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Care of the Patient with Seizures
At the end of this session the participant will:
• Describe convulsive seizures
• Describe non-convulsive seizures
• List 3 nursing actions for a patient having a convulsive seizure
• Describe nursing considerations for select anti-seizure medications.
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SEIZURES• Definition
• An abnormal electro-physiologic phenomenon of the brain resulting in abnormal synchronization of neuronal activity manifested as altered mental state, tonic or clonic movements, convulsions, or various psychic symptoms.
• Incidence• <20 >60 yrs old, occurs before age 20 in >75% of cases.
• Epilepsy versus Seizure Disorder
• Seizure Disorder-usually an underlying cause• Epilepsy-multiple, recurrent unprovoked
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SeizuresTerms:
Aura-occurs before seizure activity, may be depression, irritability, or unusual sensations.
Ictus-the period of seizure activity.
Postictus (post-ictal)-period after the seizure, pt. may or may not be conscious. If conscious, may be confused, disoriented, tired, lethargic, nauseated.
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Precipitating FactorsMetabolic
• Hypoxia• Hypoglycemia• Toxic metabolites• Acidosis• Electrolyte imbalances (Na)• Pregnancy
• (eclampsia/cerebral edema)• Abrupt withdrawal of drugs/ETOH• Drugs that alter seizure threshold
• Structural• Trauma
• Tumors
• Infection
• Hemorrhage
• Stroke, new and old
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Age-related Precipitating Factors
Neonate-may have a brain defect, birth injury, meningitis, hypoglycemia, or hypocalcemia.
Children-febrile illness is a common cause, lead toxicity (lead encephalopathy), or head trauma.
Adult-head trauma, alcohol withdrawal, metabolic disorders, tumor, abscesses, meningitis, or encephalitis
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Generalized, convulsiveGeneralized, convulsive seizures• Generalized, convulsiveGeneralized, convulsive
• Tonic-Clonic• Grand mal - “classic seizure”• Tonic - contraction of voluntary muscles,
stiffening, usually lasts 10-30 seconds.• Clonic - rhythmic contraction, jerking,
frothing, seldom lasts longer than 2 minutes.• Usually associated with loss of
consciousness. Post-ictal phase lasts 30 min. to several hours.
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Generalized non convulsiveGeneralized non convulsive seizures
• Absence Seizure (Petit mal)• Rare, more common in children• Blank stare, eye fluttering, lip smacking- begins
and ends abruptly (approx. 10 seconds), brief
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Generalized non convulsiveGeneralized non convulsive seizures
• Atonic Seizure (akinetic, astatic, “drop attack”)• Sudden collapse of individual, lasts only a few
seconds• The person either doesn’t lose consciousness or
regains it before hitting the ground.
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Partial Seizures
• Arise from a localized portion of the brain or foci
• Consciousness may or may not be impaired
• Types of partial seizures:• Simple partial • Partial sensory• Complex partial
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Partial Seizures
• Simple partial • jerking may begin in one area
of body• no loss of consciousness• cannot control movements• can spread to become
generalized seizure
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Partial Seizures
• Partial Sensory
• may not be obvious
• experiences distorted environment• hallucinations• unexplained feelings
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Partial Seizures• Complex Partial
• starts with blank stare, progresses to chewing, then other random activity
• Patient is unaware of surroundings
EEG during seizure
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SEIZURES
• Treatment• Airway Protection• PREVENT INJURY• Medical Management
• Evaluate for Cause • Describe/document
what is seen including duration
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Nursing ManagementConsiderConsider• IV access, oxygen readiness, available suction• Pad siderails (not a restraint if patient has a convulsive
disorder)• If convulsive seizure occurs
• Protect from harm - pt and staff• Do not restrain patient during seizure• Be prepared to intubate• Don’t put anything in mouth• Evaluate for underlying cause
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Medication ManagementFosphenytoin (Cerebryx)-Dosage: Load 20mg PE/kg at a rate up to 150mg
PE/minute. Converts to phenytoin in the body.Therapeutic Level: Monitored with phenytoin level and
should be 10-20mg/dl. Level to be drawn 2 hours after infusion is completed.
Side Effects: Hypotension.Instructions: May be diluted with equal volume of D5W
or NS and given on a syringe pump or mixed in a bag and given as an infusion at 150mgPE/minute. After mixing, must be refrigerated (max 7days), but can be kept at room temp. for 24 hours.
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Medication ManagementLevetiracetam (Keppra)Dosage:
Subarachnoid Hemorrhage: 500mg IV/PO x 3 days then discontinue.Traumatic Brain Injury: 500mg IV/PO x 7 days then discontinue.
Therapeutic Level: 5-65mg/dl, how to clinically interpret this data is unknown yet.
Side Effects: Agitation, fatigue, GI.Instructions: Must be diluted with NS, D5W, or LR.
Infuse over 15 minutes. Oral and IV doses are equivalent. Use IV ONLY for patients who cannot tolerate PO for first dose.
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Status Epilepticus
Definition: one continuous unremitting seizure lasting longer than 30 minutes or recurrent seizures without regaining consciousness between seizures for greater than 30 minutes.
• Emergency!• Monitor airway, prepare to intubate• Medical treatment includes benzodiazepines,
primarily Lorazepam (Ativan®)
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Seizure Mapping
• For patients with medically intractable seizures (unresponsive to medications)
• Small electrodes, are placed over the surface of the brain or skull/face
• Goal: identify areas causing seizures for possible surgical removal
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References
• http://en.wikipedia.org/wiki/Status_epilepticus
• http://emedicine.medscape.com/article/793708-overview
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