobarbital administered in aplanned sequence. Rectal diazepam gel may be pre-scribed for at-home or non-hospital use to stopbouts of prolonged seizures or clusters of acuterepetitive seizures in children with a history of thistype of seizure.

Nonconvulsive Status Epilepticus Nonconvulsive status can present in various ways,including loss of speech, automatisms and alterationof consciousness. It includes continuous absenceseizures and partial status epilepticus, as well as sta-tus involving simple partial seizures called epilepsiapartialis continua.

Although nonconvulsive status epilepticus is notusually a dangerous or life-threatening condition itmay have an adverse effect on a child’s memory andintellectual abilities, particularly if it is not recognizedearly. The treatment of nonconvulsive statusepilepticus, whether absence or complex partial statusepilepticus, is similar to the treatment of convulsivestatus epilepticus.

Epilepsy in Female StudentsMore than one million women and girls in theUnited States have epilepsy. While many of theissues they face are common to both genders,women with epilepsy must deal with unique levelsof uncertainty at various points in their reproduc-tive lives from puberty onward because of the influence of hormones associated with menstrualcycles. Epilepsy related to the menstrual cycle iscalled catamenial epilepsy. While research in thisarea is just beginning, it is already yielding impor-tant new information.

Antiepileptic drugs that induce the hepatic microso-mal enzyme system that clears drugs through theliver can, in some women, lower the effectiveness ofbirth control pills, requiring higher doses to preventconception. This is important for older female stu-dents to know, especially if they are sexually active.



Section 2THE IMPACT OF EPILEPSY

”

“Understandingwhere a child is on

the spectrum ofseverity helps indetermining the

extent of interventionnecessary at given

points in time.


The many variables in epilepsy add to the complex-ity of its impact on students. Seizures may be con-trolled or uncontrolled. They can lead to disablingevents or simply minor challenges. Medications canhave mild or severe side effects. The stigma of epilep-sy impacts self-concept and socialization skills.There fore, when evaluating the consequences ofepilepsy, it is important to recognize that the con-joined impact of all of these factors — seizures, med-ications and external and/or internalized stigma —can be significant. Each variable, alone or in combi-nation, can dramatically affect the child and definethe extent to which he/she is disabled by epilepsy.

Impact of Epilepsy on Learning While most children with epilepsy are otherwisenormal, as a group, their risk for learning problemsis significantly increased. Research suggests that abouthalf of children with epilepsy meet the criteria for alearning disability in at least one area (Fastenau et al.,2008). In this study, learning disabilities were foundin all three areas: writing (38%), mathematics (20%),and reading (13%). Under achievement often occursin language skills, reading and mathematics. The long-term adverse impact of these deficits may extendbeyond education to employment, marriage andfertility (Shinnar and Pellock, 2002).

Children who achieve seizure control relativelyquickly, with few medication side effects and nocognitive impairments, generally have the bestchance for average or above-average educationalachievement. However, it is worth noting thatchildren with epilepsy with average IQs may notachieve up to their potential, and attention problemsare identified in many children with epilepsy. Loss ofschool time, because of seizures or medical tests, mayalso affect performance, even among students whoare otherwise doing well.

Not surprisingly, students with uncontrolledseizures have difficulty with learning, memory, con-centration and attention, arising from the underly-ing cause of the epilepsy itself or from recurrentand/or uncontrolled seizures (Sperling 2004,Hermann 1993). Anti seizure medicines sometimescompound these challenges but are not completelyto blame (Prevey, 1998).

Other findings and observations about the impactof epilepsy on learning and behavior in childreninclude:

• As many as a third of children with epilepsyrequire special education (Zelnick et al, 2001).

• Young age at onset, poor seizure control,underlying brain lesions and mixed EEG patterns are some of the predictors of the needfor special education (Zelnick et al, 2001).

• When intellectual disability and seizures coexist, a higher rate of disturbed behavior is found (Sabaz, 2001).

• In a quality of life survey, intellectually normal children with refractory (uncontrolled)epilepsy had difficulty with school performanceand experienced socialization problems and areduced quality of life (Sabaz, 2001).


Section 2THE IMPACT OF EPILEPSY

TABLE 13: Factors that May Increase theRisk of Learning, Psychosocial andBehavioral Problems

• Early age of onset

• Frequent seizures

• High seizure frequency

• Multiple lifetime seizures

• Seizures in school

• Memory deficit

• Slowed motor speed


• Educational achievement is influenced by several factors: neurological and cognitiveimpairments, psychiatric problems, underlyingpathology and social and cultural influences, aswell as the degree of seizure control (Sperling,2004; Hermann, 1993).

Assessing Learning and Behavioral DisordersStudents with seizures may exhibit behaviors andhave learning consequences that should be assessedwhile determining eligibility for an IndividualizedEducation Plan (IEP) and completing theIndividualized Healthcare Plan (IHP). These mayinclude:

• Attention deficit disorder (ADD) or attentiondeficit hyperactivity disorder (ADHD)

• Learning disorders• Adjustment disorders — psychological and

social adjustment to epilepsy• Mood disorders — anxiety and depression are

most common• Mobility problems — motor deficits such as

hemiparesis or spastic paresis, which are mostlikely caused by underlying etiology. Episodicweakness or incoordination may be due to postictal effects of seizures or side effects ofmedications

• Injuries — from seizures or falls, are usuallyminor, but may include head injuries, fractures, lacerations and bruises

• Developmental delay — seizures are often asymptom of neurological dysfunction for children with developmental delay or mentalretardation

Impact of Epilepsy on the Brain Different types of seizures can have a variableimpact on the brain, lifestyle and safety. Researchsuggests that uncontrolled seizures can become partof a progressive disorder (Sutula, 2003), with persistent seizures resulting in increasing cognitivedysfunction and changes in the brain tissue as a partof disease progression. These problems are not seenin individuals with controlled epilepsy, which

reinforces the importance of early diagnosis andeffective treatment of seizure disorders.

Impact of Epilepsy on Social Development andQuality of Life One leading expert refers to epilepsy as “uniqueamong illnesses for the extent and degree of psychosocial disability it causes” (Sperling, 2004).Others confirm this, reporting:

• The unpredictable and incapacitating nature ofseizures can cause stress and embarrassment.

• Behavior problems in children with epilepsyare frequently the result of a combination offactors, including family stress and seizure frequency (Hermann and Austin 1993).Family stress is often more significant than the number of seizures and may be negativelyimpacted by lack of support from the extendedfamily, financial problems and low self esteem.Accordingly, family issues and attitudes mustbe addressed as part of any treatment plan.

Students with epilepsy are more likely to experienceimpaired self-image, behavior problems and psychi-atric co-morbidities than are students with otherchronic medical problems, such as asthma. Thosewith frequent or uncontrolled seizures may also facesocial rejection by peers.

Epilepsy still carries much stigma. This often affectspsychological well-being and, for many children, itinfluences their ability to make and keep friends andto feel confident in social settings away from theirparents. The impact of epilepsy on adolescent growthand development can be dramatic. The normal tran-sition from dependence to independence is often dis-rupted. Families report concerns about safety, socialisolation, frequently missed school days, grades and,eventually, driving (Swartztrauber K, 2003).

Epilepsy has measurable effects on most primaryareas of life including education, marriage and fam-ily and emotional adjustment. It is to be expectedthat the more severely affected an individual stu-dent or adult, the greater the social and psychosocialdifficulties they will experience. For many, however,

SECTION 2: THE IMPACT OF EPILEPSY 27


the negative reactions of others far outweigh theimpact of the condition itself, no matter how wellthey are doing or how much they have achieved. It isnot surprising then, that while some successful indi-viduals with epilepsy are willing to acknowledge theircondition, many in a position to help change socialattitudes prefer to keep their seizure disorder private.

Assessing the Impact ofEpilepsy: The Spectrum ofSeverityEpilepsy affects individuals to varying degrees, creat-ing a spectrum of disability that is broad and rangesfrom having a very limited effect on the individual tohaving a devastating impact on all aspects of life. Forthe majority (perhaps as high as 80 percent) of thosewith epilepsy, seizures can be substantially reduced orcompletely controlled, enabling children to live nor-mal or close to normal lives.

For the remaining 20 percent, epilepsy is truly disabling, marked by frequent seizures, otherimpairments, memory and other cognitive effectsand a highly compromised standard of living.Children whose seizures are not well controlledoften experience social, emotional and academicproblems that affect various stages of development.

These problems commonly extend into adult life,where the same issues become chronic barriers toemployment and independence. For many otherchildren and adults, the level of functioning actuallyfalls somewhere between these extremes.

Marshall and Cupoli (l986) have identified threecategories of severity among students with seizuredisorders. The severity of the seizures, the effects ofthe medication and the neurological status ofpatients all interact to produce these characteristiclevels of functioning.

The categories are defined as:• Uncomplicated, because the seizures are con-

trolled with medication• Compromised, because of social, emotional

and educational (cognitive) problems• Devastated, by virtue of multiple problems

Uncomplicated Children in this category are likely to have gainedcontrol of seizures fairly rapidly and have no, orinfrequent, seizures. They have limited, if any, sideeffects from medication and are cognitively intact(although memory problems are commonly citedacross all levels of severity). They have no addition-al physical or mental impairments.

While social issues based on society’s reaction toepilepsy also affect children across all severity meas-ures, epilepsy is less disabling for children withuncomplicated epilepsy. Educational/employmentproblems among this group may occur, but theirimpact is less than those with complicated epilepsy.

Compromised Children in this category have seizures that are usually controlled and do not have serious mental ormotor deficits. However, they take higher doses ofmedication to maintain control and are more likelyto experience side effects. They are also more likely toexperience a greater level of social, emotional andeducational/employment problems during their lives.

Devastated Children and adults whose lives are devastated byepilepsy often have seizures as a result of brain diseaseor injury that also impairs learning, memory, atten-tion and motor and emotional function. Theirseizures start early in life and may never be con-trolled, despite the use of multiple and combinedmedications. They are likely to be heavily medicatedand may experience some slowing or retardation.They have difficulty in maintaining family supportand social relationships and require help in everydayliving. They are more susceptible to bouts of contin-uous seizure activity (flurries) and status epilepticus.Individuals of all ages in this category have a lifelongneed for services and are substantially limited in theirability to function independently.

Understanding where a child is on the spectrum ofseverity helps in determining the extent of interven-tion necessary at given points in time. It can also bea useful reference tool in determining when addedassistance may be needed for a child whose epilepsyis destabilized by medication changes, puberty orother factors.



“

”

Basic first aid(care and

comfort) is theresponsibility of

all schoolpersonnel whointeract with achild who has

seizures.

Section 3FIRST AID


The school nurse should be informed by parents orguardians if there is a history of any type of seizurefor any student in his/her care. A seizure action planshould be developed that includes plans for bothbasic first aid and acute intervention, should theseever be needed. See Section 5 for more informationabout seizure action plans.

First aid can be broken down into two steps:

1.Basic First Aid — Care and Comfort

2.Acute Interventions and Emergency Response

Basic First Aid: Care and ComfortSeizures can last from a few seconds to a few min-utes, depending on the type of seizure. They mayaffect awareness, but are rarely medical emergenciesand usually require only basic care and comfort. If astudent has more frequent seizures than is usual forthat student, or if seizures appear different thanusual, the school nurse or a delegate should followthe seizure action plan and contact the parents orother designated emergency contact.

Basic first aid (care and comfort) is the responsibil-ity of all school personnel who interact with a childwho has seizures. The school district should providea training opportunity to all relevant staff accordingto the student’s IHP and seizure action plan so theycan respond appropriately to routine seizures. Basicfirst-aid training can be performed by the schoolnurse or by staff from a local Epilepsy Foundationaffiliate. Basic first aid does not need to be madecomplicated. Most people, with instruction, cansafely provide basic first aid.

Basic first-aid measures for seizures have commonelements. However, the type of assistance provided

to the student who loses consciousness because of aprimary or secondarily generalized seizure (see Table15) is different than that for students who experi-ence states of altered awareness as seen with com-plex partial seizures (see Table 14).

Care of Students with No Change in ConsciousnessWhen seizures do not alter the student’s awareness orconsciousness, as in simple partial seizures, schoolpersonnel who are assisting the student should focuson ensuring the student is safe. Make sure the schoolnurse or trained school personnel is with the studentduring the event, observing and recording whattranspires. After the seizure, the school nurse ortrained school personnel should ensure that the stu-dent is fully oriented to person, place and time, isable to communicate his/her needs and is capable ofresuming prior activities. If needed, the studentshould also be provided with a comfortable, safe andsupervised place to rest until he/she feels able toactively and appropriately participate.

Care of Students with Altered AwarenessAbsence seizures are characterized by brief lapses inawareness. A typical seizure lasts five to ten seconds.No specific first aid is required for absence seizures.However, when these occur in clusters, the studentmay experience a longer period of feeling spacey,out of contact or confused. In these instances theeducator/school personnel should ensure that thestudent is fully oriented and able to resume prioractivities.

Complex partial seizures last longer than absenceseizures and can affect the student’s awareness ofwhat is occurring and cause confusion. Some chil-dren report that they can hear but cannot talk.Others can talk, but may not remember what theyhave said or their speech does not make sense.


Section 3FIRST AID


If a complex partial seizure lasts more than five min-utes beyond its usual duration for that student, or ifanother seizure begins before the student fullyregains consciousness, call EMS or another pre-determined emergency assistance provider as notedin the student’s seizure action plan.

Care of Students with Seizures thatCause Loss of Consciousness Generalized tonic-clonic seizures, whether pri-mary or secondarily generalized, are often calledmajor motor seizures. Observers often believe thatthese seizures last longer than they actually do. For

example, while the student may not be able torespond appropriately for 20 minutes or more, the actual seizure, with stiffening and/or jerkingmovements of the arms or legs, may last one to twominutes or less.

After a Seizure Episode A written protocol dictating what happens after a student has a seizure should be included in thestudent’s seizure action plan. This protocol shouldbe a collaborative effort between the school nurse,parent(s) and the healthcare team. The majority ofstudents will not need to leave the classroom or

SECTION 3: FIRST AID 31

TABLE 15: Care and Comfort for aGeneralized Tonic-Clonic Seizure

If a student is having a generalized tonic-clonicseizure:

• Stay calm and reassure the student thathe/she is safe

• Reassure the other students

• Help the student to lie down, if necessary

• Observe and time events

• Turn the student on one side

• Protect the student’s head and removeeyeglasses

• Loosen any tight clothing from around the neck

• Remove potentially harmful objects from thesurrounding area

• Follow the seizure action plan

• Call EMS (or other pre-determined emergencyassistance) if the seizure lasts more than fiveminutes unless the student’s typical seizure is longer as noted in the seizure action plan

Caregivers should NOT:

• Restrain the student’s movements

• Put anything in the student’s mouth

• Expect instructions to be followed

• Shout

TABLE 14: Care and Comfort for aComplex Partial Seizure

Caregivers responding to a complex partialseizure should:

• Stay calm and reassure the student thathe/she is safe

• Reassure the other students

• Speak softly and calmly, keeping in mind thatthe student may not be able to obey verbalinstructions

• Protect the student’s privacy wheneverpossible

• Direct the student away from potentiallyharmful objects such as tables, chairs anddoors

• Allow a wandering student to walk in acontained area

• Stay with the student until completeawareness of the environment is maintained

• After the event, reorient the student to thesurroundings and provide a comfortable, safeand supervised place to rest, if needed

Caregivers should NOT:

• Restrain the student’s movements

• Expect instructions to be followed

• Shout


school after a seizure. Whether a student leavesschool after a seizure is often dependent upon thefinal assessment of a professional school nurse.Some students will need to rest in the school nurse’soffice or another comfortable, safe and supervisedarea until they are able to return to normal activi-ties. If the student is not able to resume scheduledactivities within a reasonable period of time, as doc-umented in the seizure action plan, the school nurseor other trained school personnel should contactthe student’s parent(s) or healthcare professional(s)to determine the best course of action.

Acute Interventions andEmergency ResponseThe school nurse should develop a seizure actionplan for every student with a known seizure condi-tion. This should include a detailed description ofrecommended seizure abortive therapy and appro-priate emergency responses to ensure the studentremains safe in the event of an acute seizure emer-gency, including status epilepticus.

Each school typically has a system in place for schoolnurses and other personnel to call for emergencymedical assistance. In some school districts, 911 isavailable. In others, the school may have arrange-ments with local hospitals or healthcare systems. Theschool nurse should inform parents of students withseizures about emergency system options and discusswhen these systems would be needed. She/he canthen develop guidelines in concert with the parentsand healthcare team, defining specifically what con-stitutes an emergency for that student and how torespond appropriately. All of this information shouldbe included in the seizure action plan.

Currently the Epilepsy Foundation recommendsinitiating acute interventions after five minutes ofcontinuous seizure activity. The school nurse orother trained school personnel should also be pre-pared to administer (within the state law) PRNmedications as prescribed and incorporated into theseizure action plan.

Use of Medications for Prolonged or Cluster SeizurePhysicians sometimes prescribe an antiepilepticmedication for PRN use for children who have clus-ters of seizures (multiple seizures within a definedperiod of time), prolonged seizures (status epilepti-cus) or a tendency to have seizure emergencies. Theadministration of oral medications during a seizureshould be avoided, but if the student is alertbetween seizures, a fast-acting antiepileptic drug,such as lorazepam (Ativan®) or midazolam can begiven buccally or sublingually, as prescribed by thestudent’s physician. If a student is not alert or ifother routes cannot be used, diazepam rectal gel(Diastat® AcuDial™) may be used.


When is a Seizure Considered an Emergency?

Call 911 and seek emergency assistanceimmediately when a seizure occurs in a student who:

• Has no previous history of seizures

• Has a convulsive (generalized tonic-clonic)seizure that lasts longer than five minutes

• Experiences repeated seizures with loss ofconsciousness or a second seizure occursbefore the student regains consciousness

• Has more seizures (of any kind) than usualor has a different kind of seizure than nor-mally experienced as noted in student’sseizure action plan

• Has an actual injury (or a suspected one)as a result of a seizure or if parents orguardians request emergency help or anevaluation

• Has diabetes, is pregnant or has anothermedical condition

• Does not resume normal breathing at theconclusion of the seizure

IMPORTANT: If a student is not breathing atthe conclusion of the seizure, begin mouth-to-mouth resuscitation immediately and call 911or the local emergency medical personnel.


Medication administration for acute or prolongedseizures may be accomplished in different waysdepending on a state’s nurse practice act, school dis-trict policy, school policy, state laws, physician orderand parent preference and should be noted in theseizure action plan. In many states, the school nursehas the primary responsibility for administeringmedications, but this is not always the case. Goodnursing practice requires the school nurse to workproactively with the student’s parents and health-care providers to clarify indications and instructionsfor the medication’s use.

The student’s seizure action plan should incorporateinstructions for medications to be used during pro -longed seizures or seizure emergencies. Seizure med-ication and treatment instruc tions should include:

• Brand and generic name of the antiepileptic medication

• Dosage

• Dosing regimen

• Special instructions for administration

• How to monitor responses

• Potential side effects

• Possible drug interactions

• What to do if a dose is missed

• What to do if side effects are observed

Vagus Nerve Stimulation and Magnet UseVagus nerve stimulation therapy delivers prepro-grammed electrical impulses to the vagus nerve on anongoing basis. A Vagus Nerve Stimulator (VNS),usually implanted in the upper left chest or under thearm, stimulates the vagus nerve, which in turn trans-mits electrical impulses to critical brain areas that areinvolved in seizure generation or spread.

A VNS device may be stimulated manually with theuse of a magnet, typically worn on the wrist or belt.If the student has a seizure warning sign (aura), orat the onset of a seizure, the student, school nurse ortrained school personnel may swipe the magnetover the VNS device to trigger an extra burst ofstimulation. Many people with epilepsy report thatactivating the VNS device in this manner helps to

abort the seizure or lessens its intensity. The magnetmay be used as often as needed with at least a minutebetween swipes.

If the magnet is held over the VNS device for sixseconds it will turn it off temporarily. The studentmay consciously do this to avoid certain side effects,such as changes in voice or coughing during activi-ties involving public speaking or singing or whenstimulation is uncomfortable.

The most common side effect of vagus nerve stim-ulation is mild hoarseness and slight tingling in theneck when the signal is activated. Other reportedside effects include dyspepsia, insomnia and diffi-culty swallowing.

A magnet should be with the student at all times.However, the student should be reminded to keepthe magnet away from anything that is sensitive tomagnetic fields including computers, cards withmagnetic strips (e.g. credit cards) and videotapes.

Instructions for VNS magnet use should be incor-porated into the seizure action plan for studentswith a VNS device as a first-aid intervention thatcan be administered by the student, school nurse ortrained school personnel. Students with a VNSimplant should also carry VNS identification cards.

Videos that demonstrate the use of the Vagus NerveStimulator are available from the manufacturer, asare magnets. Visit www.vnstherapy.com to obtainordering information (please see page 39 for addi-tional information on VNS therapy).

Delegation of AcuteIntervention ResponsibilitiesFederal laws like Section 504 of the RehabilitationAct of 1973, the 1990 Americans with DisabilitiesAct (ADA) and the 2004 reauthorized Individualswith Disabilities in Education Act (IDEA) mandatethat reasonable accommodations be enacted inschools to ensure that a student with a disability hasfull access to all school activities in the least restrictiveenvironment and that each student has educationalopportunities equal to his/her non-disabled peers.

SECTION 3: FIRST AID 33


This mandate requires that both public and privateschools make appropriate arrangements to accom-modate a student who may need to receive PRNmedications while at school or during school activi-ties such as routine school bus rides, field trips andsporting or fine arts events. Whether this administra-tion is accomplished by a licensed professional schoolnurse or a delegate depends on state laws, a state’snurse practice act, school district and school policyand finally, parent and child preference. Where statelaws restrict the delegation of medications, the schoolnurse, individual school, school district and student’sparent(s) must discuss this issue and develop a planfor how to provide the student who may requirethese medications with full access to all activities.

Unfortunately, even when it is determined that del-egation of acute intervention responsibilities is legaland necessary, there may be no one immediatelyavailable or willing to perform this function. Whenthis occurs, the school nurse, parents and schooladministrators must seek (within state law) a work-able solution to ensure that an appropriately trainedindividual is delegated the authority and is availableto perform this function.

When delegation of an acute intervention is consid-ered, the school nurse should make certain that allinvolved in the delegation process (i.e. teachers, par-ents, school staff, classmates or other students)understand that the school nurse must:

• Put the health, safety and welfare of the student above all other considerations

• Abide by the state nurse practice act• Abide by the school and school district policies• Abide by applicable state and federal mandates• Abide by state education, public health and

pharmacy laws and regulations• Determine if a nursing task can be delegated

under her nursing license

If a determination is made that a school nurse candelegate a task under her nursing license, dependingon state law, the nurse is then responsible for thefollowing:

• Ensuring that the chosen delegate is appropriate

• Providing training and ongoing assessment and documentation of the competence of the delegate

• Providing ongoing assessment of the student’shealth

Note: In situations where a professional school nurse isnot available, the training and supervision of approveddelegates may fall on the student’s prescribing physician.



”“The goal of treatment

for the student withepilepsy is no seizures

and no medicationside effects.

Section 4TREATMENT FOR SEIZURE PREVENTION


When treatment is indicated for the student withepilepsy, there are a variety of options which, usedalone or in combination, can help prevent seizuresand minimize their impact and severity. Theseinclude:

• Antiepileptic drugs (AEDs) are the corner-stone of epilepsy treatment and the most com-mon approach. (Please see Appendix C formedications used in the United States alongwith dosage information and the most com-mon side effects.) PRN AEDs are essential inmanaging acute seizures and status epilepticus.

• Surgery is an option when there is a brainlesion or abnormality that can be identified asthe origin of seizure activity and can beremoved safely.

• The ketogenic diet is high in fat and low inprotein, carbohydrates and fluids. It produces aketotic state that is beneficial in reducingseizures in some individuals with epilepsy.

• Vagus nerve stimulation therapy sends anelectric stimulus to the brain, averting seizures.

• Alternative therapies, while not well studied,are currently under investigation by researchers.

Antiepileptic Drugs (AEDs)Before 1990, antiepileptic medication choices werelimited, but since then, nine new products havebeen introduced. Some work well for some individ-uals, so it is important for the student’s healthcareproviders and parents to determine the best courseof treatment. (See Appendix C for more informa-tion on drug therapies.)

Initiating Drug TreatmentThe decision to begin drug treatment is based uponmany factors, including the risk of having recurrentevents. Clinical experience and research findingsdemonstrate that monotherapy is effective for controlling seizures in approximately 65 percent of

patients. Treatment with two AEDs controls seizuresin another 10 percent.

It is common practice today to start treatment withone antiepileptic drug after the child has had twounprovoked seizures. If the child does not respondto one drug, a second drug is often added. In moreresistant seizures, multiple medications are addedand may control seizures. Unfortunately, multiplemedications can also have negative side effects.There is frequently an effect on attention, somno-lence and/or cognition when medications are usedin high doses or in combinations.

Antiepileptic Drugs in UseThere are many antiepileptic drugs in use today.The oldest of these are Dilantin® (phenytoin), phe-nobarbital, Tegretol® (carbamazepine), Zarontin®

(ethosuximide) and Depakote® (valproic acid).

The newer AEDs are Felbatol® (felbamate),Gabitril® (tiagabine), Topamax® (topiramate),Zonegran® (zonisamide), Keppra® (levetiracetam),Lamictal® (lamotrigine), Trileptal® (oxcarbazepine),Lyrica® (pregabalin) and Neurontin® (gabapentin).Many of these products are available in differentformulations for ease of administration.

The student’s healthcare provider, along with his/herparents, will decide when treatment is necessary andwhich medication should be used. The prescribedtreatment and medications are usually based onseizure type, frequency and severity and the abilityto perform daily living tasks at home and school asappropriate to the child’s age and stage of develop-ment. Titration of medication in epilepsy is routine-ly needed, because dosages are adjusted for weight,side effects and efficacy. When new medications arebeing introduced and/or current medications arebeing weaned, flexibility is needed. These processescan be time-consuming and can put the student atrisk for seizures during the period of adjustment.


Section 4TREATMENT FOR SEIZURE PREVENTION


Approximately 25 percent of those with epilepsyhave seizures that are not completely controlledwith medications alone. It is important to makeearly determinations of treatment intractability andpromptly refer the child to an epilepsy specialtycenter to minimize both the psychosocial conse-quences of uncontrolled epilepsy and the potentialfor physical sequela (Wiebe, 2004).

The primary risks related to drug therapy rangefrom common side effects (dizziness, drowsiness ornausea) to toxicity from medication, which can beidiosyncratic, dose-related or chronic. Conversely,allowing a child to have seizures also has risks. Theseinclude physical injury associated with falls and psy-chosocial issues associated with restrictions placedon the child because of epilepsy, the social stigma ofseizures and the child’s ongoing concerns abouthaving another seizure.

PRN Medications for Prolonged orAcute Repetitive SeizuresSeveral fast-acting AEDs are currently prescribedfor PRN use for students who have clusters ofseizures (multiple seizures within a defined periodof time), prolonged seizures (status epilepticus) or atendency to have seizure emergencies. Theseinclude AEDs such as lorazepam (Ativan®) andmidazolam (Versed®), both of which may be givenbuccally or sublingually, and diazepam rectal gel(Diastat® AcuDial™).

Diazepam rectal gel, often referred to as a seizure rescue medication, is the most commonlyprescribed medication for out-of-hospital use tostop acute or cluster seizures. It is approved by theU.S. Food and Drug Administration for use byfamily members or other non-medical caregivers. It is supplied in pre-packaged syringes for rectaladministration, with dosages tailored to the child’sweight. Remember that medication administrationin the school setting depends on state laws, thestate’s nurse practice act, school district and schoolpolicy and finally, parent and child preference.

Diazepam rectal gel is usually well tolerated. Somestudents may be tired after the drug is given andneed to rest, while others can resume their usualactivity immediately. Primary concerns aboutdiazepam rectal gel include student privacy duringadministration, the ability to assess when to admin-ister and respiratory depression. Despite concerns,respiratory depression is not a common side effectof this medication.

Videos demonstrating the use of the diazepam rectal gel are available from the manufacturer, as arerectal syringes. Visit www.diastat.com to obtainordering information.

Midazolam treatment by intranasal routes is alsoindicated for the treatment of prolonged seizures inchildren. Although this nasal spray is not currentlyindicated for out-of-hospital use in the UnitedStates it shows promise as an effective seizure rescuemedication in the future. In preliminary studiesintranasal midazolam has been shown to be at leastas effective as diazepam rectal gel in stopping prolonged and cluster seizures in children(Harbord, 2004).

The Cognitive and Behavioral Effectsof Antiepileptic DrugsIn children, the side effects from AEDs can beunpredictable and must be weighed against the

SECTION 4: TREATMENT FOR SEIZURE PREVENTION 37

TABLE 16: Drug Reaction Warning Signs

• Rash

• Prolonged fever

• Severe sore throat

• Mouth ulcers

• Easy bruising

• Pinpoint bleeding

• Weakness

• Excessive fatigue

• Swollen glands

• Lack of appetite

• Increased seizures


benefits. Some common adverse effects includedouble vision, sedation, dizziness and ataxia. Othereffects, like depression and psychosis, are dosedependent. Carbamazepine can induce anxiety, agitation and insomnia. Valproate can produceincreased appetite and weight gain. Barbiturates canproduce hyperactive responses. Phenytoin and phe-nobarbital have been associated with alterations inpersonality and changes in intellectual functioning.Although the newer agents (Lamotrigine®,Topiramate® and Gabapentin®) are less well studiedthan older medications, they appear to have fewercognitive side effects.

The long term effects of AEDs in children are notclear but, given the developmental challenges of anormal childhood and adolescence, even mild drugeffects can have an adverse impact (Drone, 2002).

Discontinuing TreatmentAntiepileptic medications prevent seizures but donot change the status of the underlying epilepsy.Research has shown that if a child is seizure-free fortwo years on medication, he/she is likely to remainseizure free without medication. With that in mind,children can be weaned off AEDs in a process that isusually accomplished over a period of several weeks.

During the drug withdrawal process and for sometime thereafter, school personnel should beespecially observant for signs of recurrent seizures.The majority of seizures recur within six months of having medication withdrawn. For children withno major risk factors for recurrence, the rate ofrecurrence following withdrawal of drug therapy isless than 15 percent (Shinnar and Pellock, 2002).

SurgeryAbout 25 percent of children have seizures that arenot well controlled, even with medications. Thosewho have not responded to the first drug, or even asecond one, have a reduced chance of obtainingcontrol of their seizures through standard medi -cation therapy. In these situations, the addition ofthird and fourth medicines is unlikely to besuccessful. Some of these children are candidates forsurgery.

Several different surgical procedures have been shownto control seizures. The more common include focalresection, temporal lobectomy, lesionectomy andcorpus callosotomy. Surgery typically offers relativelyhigh post-surgical cure rates. Some studies suggestthat post-surgical seizure-free rates are as high as 75percent one year after surgery.

Evaluation prior to a surgical procedure is rigorousand generally includes inpatient video/EEGmonitoring for five to ten days. The goal is to locatethe area of the brain from which seizures areemanat ing as well as areas affected by seizures.Besides noninvasive and invasive EEGs, the workupoften includes diagnostics such as magneticresonance imaging (MRI), positron emission tomo -graphy (PET) and/or single photon emissioncomputed tomography (SPECT). Neuro psycho -logical testing may also be conducted.

Side effects can take several weeks or months tocompletely disappear. Typical side effects includeheadaches, dizziness, unsteadiness, jaw aches,swelling or bruising of head and face, blurred visionand sensation changes, especially numbness aroundthe operation site. Depression or mood changesmay also occur, but are generally temporary.Headaches often worsen with coughing, sneezing orstraining. Jaw aches occur because the muscles con-trolling the jaw may need to be cut. Blurred visioncan last for several weeks.

A child will usually go home after seven days in thehospital and will likely miss several weeks ormonths of school. Therefore, it is advisable to discuss post-surgical academic needs with a studentand their parents prior to the surgery and develop aplan for re-entering the school environment.

Ketogenic Diet The ketogenic diet was first introduced as atreatment for intractable seizures in the late 1920s.This diet, which is high in fat and low in protein,carbohydrates and fluids, produces a ketotic state inthe child. It appears to be most effective formyoclonic seizures which involve brief, shock-likejerks of a muscle or a group of muscles. It may alsobe helpful for other seizure types, such as tonic-



clonic and complex partial seizures. The precisemechanism of action is not completely understood.

The physician, nutritionist and nurse must collabo-rate to supervise elements of this dietary therapy.The child is usually hospitalized when the diet isinitiated, because two to three days of fasting areneeded to produce the initial ketotic state. After -ward, the diet must be strictly followed. Even aminute amount of sugar can disrupt the ketosis andjeopardize the child’s seizure-free state.

Parents need to provide prepared meals and snacksfor the child, who is not allowed to eat anythingelse. Each item provides nutrients mathematicallycalculated to keep the child in a state of ketosis. Thediet also includes fluid restrictions. Supplementalvitamins and minerals are given in sugar-free form.

Not surprisingly, compliance is the main problemthat school nurses see with students on this regi-men. If an older student is doing well on the diet,the school nurse can often promote compliance byemphasizing its benefits. Younger students need tobe observed carefully to prevent them from eatingand drinking another student’s food. Teachers andother school personnel and volunteers need educa-tion on the importance of maintaining the student’sdietary restrictions.

As with other forms of treatment, the ketogenic diet does have side effects. Renal calculi and cardio -myopathy can occur. Blood abnormalities may occurbut are not common.

Vagus Nerve Stimulator (VNS) Vagus nerve stimulation therapy is usually reservedfor adjunctive treatment in refractory epilepsy. Thisapproach to managing seizures consists of implantinga generator subcutaneously in the left upper chest orunder the arm. A wire conducts the electric impulsefrom the generator to the left vagus nerve in the neck.When the generator sends an electric signal throughthe wire, the vagus nerve sends this stimulation tothe brain. Although the exact mechanism of actionis not completely understood, these intermittentelectrical signals interrupt epilepti form activity forsome people.

The generator is programmed to automaticallydeliver intermittent stimulation to the vagus nerve.The frequency and amount of stimulation can becontrolled with a programming device. Initially, thechild is started on a low level of current that isincreased gradually. Periodic reprogramming of thegenerator is generally needed, based upon seizurecontrol and patient response to treatment. A VNSdevice may also be stimulated manually with the useof a magnet, typically worn on the wrist or belt.Many people with epilepsy report that activatingthe VNS device in this manner helps to abort theseizure or lessens its intensity. (See page 33 for moreinformation on VNS magnet use as a seizure first-aid intervention.)

Alternative TherapiesAlternative therapies for treating epilepsy have notbeen validated by rigorous scientific studies andtheir usefulness has not been established. It isimportant to question parents about the use of anyalternative therapies, since these approaches mightinterfere with the effects of medical treatment.

Some complementary therapies that have been usedfor seizure control include acupuncture, aromather-apy, biofeedback and stress management tech-niques. Research regarding the effectiveness of theseapproaches is underway.

Advances in TreatmentClinical testing of new medications continues andmany of the more recently approved medicationsare only now being used often enough in childrento provide insight into their pharmacological properties and potential. In addition, technologicaladvances in radiology and imaging are helping tobetter define the anatomy and physiology of thebrain.

Knowledge gained from this research will promotemore precise diagnoses and create greater potentialfor surgical solutions for certain types of epilepsy.Research will also help provide clues to the pathogenesis of epilepsies, which in turn will aid indeveloping new AEDs.

SECTION 4: TREATMENT FOR SEIZURE PREVENTION 39


Section 5SEIZURE ACTION PLANS

”“To ensure the student’s

needs are met, a seizureaction plan must bestudent-centered andidentify strategies to

overcome barriers withinschool settings.


A seizure action plan is a tool used by school nursesand other school personnel to organize, communi -cate and tailor the healthcare and educational needsof the student with seizures. The plan helps ensure asafe environment for students, while maximizingopportunities for learning and development. Inaddition to documenting seizure type and treat ment,this plan should document basic and emer gency first-aid procedures and list specific inter ventions andstrategies that will minimize the potential forstigmatization, while maximizing learning and socialdevelopment opportunities. A seizure action plan isspecific for each student with a known seizurecondition and should also include the date of lastseizure, aura, length of a typical seizure for thatstudent, frequency and how the student respondsafter a seizure.

Crafting the plan requires collaboration among theschool nurse, student, parents/guardians, school per-sonnel and the student’s treating physicians. Toensure the student’s needs are met, a seizure actionplan must be student-centered and identify strategiesto overcome barriers within school settings. Thisinformation may be incorporated into IndividualHealthcare Plans (IHPs), 504 Plans or IndividualizedEducation Plans (IEPs). The seizure action plan mayalso serve as the basis of the training curriculum forother school personnel (see Table 17).

Assessing the Student’s NeedsThe first steps for the school nurse in assessing astudent are to gather, document and review infor-mation from the student, parents, teachers and thestudent’s treating physician. These steps also help


Section 5SEIZURE ACTION PLANS

TABLE 17: Key Components of a Seizure Action Plan

Assess the Student’s Needs

• Gather information from parents, teachers, healthcare professionals and others.

• Observe and document seizures and circumstances (seizure precipitants and precautions).

• Observe and document responses to medications.

• Observe and document impact on learning, behavior, socialization and mood.

Customize an Action Plan

• Document treatment.

• Detail first aid (care, comfort, emergency).

• Detail strategies for managing seizures in special circumstances.

• Document strategies and accommodations to address learning, behavioral and psychosocialissues.

Teach and Tailor Interventions as Needed

• Teach all relevant school personnel and students (first aid, relevant accommodations, myths).

• Tailor and test interventions and accommodations.

• Provide supportive counseling and referrals, as necessary.


identify coexisting learning, behavior, mood ormobility problems that occur as a consequence ofthe epilepsy, the medications and any associatedstigma. Completing a thorough assessment helpspredict and address issues before they arise. (Pleasesee Appendix A for forms and questionnaires thatschool nurses can use to collect data and structureinterventions.)

Medication Documentation and AdministrationThe school nurse or her delegate is responsible fordocu menting and administering medications.Fortunate ly, many of the newer seizure medicationscan be given once or twice a day, often eliminatingthe need for the student to take medications duringschool hours. However, detailing daily AED admin-istration procedures is still a critical function of theseizure action plan for most students with seizures(see Table 17).

Documenting Seizures and CircumstancesManaging seizures in school settings begins withobserving, recognizing and documenting seizurebehaviors that are occurring. This can be challenging,because many symptoms are subtle, difficult to detector occur without warning. Many are easily confused

with other behavioral symptoms or problems. Forexample, brief staring episodes during absenceseizures are often mistaken for attention disorders ordaydreaming. Confusion, headaches, dizziness andlanguage problems can also be symptoms of seizuresthat are often overlooked in school-aged children.(Please see page 21 for more details on conditonsthat might mimic epilepsy.)

Parents of students already diagnosed with epilepsycan help school personnel to observe and recognizepossible seizure behaviors. They should provide the name and seizure type, detailed descriptions ofthe student’s typical seizure(s), the date of the lastseizure, the aura, usual length of a seizure, frequencyand how the student responds after the seizure andfirst-aid measures used at home.

Non-medical school personnel need to be enlisted tohelp observe the student and gather information andinsights into his/her seizure behaviors. Informationshould be gathered about what happens before, dur-ing and after the seizure.

Behaviors Before a Seizure Children may experience changes in mood hours —or even days — before a seizure event. Some childrenhave a warning, or aura, such as a strange feeling,

SECTION 5: SEIZURE ACTION PLANS 43

TABLE 18: Medication Documentation and Administration

The following medication information should bedocumented in the seizure action plan:

• Brand and generic name of the antiepilepticmedication

• Dosage

• Dosing regimen

• Special instructions for administration

• How to monitor responses

• Potential side effects

• Possible drug interactions

• What to do if a dose is missed

• What to do if side effects are observed

TABLE 19: Documenting Seizure Activity

When a seizure is suspected, school personnel should:

• Observe in detail the student’s behaviors

• Time the length of the seizure

• Keep a written log of seizure descriptions in a communication book or flow sheet that canbe shared with the school nurse, parents/guardians and healthcare team

• Recall and document what behaviorsoccurred before the seizure

• Determine if there is a pattern in the timing of the seizure and/or if there are triggersinvolved


tingling, numbness or nausea that immediatelyprecedes a seizure. Children may also report strangetastes or smells, ringing in their ears, vision changes ora headache. Sudden changes in emotion (fear, anxiety,unpleasant feelings) should also be documented.

Is There a Pattern?School personnel who observe a seizure should beinstructed to look for a pattern in the timing of theseizure and possible seizure triggers. They shouldfirst note the date and time of day of each seizure.Noting and reporting all possible environmentaltriggers is helpful and serves to inform the seizureaction planning process.

For a small number of students a specific seizuretrigger may be identified. Flashing lights (photosen-sitivity) and hyperventilation are two documentedseizure triggers.

Many other factors not considered to be true seizuretriggers are also known to increase the likelihood ofa seizure in students with epilepsy. These includethe following:

• Missed or late medication (#1 reason)

• Overheating/overexertion

• Stress/anxiety

• Lack of sleep or fatigue

• Poor diet/missed meals

• Hormonal changes, particularly in adolescent girls

• Alcohol use

• Drug interactions

A school safety evaluation should be done to assesspossible seizure triggers. During this assessment it isimportant to ask parents about seizure triggers intheir child. The assessment may reveal that activitiesin which the child engages may need to be modifiedto reduce exposure to situations that trigger seizures.For example, flashing lights in movies, television andcomputers may be seizure triggers. In many cases,however, there is no identifiable trigger or precipi -tating factor.

What Happens to the Student During aSeizure?Teachers and others should observe and make noteof the following:

• Awareness/consciousness – Is the student confused, disoriented, not responsive,unconscious?

• Speech – Is the student able to talk clearly?Does he/she respond with only a few words orsounds? Is his/her speech nonsensical orincoherent? Is there speech arrest?

• Facial expression – Is the student staringblankly? Are eyes blinking in an unusual way?Is there facial droop or drooling?

• Turning – Is the student turning his/her head,eyes or body in an unusual way?

• Muscle tone – Is the student’s body stiff orlimp?

• Twitching – Is the student jerking, withmovements of face, arms or legs?

• Automatisms – Is the student aimlessly lipsmacking, chewing, swallowing, picking atclothes, rubbing hands or tapping his/her feet?

• Walking, running or wandering – Is the student moving about without awareness ofactivity?

• Falling – Is the student walking unsteadily?

• Skin color – Is skin pale, cyanotic, sweating?

• Respiration – Are there breathing changes?

• Control of urine or bowels – Is the studentincontinent?

What Was the Length of the Seizure? Observers should accurately record the time fromthe beginning of the seizure to cessation of move -ment or altered behavior (ictal phase) and from theend of the seizure to the point in time when thestudent resumes normal activity (postictal phase). Ifthe student transitions directly into postictal sleep,record the length of sleep.

Behavior After the Seizure? Important observations after a seizure include:

• Is the student able to respond to voice or



touch?

• Is the student aware of person, place or time?

• Is there memory of the seizure event?

• Can the student talk?

• Is there weakness or numbness in the arms or legs?

• What is the student’s mood?

• Is he/she fatigued or sleepy?

Observing Responses to TreatmentThe school nurse needs to gather detailed informa-tion about the student’s AED regimen and thepotential side effects of medication. He/she shouldalso be aware whenever medication changes arebeing made. When appropriate, the school nurseshould educate the student’s teachers on behavioralor mood changes they may observe and establish ameans of communicating these observations back tothe school nurse, parents/guardians and the student’shealthcare provider(s) as needed.

Assessing Learning and Psychosocial IssuesChildren with seizures often experience problemswith learning, behavior, mood and mobility as a con-sequence of the epilepsy or its underlying etiology.These consequences may impact the child in theschool setting more than occasional seizures them-selves. Recognition and treatment of these issues arecritical to successful school experiences.

The school nurse’s role in identifying and managingconsequences of seizures will vary depending uponthe severity of the student’s condition. For example,the student with intractable seizures who experi-ences many injuries will need help from the schoolnurse to ensure that appropriate safety precautionsare in place to prevent injury and allow him/her toparticipate fully in activities.

Evaluating the impact of seizures and medicationson each student’s learning and educational achieve-ment will help identify learning or mood problemsin students with seizures. The school nurse’s roleshould focus on communicating concerns with the

parents and healthcare professionals and on encour-aging additional educational and medical evalua-tions. Strategies and accommodations to addresslearning deficits, mood issues and other identifieddisabilities should be included in both the student’sseizure action plan and the IEP.

Customizing an Action PlanOnce an assessment and the collection of keyinformation are complete the school nurse mustwrite a customized seizure action plan for eachstudent with seizures. The plan should bedistributed to relevant school personnel. In additionto documenting seizure type and treatment, thisplan should document basic and emergency first-aid procedures and list specific interventions andstrategies that will minimize the potential forstigmatization while maximizing learning and socialdevelopment opportunities.

Seizure first aid used to be thought of as protectinga student during a seizure or calling for emergencyhelp. Seizure action plans, however, recognize thatmore can be done to help a student during a seizureand, in some circumstances, to intervene to helpprevent, stop or lessen part or all of a seizure.

Educational AccommodationsThe school nurse should work with teachers tomake sure that they understand the dynamics ofseizure disorders and their impact on the educa-tional process for each student. Teachers should be


TABLE 20: Simple Educational Accommodations

• Extra test time or untimed tests

• Verbal responses on tests

• Moving chair closer to the front of the room

• Tutoring or peer assistance

• Dimming flourescent lights

• Allowing student to wear a hat if needed todim lights

• Limit computer time


encouraged to make accommodations to assist thestudent through easy-to-implement classroom prac-tices. These accommodations may also need to beincluded in the student’s IHP, IEP and/or 504 Plan.

Special Circumstances and PrecautionsStudents with seizures should be allowed to parti -cipate in field trips, recesses and after-schoolactivities. To ensure full participation, the schooldistrict should provide a training opportunity to allrelevant staff so they can respond appropriately toseizures. The school nurse should incorporateprocedures and strategies to address special needsidentified by the student and his/her parents duringthe assessment. For example, when students withfrequent seizures, a tendency to seizure clusters orlong seizures participate in a field trip or after-school activity, the school nurse may need to workcreatively with the student and his/her parents toprovide training for teachers and chaperones inseizure recognition and first aid so they can respond

appropriately until additional help is available.Other circumstances that may require special pre -cautions include:

• Students involved in school sports, especiallyswimming and contact sports

• Students in wheelchairs

• Students who have specific, identified seizuretriggers

Teaching and TailoringInterventionsIt is essential that the school nurse teach otherschool personnel how to respond to seizures inschool settings and help to implement any specialstrategies and classroom or extracurricular accom-modations. It is advisable to conduct a thoroughassessment of the needs of the student with seizures,as well as those of teachers and other school person-nel prior to implementing a training program. Thiswill help ensure that training is focused on the most


A customized seizure action plan should clearly answer the following questions:

• What medication and treatment protocol have been prescribed by the student’s healthcare team?

• What is the most appropriate approach to basic first aid? This is specific to seizure type andwhether consciousness is impacted.

• What is the most appropriate way to offer care and comfort after a seizure episode?

• What is normal for this student? Does the student experience an aura? Can the student usuallyresume normal activities within a reasonable time? If yes, the plan should define reasonable time anddocument who should be contacted.

• What constitutes a seizure emergency for this student? Clarify guidelines in concert with parentsand the student!s healthcare team.

• What is the appropriate response to an emergency? Call 911? Give PRN medications? ActivateVagus Nerve Stimulator?

• What are known seizure triggers and what precautions can be taken for avoiding them?

• What are recommended training protocols for school personnel and students?

• What aspects of the student’s disorder may require referrals? For example, does the student showsigns of serious depression?

• What learning, psychosocial and behavioral deficits have been identified?

• What strategies and accommodations have been implemented to support the student?


important issues. For example, teachers and otherschool personnel who have a student who uses aVagus Nerve Stimulator and is going through med-ication changes, or has a tendency to have seizureclusters, may require special training. In addition,teachers and other school personnel who expresssignificant fears and concerns about having a stu-dent with seizures in their classrooms may needadditional training or counseling assistance.

Training protocols for school personnel must focuson dispelling myths and fears and teaching basicfirst aid. The training should emphasize that, whilemost students will not have seizures at school, theymay still experience social, emotional and cognitiveproblems that interfere with school performance.(For more information on training school person-nel, please see Section 6 of this guide.)

Interventions, whether they include training, specific accommodations or ongoing counseling,must be tailored to address the special circumstancesof the student. These should be monitored andadjusted regularly to allow for medication changesand natural hormonal and growth-related shifts thatcan impact seizure control. Over time, additionalinterventions and precautions may be needed, as theoriginal guidelines for managing each student’s sit-uation change.

This type of proactive, caring approach helps students with epilepsy to grow up to be successful,well-adjusted individuals.

Supportive Counseling andReferralsStudents with epilepsy and their families may needsupportive counseling and referrals. A thoroughassessment of psychosocial, learning and behavioralrisk factors will help determine the best course ofaction. Understanding where the student is on thespectrum of severity will also help predict the likeli-hood of the student’s developing a truly disablingcondition.

The school nurse, in collaboration with a schoolcounselor, social worker and/or school psychologist

may choose to address basic behavioral, social andlearning issues directly through supportive and edu-cational counseling with the student and his/herparents. Some issues that can be addressed include:

• Medication compliance

• Dating, driving and disclosure

• Parental over-protectiveness

• Minor memory and learning impairments

• Socialization issues (anger, withdrawal, embarrassment)

• Career choices and possible work limitations

When to Refer to a SpecialistStudents with more significant and severe conse-quences, who are not currently under the care of aspecialist, may require additional referrals to medical specialists or mental heath professionals.Referrals should be considered for the following:

• Uncontrolled seizures and status epilepticus

• Significant mood and anxiety disturbances

• Major memory and learning deficits

• Sudden change in seizure type

• Signs of medication toxicity or allergy



”“There is a real

need to share facts,dispel myths andreduce fears about

seizures.

Section 6TRAINING TEACHERS AND OTHER SCHOOL PERSONNEL


The attitude and full cooperation of teachers andother school personnel are key factors in promotingpositive social and educational outcomes for thestudent with epilepsy. Appropriate training opti-mizes seizure management strategies and helpsensure the full integration of the student withepilepsy into all school activities while minimizingfurther stigmatization.

General Curriculum forTraining Others in the SchoolSettingSince seizures only last a few seconds to a fewminutes, the seizure is often over by the time theschool nurse arrives. Therefore it is important thatall of those who may be in a position to assist thestudent with epilepsy receive information aboutseizure recognition, seizure first aid and the impactof seizures and epilepsy on learning and psycho socialdevelopment. This includes, but is not limited to,teachers, secretaries, athletic coaches, bus drivers,foodservice workers, administration personnel,counselors, volunteer parents and classmates.

The school nurse, the student’s physician or anEpilepsy Foundation staff member or volunteer canconduct seizure recognition and first-aid trainingfor teachers and students. A variety of training aidsare available from the Epilepsy Foundation to assistwith this training. These include, but are not limit-ed to, the following:

• Seizure Training for School Personnel: A Presentation Guide and Toolkit

• Be Seizure Smart! – Teacher Information Kit

• Seizures and You: Take Charge of the Facts –An epilepsy awareness program for teens

• Brochures, videos, books and pamphlets target-ing teens, parents, teachers and siblings

• Fact sheets on various subjects related toepilepsy and seizures, including specific treat-ments and classroom accommodation issues(visit www.epilepsyfoundation.org/schoolnurseto access to these fact sheets)

Training ObjectivesAfter training, school personnel should be able to:

• Recognize seizures

• Provide appropriate first aid

• Recognize when a seizure is a medical emergency

• Provide appropriate social and academic support

Considerations in Curriculum DevelopmentSeizure recognition and first aid should be providedfor all school personnel who interact with studentswith seizures. Training should include at least thefollowing information:

• What is a seizure? What is epilepsy?

• Who has epilepsy? (incidence and prevalence)

• What do seizures look like?

• What are common myths about epilepsy?

• How might seizures and epilepsy impact learning?

• What is appropriate first aid for seizures?

• When is a seizure an emergency?

• What causes seizures?

• What are common seizure triggers?

• What can be done to prevent stigma?

• What is a seizure action plan?

The following optional topics might be included ifrelevant:

• Use of “rescue” medication including Diastat®

AcuDial™

• Use of the Vagus Nerve Stimulator magnet


Section 6TRAINING TEACHERS AND OTHERSCHOOL PERSONNEL


• Use of the ketogenic diet• Seizures in a wheelchair• Seizures in the water• Seizures on a bus• Seizures in a non-classroom area

Dispelling Myths and Reducing FearsAll school personnel should be taught the followinginformation to dispel myths and reduce their fear ofstudents with seizures:

• Most seizures are not medical emergencies.• Children are usually not aware they are having a

seizure and will not remember what happened.• Epilepsy is not contagious.• Epilepsy is not a form of mental illness.• It is extremely unlikely that a child will die or

have brain damage during a seizure.• It is very rare for a child to become violent

during a seizure.• It is not possible to swallow one’s tongue

during a seizure or at any other time.

Teaching About the Impact of Epilepsyon LearningInput from school nurses can help explain the needto modify the educational plan for some studentswith epilepsy. Teachers should be aware of the fol-lowing information:

• Seizures often cause short-term memoryproblems. After a seizure event, courseworkmust be re-taught.

• Seizure activity in the brain, without obviousphysical symptoms, can still affect learning.

• Learning will occur more easily on some daysthan on others.

• Medication may cause drowsiness, inattention,concentration difficulties and behavior changes.

• Children with epilepsy are more likely to sufferfrom depression and low self-esteem thanchildren with diabetes or asthma.

• Children are not always aware of their seizures.• School difficulties are not always epilepsy related.• Each student’s seizure action plan, IHP, 504

Plan and/or IEP should address these issues.

Managing Seizures in the ClassroomTeachers play a special role in setting the tone whena student experiences a seizure. If the teacher is calmand matter-of-fact and it’s clear that he/she knowswhat to do, the student’s classmates are reassured byboth actions and words. The teacher should also notekey information about the seizure so these details canbe shared with the school nurse, the student’s parentsand the student’s treating physician.

If the student with epilepsy and his/her parents agreeto share information about the seizure with other stu-dents, then it is important that the class be able todiscuss the event afterward and have a clear explana-tion of what happened. The following list provideskey messages a nurse or teacher should convey to stu-dents who have witnessed a seizure in the classroom:

• What happened is called a seizure.• Having a seizure is part of a health condition

called epilepsy.• No one knows exactly what causes epilepsy

in some children. Fortunately, most willoutgrow it.

• The seizure happened because, for just a very short time, the electrical impulses in the student’s brain did not work properly andsent mixed messages to the rest of the body.Now that the seizure is over, his/her brain isworking properly again.

• Epilepsy is not a disease and it cannot becaught from or given to other students.

• Epilepsy is not a mental illness or a psycho -logical problem.

• Children who have this condition takemedicine to prevent seizures, but sometimesseizures occur anyway (Even taking coughmedicine does not always stop a cough).

• Seizures stop by themselves, but it is importantto know first-aid steps that will keep thestudent safe while the seizure is happening.

Managing Seizures Under Special Circumstances

On the School BusThe school district should allow time for the schoolnurse to provide basic training to all school personnel,

SECTION 6: TRAINING TEACHERS AND OTHER SCHOOL PERSONNEL 51


including school bus drivers, so that they areequipped to deal with a student who experiences aseizure.

A seizure occurring on a school bus can be chal -lenging for the school bus driver, who must safelynavigate in traffic while directing students toprovide first aid. During a generalized tonic-clonicseizure, the bus driver should attempt to pull overand stop the bus. The student should be placed onone side across a seating section with his/her headtoward the aisle and facing away from the seat back.Alternatively, the student can be placed on one sidein the aisle. Basic first-aid measures should beprovided until the seizure abates and the studentregains full awareness and consciousness.

Once the seizure has passed the bus driver mayreturn to driving the bus. The bus driver’s decisionto return to school or proceed to the final destina-tion should be based on school policy and theseizure action plan.

For a Student in a WheelchairA student in a wheelchair should remain in thechair if at all possible. First-aid responders shouldsecure the wheelchair to prevent it from moving and

gently support the student’s head and body to prevent injury. Fasten the student’s seatbelt (loosely)to prevent the student from falling from the wheel-chair. Allow for unobstructed movement andbreathing and for secretions to flow out of themouth. If possible, pad the wheelchair to preventinjury to the student’s limbs. Follow the relevantfirst-aid protocol. The student’s seizure action planshould be reviewed for specific first aid and emergency treatment procedures.

When Seizures Occur in WaterRemove the student from the water immediately,supporting the head so that both the mouth andnose are always above the water. If the student is notbreathing, begin rescue breathing. Always transportthe student to the emergency room even if he or sheappears fully recovered.

In Non-Classroom Areas of the School For each area of the school (hallway, cafeteria, gymnasium, playground, playing field, auditorium,restroom), there should be a trained first responderand a backup first responder listed in the seizureaction plan procedures for seizure response.Responsible students as well as adults can be trainedas first responders.



”

“School nurses andeducators should act as

role models for otherschool personnel andstudents, helping themsee that seizures are amedical problem thatcan be treated easily.

Section 7EPILEPSY RESOURCES


The resources listed in this section will be of valueto the school nurse dealing with students withseizures. For more details and an up-to-date list ofresources, school nurses can visit a special section onthe Epilepsy Foundation Web site at the following:www.epilepsyfoundation.org/schoolnurse.

Community ResourcesAt the time of this publication, there are 52 EpilepsyFoundation affiliates serving local communitiesthroughout the United States. To locate the affiliatenearest you, please call the national office of theEpilepsy Foundation at (800) 332-1000 or visit www.epilepsyfoundation.org/aboutus/AffiliateLookup.cfm

Internet ResourcesBelow is a short list of valuable Internet resources.For a more exhaustive and updated list please visitwww.epilepsyfoundation.org/schoolnurse.

The Epilepsy Foundationwww.epilepsyfoundation.orgThe Epilepsy Foundation is the national voluntaryagency solely dedicated to the welfare of the 3 millionpeople with epilepsy in the U.S. and their families.The organization works to ensure that people withseizures are able to participate in all life experiences;and to prevent, control and cure epilepsy throughresearch, education, advocacy and services.

American Epilepsy Societywww.aesnet.orgThe American Epilepsy Society promotes researchand education for professionals dedicated to theprevention, treatment and cure of epilepsy.

Epilepsy.comwww.epilepsy.comEpilepsy.com is an online resource provided by TheEpilepsy Project. Its mission is to inform and empow-

er two groups of patients and their families: those fac-ing newly diagnosed epilepsy and those strugglingwith epilepsy that has resisted the usual treatments.

American Academy of Neurology www.aan.comThe American Academy of Neurology provides valu-able resources for medical specialists worldwide whoare committed to improving the care of patients withneurological diseases.

American Clinical NeurophysiologySocietywww.acns.orgThe ACNS is a professional association dedicatedto fostering excellence in clinical neurophysiologyand furthering the understanding of central nervoussystem function in health and disease througheducation, research and the provision of a forum fordiscussion and interaction.

American Neurological Associationwww.aneuroa.orgThe American Neurological Association is a professionalsociety of academic neurologists and neuroscientistsdevoted to advancing the goals of academic neurology,to training and educating neurologists and otherphysicians in the neurological sciences and to expandingboth our understanding of diseases of the nervoussystem and our ability to treat them.

Centers for Disease Control andPrevention Epilepsy Web Sitewww.cdc.gov/epilepsy/index.htmThe national Centers for Disease Control and Preven -tion is recognized as the lead federal agency for pro-tecting the health and safety of people at home andabroad, providing credible information to enhancehealth decisions and promoting health through strongpartnerships. Its epilepsy Web site details current part-nerships and health promotion activities being sup-ported by the agency’s epilepsy program.


Section 7EPILEPSY RESOURCES


The Charlie Foundationwww.charliefoundation.orgThe Charlie Foundation was established in 1994 toraise awareness about the ketogenic diet as a treat-ment for childhood epilepsy. It facilitates basic andclinical research, educates professionals and informsfamilies about the current status of the ketogenicdiet.

The Child Neurology Societywww.childneurologysociety.orgThe Child Neurology Society is the preeminentnon-profit professional association of pediatric neu-rologists in the United States, Canada and else-where in the world.

The Child-Neuro Web Site www-personal.umich.edu/~leber/c-n/The main purpose of this site is to coordinate theavailable internet resources in child neurology forprofessionals and patients.

The Epilepsy Centerwww.epilepsycenter.orgThe Epilepsy Center is a non-profit organizationdedicated to providing resources for better living tothose persons with epilepsy and/or developmentaldisabilities, as well as to their families and friends.

The International Bureau for Epilepsywww.ibe-epilepsy.orgThe International Bureau for Epilepsy was estab-lished in 1961 as an organization of laypersons andprofessionals interested in the medical and non-medical aspects of epilepsy. The IBE addresses suchsocial problems as education, employment, insur-ance, driver’s license restrictions and public aware-ness.

The International League AgainstEpilepsy www.ilae-epilepsy.org The International League Against Epilepsy works toadvance and disseminate knowledge concerningepilepsy. Membership is comprised of national pro-fessional organizations and individuals involved inresearch and those interested in the exchange of sci-entific information concerning epilepsy.

The National Institute of NeurologicalDisorders and Stroke www.ninds.nih.govThe National Institute of Neurological Disordersand Stroke supports and conducts research on brainand nervous system disorders. By supporting andconducting neurological research, the NINDS seeksbetter understanding, diagnosis, treatment and pre-vention of these disorders.

Neuroscience for Kidsfaculty.washington.edu/chudler/neurok.htmlNeuroscience for Kids was created for all studentsand teachers who would like to learn about thenervous system.

PACE (Parents Against ChildhoodEpilepsy, Inc.)www.paceusa.orgPACE was founded in 1996 by a group of parentsin response to their experiences in caring for themedical, physical, social, educational, developmen-tal and emotional needs of their children who haveepilepsy and severe seizure disorders.

Books, Kits, Pamphlets and Videos Many books, kits, manuals, pamphlets, posters andvideos targeting health professionals, parents, chil-dren, teens and other populations are available forsale through the Epilepsy Foundation Marketplace.These items can be purchased online at www.epilepsyfoundation.org/marketplace or ordered byphone at (866) 330-2718. For a complete and cur-rent list of all products and prices, please visit theEpilepsy Foundation Marketplace Web site. Forquestions about specific products, call the EpilepsyFoundation Marketplace.

Materials for TrainingTeachers and Other SchoolPersonnelA tool kit titled Seizure Training for School Personnelis available to assist school nurses in training teachersand other school personnel. This kit includes over-head slides, a video/DVD program and a facilitator’s

SECTION 7: EPILEPSY RESOURCES 55


guide. For questions about this product and its current availability, call the Epilepsy FoundationMarketplace at (866) 330-2718.

Information packets designed specifically for teach-ers, parents and students are available. A smallquantity may be ordered by contacting the EpilepsyFoundation’s Answer Place at (800) 332-1000. Forlarger quantities, please call the Epilepsy FoundationMarketplace at (866) 330-2718.

Fact Sheets on EpilepsyThe Epilepsy Foundation has fact sheets on a varietyof epilepsy-related topics including seizure-specificinformation, treatment, education, insurance andemployment. A complete list of fact sheets can beaccessed from the school nurse web page at www.epilepsyfoundation.org/schoolnurse. Many of thefact sheets can be downloaded for your immediateuse. Please check the Web site regularly as this list isperiodically updated.

Below is a partial list of topics covered:• Alcohol and Drug Abuse• Blood-Level Monitoring of Antiepileptic

Medication• Diagnosing Epilepsy and Seizure Disorders• Effects of Epilepsy on Learning and Memory• Financial Aid: Scholarships, Grants and

Fellowships• IDEA: Elementary and Secondary Education• Insurance Issues in Epilepsy and Seizure

Disorders• Nonepileptic Seizures• Patterns of Seizure Frequency• Photosensitivity and Seizures• Prognosis in Epilepsy and Seizure Disorders• Remission vs. Cure for Epilepsy• Seizure Classifications: Absence Seizures• Seizure Classifications: Complex Partial

Seizures• Seizure Classifications: Tonic-Clonic Seizures

Driving and EpilepsyEvery state regulates driver’s license eligibility forthose with certain medical conditions. The mostcommon requirement for those with epilepsy is that they be seizure-free for a specific period of time and submit a physician’s evaluation of their abil-ity to drive safely. Another common requirement isthe periodic submission of medical reports. In somestates, this is for a specified period of time, whileother states require routine reporting as long as theperson remains licensed. To determine the regula-tions for your state, visit www.epilepsyfoundation.org/schoolnurse.



Section 1 DeLorenzo RJ, Towne AR, Pellock JM, Ko D.Status epilepticus in children, adults, and the eld-erly. Epilepsia. 1992;33(Suppl 4):S15-S25.

Devinsky O. Epilepsy: Patient & Family Guide.Philadelphia, Pa: F.A. Davis Company; 2002.

Glauser T. Pediatric epilepsy syndromes. CurrentOpinions in Pediatrics. 1995;7:640-649.

Hauser A. Epidemiology of epilepsy. In: SanntilliN, ed. Managing Seizure Disorders. Philadelphia,Pa.: Lippincott-Raven; 1996:7-18.

Hauser A. Epidemiology of epilepsy in children.In: Pellock J, Dodson W, Bourgeois B, eds.Pediatric Epilepsy: Diagnosis and Therapy. NewYork: Demos, 2001:81-96.

McDermott S, Moran R. Prevalence of Epilepsy inAdults with Mental Retardation and RelatedDisabilities in Primary Care. American Journal onMental Retardation. January; 2005 - Vol. 10, No.1:48-56.

Palencia R. Prevalence and incidence of epilepsy in childhood. Revista de Neurologia 2000: Suppl 1:S1-4.

Prensky A. An approach to the child with paroxys-mal phenomena with emphasis on nonepilepticdisorders. In: Pellock J, Dodson W, Bourgeois B,eds. Pediatric Epilepsy: Diagnosis and Therapy. NewYork: Demos, 2001:97-115.

Smith EA, VanHauten R. A comparison of thecharacteristics of self-stimulating behaviors in“normal” children and children with developmen-tal delay. Res Dev Disability. 1996: 17:253-268.

Section 2Drone DL, Meador KJ. Cognitive and behavioraleffects of AEDs. Epilepsy and Behavior. Oct 2002;3; 2: S49-S53.

Hermann BP, Austin J. Psychosocial status of chil-dren with epilepsy and the effects of epilepsy sur-gery. In: Wyllie E, ed. The Treatment of Epilepsy.Principles and Practices. Philadelphia, Pa.: Lea andFebiger; 1993: 99:1141 -1148.

Fastenau, P.S., Shen, J., Dunn, D.W. & Austin,J.K. Academic underacheivement among childrenwith epilepsy: proportion exceeding psychometriccriteria for learning disability and associated riskfactors. Journal of Learning Disability 2008;41(3):195-207.

Prevey M, Delancey RJ, Cramer R et al. EpilepsyCooperative study 264 group. Complex partialand secondarily generalized seizure patients:Cognitive functioning prior to treatment with antiepileptic medicine. Epilepsy Research. 1998; 30:1-9.

Sutula TP, Hagen J, Pitkanen A. Do EpilepticSeizures Damage the Brain? Curr Opin Neurology.2003; 16:189-195.

Sabaz M, Cairns D, Lawson JA, et al. The health-related quality-of-life of children with refractoryepilepsy: A comparison of those with and withoutintellectual disability. Epilepsia. 2001; 42: 5:621-628.

Sperling, M. The Consequences of UncontrolledEpilepsy. CNS Spectrums. 2004; 9; 2:98-108.

Swartztrauber K, Dewar S and Engel J. Patientattitudes about treatment for intractable Epilepsy.Epilepsy and Behavior. 2003, 4:19-25.

57

BIBLIOGRAPHY


Wiebe S. Effectiveness and safety of epilepsy sur-gery. What is the evidence? CNS Spectrums. 2004;9; 2:120-132.

Zelnick N, Salado L et al. Seizure control and edu-cational outcome in childhood onset epilepsy. J Child Neurol. 2001; 16:820-24.

Section 4Harbord MG, Kyrkou MR, Kay D, Coulthard KP.Use of intranasal midazolam to treat acute seizuresin paediatric community settings. J Paediatr ChildHealth 2004; 40(9-10):556-8.

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59

APPENDICES


APPENDICES 61

Appendix A:SEIZURE ACTION PLANNING FORMS

The sample forms that follow provide guidelines for collecting data relevant to educational and seizure actionplanning for students with epilepsy. They can be adapted to meet individual and institutional needs. Each formprovides a framework for collecting and sharing information critical to appropriate health management plan-ning, which can occur only if the data are used collectively. Editable copies of these forms can be accessedthrough the following Web site: www.epilepsyfoundation.org/schoolnurse.

1. Questionnaire for Parent of a Student with SeizuresThis form should be completed by the student’s parent(s). In some cases the school nurse may need to inter-view the parent(s) to clarify and complete the information requested on this form. The form should be updat-ed annually or when any changes occur in the student’s health status. This information will assist school per-sonnel in recognizing a student’s seizure(s) and responding appropriately.

2. Seizure Observation RecordThis form should be completed by school personnel when reporting a seizure.

3. Seizure Action Plan This form is designed to provide basic information about a student’s seizure(s) and medication. A completedseizure action plan should be distributed to all relevant school personnel at the beginning of a school year,when a diagnosis is made or when a change in health status occurs. This should generally be signed andapproved by the treating physician.


Seizure Observation Record


Appendix B: SEIZURE RECOGNITION AND FIRST-AID CHART

APPENDICES 69


1-800-332-1000 www. epilepsyfoundation. org

© 2008 Epilepsy Foundation of America, Inc. b

EFA 341

d Prevention (grant number 5U58DP00606-03)


www.epilepsyfoundation.org

FUNDING WAS MADE POSSIBLE BY GRANT #U58 DP000606-02 FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

© 2008 Epilepsy Foundation of America, Inc. EFA342

EFA 3 42

© 2008 Epilepsy Foundation of America, Inc. b

d Prevention (grant number 5U58DP00606-03)

1-800-332-1000 www.epilepsyfoundation.org


APPENDICES 75

Appendix C:ANTIEPILEPTIC MEDICATIONS CHART


Ind

ex

79

Absence Seizures, 17, 19, 20, 21, 24, 30, 43, 56Accommodations, 33, 42, 45, 46, 47Acute Interventions, 30, 32Alternative Therapies, 36, 39Antiepileptic Drugs, 21, 22, 24, 36, 37, 75Atonic Seizures, 16, 17, 20Automatisms, 14, 16, 17, 20, 24, 44Basic First Aid: Care And Comfort, 30Benign Rolandic Epilepsy, 15, 18, 19Cerebral Palsy, 14, 15Childhood Absence Epilepsy, 15, 19Clonic Seizures, 17, 18, 19, 20, 21, 22, 31, 38, 56Cluster Seizures, 37Cognitive Dysfunction, 27Complex Partial Seizures, 16, 17, 20, 22, 30, 39, 56Counseling, 23, 42, 47Delegation, 33, 34Driving, 27, 47, 52, 56Drop Attack, 17, 20Emergency Response, 30, 32Epileptic Syndromes, 15, 17, 18

Benign Rolandic, 15, 18, 19Childhood Absence, 15, 19Frontal Lobe, 20Juvenile Myoclonic, 19Landau-Kleffner, 21Lennox Gastaut, 18, 20Progressive Myoclonic, 20Temporal Lobe, 20, 38

Females and Epilepsy, 24Frontal Lobe Epilepsy, 20Generalized Seizures, 17Intractable Epilepsy, 23Juvenile Myoclonic Epilepsy, 19Ketogenic Diet, 36, 38, 39, 50, 55Landau-Kleffner Syndrome, 21Learning, Impact of Epilepsy on, 26-27Lennox-Gastaut Syndrome, 18, 20Managing Seizures

In A Wheelchair, 46, 51, 56In Non-Classroom Areas, 52In the Classroom, 37, 51In Water, 52On The School Bus, 51

Memory Problems, 20, 28, 51

Menstrual Cycles, 24Mental Retardation, 14, 15, 20, 27Myoclonic Seizures, 18, 38Myths, Dispelling, 42, 47, 49, 50, 51Partial Seizures, 15-20, 22, 24, 30, 39, 56Photosensitivity, 44, 56PRN Medications, 32, 34, 37, 46Progressive Myoclonic Epilepsy, 20Pseudoseizures, 22Psychogenic Seizures, 22, 23Quality of Life, 11, 23, 26, 27, 57Reflex Epilepsy, 21Resources, 53, 54, 55Seizure Action Plans, 30, 41-45, 47, 61Seizure-Like Phenomena, 21Seizures

Absence, 17, 19, 20, 21, 24, 30, 43, 56Atonic, 16, 17, 20Atypical Absence, 17, 20Clonic, 17, 18-22, 31, 38, 56Complex Partial, 16, 17, 20, 22, 30, 38, 56Myoclonic, 18, 38Psychogenic, 22, 23Simple Partial, 16, 17, 19, 20, 24, 30Tonic, 16, 18, 20Tonic-Clonic, 18, 19, 20, 21, 22, 31, 56

Self Esteem, 23, 27, 51Simple Partial Seizures, 16, 17, 19, 20, 24, 30Spectrum of Severity, 25, 28, 47, 57Status Epilepticus, 20, 23, 24, 28, 32, 36, 37, 47

Nonconvulsive, 24Stigma, 23, 26, 27, 37, 42, 43, 45, 50Surgery, 36, 38Syncope, 21, 22Temporal Lobe Epilepsy, 20, 38Training Teachers, 46, 50-52, 55Treatment, 15, 18, 21, 23, 24, 27, 35-39, 42, 45, 46,

50, 52Antiepileptic Drugs (AEDs), 36, 37, 75Drug Reaction Warning Signs, 37Ketogenic Diet, 36, 38, 39, 50, 55Surgery, 36, 38, 57Vagus Nerve Stimulation, 33, 39

Vagus Nerve Stimulator, 33, 36, 39, 46, 47, 50

INDEX


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