SEIZURE DISORDERS - PowerPoint Presentation

Slide1

SEIZURE DISORDERSJoyce Estes RN, MSN Slide2

ObjectivesBy the end of this module, the student will be able to:

Explain what a seizure is and the incidence of patients who have seizures.Differentiate between seizures and epilepsy.Discuss the causes of seizure activity.Discuss the types of seizures based on the type of movement presented with each.Slide3

Objectives (cont.)Discuss the

stages of a seizure and apply to the assessment and document of seizure activity.Compare types and activity of childhood seizures with the adult seizure.Discuss the various diagnosis, treatments and medications used to manage seizure disorders.Describe the appropriate nursing diagnosis and interventions for the management of seizures. Slide4

Seizures in History and FYI400 AD-The

Greek physician Hippocrates writes the first book on epilepsy.Seizures were known as “convulsions or fits”1494-women with seizures were thought to be witchesSome people known to have seizures and epilepsy:SocratesCharles Dickens

Vincent Van Gogh

Alfred Nobel

Richard Burton

Agatha Christie

Notice those people with seizures/epilepsy are gifted writers, thinkers, painters. Slide5

What is a seizure?What is epilepsy?A seizure is the clinical event that result from

abnormal nerve cell (neuronal) activity.Excessive bursts of disorganized electrical impulses from neurons in the cerebral cortex. Epilepsy is two or more unprovoked seizures.Thought to be an imbalance of neurotransmitters, or abnormal neuronal, or both.Slide6

Incidence of seizuresAccording to the Epilepsy Foundation®, more than 2 million people in the United States and about 65 million worldwide suffer from epilepsy.

In the United States, about 150,000 new cases are diagnosed each year, About 300,000 people with epilepsy are under the age of 14 500,000 are over the age of 65.

One

in ten people will have a seizure at some point during their life.

http://www.epilepsyfoundation.org/Slide7

EpilepsyEpilepsy is a generic term used to define a variety of disorders characterized by recurring seizures

. Epilepsy means that a person has an underlying condition that affects the delicate systems which govern how electrical energy behaves in the brain, making it susceptible to recurring seizures. Slide8

SeizuresA seizure is a brief, temporary disturbance in the electrical activity of the brain. Seizures are a symptom of epilepsy.

Having a seizure does not necessarily mean that a person has epilepsy.People can experience different types of seizures. Slide9

What Causes Epilepsy?In about 70% of people with epilepsy, the cause is not known (idiopathic)

In the remaining 30%, the most common causes are:Head trauma - Infection of brain tissue

Brain

tumor and stroke

Heredity

Lead

poisoning

Prenatal

disturbance

of brain developmentSlide10

Medical Causes of SeizuresHeart

diseaseHeat illness (or heat intolerance)High feverIllicit drugs, such as angel dust (PCP), cocaine, amphetaminesKidney or liver failureLow

blood sugar

Phenylketonuria

(PKU), which can cause seizures in infants

PoisoningSlide11

Medical Causes of SeizuresStroke

Toxemia of pregnancy• Uremia related to kidney failure• Very high blood pressure (malignant hypertension)• Venomous bites and stings (see snake bite)

• Withdrawal

from alcohol after drinking a lot on most

days

• Withdrawal

from certain drugs, including some painkillers and sleeping pills

• Withdrawal

from benzodiazepines (such as

Valium)Slide12

Seizure CausesSometimes no cause can be

identified, called idiopathic seizures. Usually are seen in children and young adults but can occur at any age. There may be a family history of epilepsy or seizures.Slide13

What happens during a seizure?The kind of seizure a person has depends on where in his brain the abnormal electrical activity starts and where it spreads.

The seizure may be classified according to the movement that is experienced. Slide14

200714

What Happens During a SeizureGeneralized seizureInvolve the whole brain and loss of consciousnessAbsence: characterized by brief loss of consciousness

Tonic-clonic: characterized by rhythmic jerking of muscles

Partial seizure

Involve

only part of the brain; may or may not include loss of consciousness

Symptoms relate to the part of the brain affectedSlide15

Types of Generalized1.

"Grand Mal" or Generalized tonic-clonic- Unconsciousness, convulsions, muscle rigidity 2. Absence-Brief loss of consciousness 3. Myoclonic-Sporadic (isolated), jerking movements 4.

Clonic-Repetitive

, jerking movements

5.

Tonic-Muscle

stiffness, rigidity

6. Atonic

-Loss

of muscle tone Slide16

Generalized Seizures

Tonic-Clonic-involves the whole brain at once. More commonly known. The muscles contract simultaneously, becoming very rigid and the person may cry out as breath is forced out of the lungs when the diaphragm contracts.Person loses consciousness and will fall down if standing.

Rhythmic

jerking of the head, legs, and arms may occur as massive signals from the brain stimulate the muscles to alternately tense and relax. Slide17

Tonic-ClonicInjuries and accidents may occur, such as tongue biting and urinary incontinence.

http://www.youtube.com/watch?v=dZwFhSL1bK0(please remove the word neurology from the screen after starting this video. )This tonic-clonic

seizure shows a good example of the movement and the tonic-

clonic

movement that disrupts the diaphragm. Notice the sucking and blowing out of air.Slide18

Generalized SeizuresABSENCE (formerly known as petit-mal)

generalized seizure a brief loss of consciousness, which usually lasts no more than a few seconds.The person is essentially “absent.” Frequently overlooked, often being mistaken for daydreaming. Autonomic phenomena

Behavioral phenomena

Motor phenomenaSlide19

Absence SeizuresThese seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time."

http://www.youtube.com/watch?v=BzIs8YeafZMSlide20

http://www.ieaecell.org/epilepsy-03.htmlSlide21

Partial Seizures

The symptoms of a partial seizure relate to the normal function of the brain area that is involved. The person may experience involuntary movements or tingling, light flashes, or other symptoms. You may hear these called focal seizures. There are two forms of partial seizures, simple and complex. Slide22

Simple Partial Seizures

Simple partial seizures are generally brief and do not involve loss of consciousness. Simple partial seizures may cause jerking motions or hallucinations, but the person often remains aware of what is happeninghttp://www.youtube.com/watch?v=dKItDS30nvcAlthough the child is having simple partial, she also looks as if she my be having some complex there at the end. Her eyes have become

dysconjugate

.Slide23

Complex PartialA person having this type of seizure will be unaware of his surroundings during the seizure, may wander aimlessly, run, do a series of repetitive

movements (automatisms), pick at clothes, chew, mumble and, to a casual onlooker, appear to be drunk.http://www.youtube.com/watch?v=XGzpD1u42BcSlide24

(from vanumu.com)Slide25

Prodromal PhaseSome patients may experience a Prodromal phase which can occur hours or days before the seizure begins.

Some symptoms are:Sleep disturbancesLightheadednessFeelings of being uncomfortableSlide26

Stages and Care Stage 1-Aura is also known as “Pre-

ictal”This stage is a beginning. Not every patient has an aura, but it is considered the “warning stage” . Auras are usually visual, auditory or a strange feeling or smell. Some may have tingling or the feeling of déjà vu.Nausea and vomiting are a common aura for some patients who experience seizures“Feeling butterflies” is a common aura. There are as many auras as there are seizures. Each patient has their own descriptions. Slide27

Nursing Care During an AuraWhen with a patient who has an aura, you have the opportunity to get them to a safe place.

Once they are safely positioned, you will have the opportunity to watch them during the seizures and take the appropriate actions. Documentation should include the time the aura started and the symptoms. Important is to note if the patient was cognitive at during the aura.Slide28

The Ictal Stage

Stage 2-The ictal stage is the actual event. The goal is to protect the patient from injuryTurn the patient on their side to keep the airway clear. Maintain the airway; use oxygen and suction as needed.Loosen any restrictive clothing.Do not restrain the patient or stop movement. Guide the movement if necessary. Especially those patients who want to walk around.

Note the time the seizure began and ended.

NEVER FORCE ANYTHING INTO THE PATIENT’S MOUTH!!Slide29

Post-ictal stage

Stage 3-During the post-ictal stage, the brain is in a state of recovery.Patient may become confused or disoriented.With tonic-clonic seizures or some complex-partial, the patient will become extremely drowsy and fall to sleep. This can last from 5-30 minutes.

Take the patient’s vital signs.

Perform neurological checks.

Allow the patient to rest.

Keep the patient on their side.

Slide30

Post-ictal

Assess the patient for any bleeding inside the mouth when awake. (Do not put your fingers into their mouth).Many seizure patient will bite and chew their tongues or cheeks. Patient may need oxygen at this time. Slide31

Focused AssessmentWhen observing and documenting the seizure, the following is important:

Date, time and duration of the seizure, was there more than one. Description of the seizure: movement, staring, blinking, automatisms,Was there more than one type of seizure? If you are not sure of the type, document the movements of the seizure.Which body part was first involved?How long did the seizure last?

Was there an aura?

What was involved in the aura? Visual, Auditory, GI disturbances?

What did the patient do after the seizure (post-

ictal

)?

Drowsy, weak?

Did the patient resume normal behavior?

Was the patient aware the seizure took place?

How long did it take for the patient to return to pre-seizure statusSlide32

Observations during the seizure

Observations and documentation during the seizure:Was there any eye deviations or changes in the pupil size, eye fluttering.Level of Consciousness, was the patient able to follow commandsPresence of apnea, cyanosis, salivationMovement and progression of motor activity; was a side more active during the seizure? (R vs. L)Lip smacking or other automatisms

Biting of tongue or lip. Slide33

Diagnosis of seizure/epilepsyWith first seizure, patient should go to the Emergency Room.

Did they or did they experience a seizure?First-a thorough past and present medical history!!!Alcohol or drug use, medicationsDetailed information regarding the seizure: aura, movement, LOC, any injuries associated with the seizure. Slide34

DiagnosticsLaboratory studies

CBC, Metabolic Package, Drug screen, Urine drug screenOther labs to rule out medical conditions:Lumbar puncture (Meningitis)Prolactin-will increase 3x’s the normal after seizure for 12 hours after seizures.Slide35

DiagnosticsHead CT Scan-r/o stroke, head injury, tumors

MRI-can identify possible epilepsy lesionsElectroencephalogram-EEG-electrical signals of the brain are recorded. This electrical activity is detected by electrodes, or sensors, placed on the patient's scalp and transmitted to a machine that records the activitySlide36

NORMAL

Epileptic spikes and waves Slide37

Electrodes connected to scalp

. The EEG shows the abnormal “waves” that are associated with the seizure.The brain waves consist of

Beta

Alpha

Theta

Delta

See the next slide for what these waves are associated with.

Slide38

http://www.angelfire.com/journal/ldps/SleepingDisordersSlide39

Treatments for Seizures

Antiepileptic drugs (AED)The drug should be: 1. highly effective, but exhibit a low incidence of toxicity. 2. effective against more than one type of seizure and for mixed seizures.

3. long

acting and

nonsedative

so that the client is not incapacitated with sleep or excessive drowsiness.

4

. tolerated by the client and inexpensive, since the client may have to take it for years or the rest of his/her life.

5

. control seizures and permit a client to function effectively in any environment.

6. Tolerance

to the therapeutic effects of the drug should not develop.Slide40

Main Pharmacologic effects are: (1) to increase motor cortex threshold to reduce its response to incoming electric or chemical stimulation.

(2) to depress or reduce the spread of a seizure discharge from its focus (origin) by depressing synaptic transport or decreasing nerve conductionSlide41

Common medications Barbiturates

– phenobarbital. One of the first anticonvulsants used.Benzodiazepine- To suppress the propagation of diazepam (Valium) seizure activity produced by foci in the cortex, thalamus, and limbic areas.Hydantoins - Inhibit spread of seizure

.

Phenytoin (Dilantin

).

Blurred

vision, gingival hyperplasia

Elevated

incidence of birth defects in children of

mothers taking

phenytoin. Slide42

AEDs

divalproex (Depakote). Derived from valproaic acid. Has been used during pregnancy but has been associated with spina bifida, fatal hepatic problems in infants

www.drugs.com/pregnancy/divalproex-sodium.html

•

Carboxamides

(

Oxazolidinediones

)

Carbamazepine

(

Carbatrol

,

Tegretol

)

Oxcarbazepine

(

Trileptal

)

•

GABA Analogues

Gabapentin

(Neurontin)

Pregabalin

(

Lyrica

)

Tiagabine

(

Gabitril

) Slide43

Surgical ManagementAbout 20% of patients with epilepsy do not respond well to drug therapy. (Intractable seizures) These patients may undergo procedures to remove the foci of the seizures or to stop the progression of the seizures.

The presurgical work-up is comprehensive and is directed at the identification of the seizures and the area of the brain it is located. Slide44

Vagus Nerve Stimulation

Was approved for use in adults and children over 12 with partial-onset seizures and cannot be controlled by AEDs An implantable programmed signal generator is placed in the left upper chest. A bipolar VNS lead connects the lead to the left vagus nerve in the neck.This sends stimulation to the brain stem which sends info to othe rest of the brain and interrupting the seizure. Slide45

Vagus

Nerve StimulatorApproved since 1997Slide46

Ketogenic Diet

One of the oldest treatments for epilepsyIt is intended to maintain starvation or fasting metabolism over a long period of time. In a fasting state, it creates ketones, a by-product of fat-burning metabolism. The diet is very high in fat and low in carbohydrates

. High fats=ketones.

It has been found

that seizures often lessen or disappear during periods of fasting in some individuals with epilepsy.Slide47

Ketogenic Diet

Diet has been used mostly in children with difficult-to-control, generalized epilepsies –Recommended for children ages 2 through 12 who have been diagnosed with a generalized type of

epilepsy and are not responding to drugs.

I

nitiation of the diet usually

takes place in the

hospital

Patient should be

monitored for potential side effects such as vomiting, low blood sugar, dehydration, and seizures. Slide48

Status EpilepticusContinuous seizures that last at least 5 minutes, or there are 2 or more seizures together with no recovery between the seizures.

Usually a tonic-clonic seizure, in 50% of patients it is usually their first seizure. (Hickey, 2009).Although there are many types of status epilepticus, this information is based on the tonic-clonic seizure the most common and constitutes a medical emergency.Slide49

Status EpilepticusInitial nursing management:

ABCsPosition for airway clearance, suction to maintain patency.Oxygen at 100% via nasal cannula. (turn it up!) Monitor with pulse oximetry. Severe status can cause extreme cerebral hypoxia and can result in severe irreversible neurological deficits. Secure IV access with frequent vital sign monitoring.

Protect the patient from injury

Provide information to

to

the family.Slide50

Status Epilepticus (SE)Medications used for SE are:

BenzodiazepinesValiumLorazepamThese are ordered by mg per kg. The dose is usually given every 5 minutes until the seizure stops. Slide51

Seizure Precautions

Each medical facility has its own policy for the safety of patients with seizures. Most protocols or standards of care include:Safety concerns-Side rails up, padded.Call bell at bedside, within patient’s reachO2 and suction at bedside, check function at the beginning of each shiftBed in low positionRemove glasses, sharp objects when seizing

Maintain IV accessSlide52

Nursing DiagnosisIneffective Breathing Pattern related to neuromuscular dysfunction during seizure.Ineffective airway clearance related to inability to control secretions during seizure.

Risk for injury related to seizure activityFear related to the possibility of seizuresDeficient knowledge related to epilepsy and its controlSlide53

Patient EducationEducate patient and family on:Recognition of seizures and their safety

Compliance with medicationsDriving and seizure activityMedical ID braceletFamily SupportCommunity ResourcesSlide54

Epilepsy Syndromes and Childhood Seizures

A major advance in recent epileptology is the recognition of epileptic syndromes that allows an accurate diagnosis and management of seizure disorders.Important clinical features include the type of seizurestheir localizationfrequency

sequence

of

events

circadian distribution

precipitating

factors

age

at

onset

mode

of

inheritance

physical or mental symptoms and

signs

prognosis

, and response to

treatment (epilepsy.com/professionals)Slide55

Childhood Seizures Children are more likely to experience seizures than adults.

Newborns and young children have seizures most frequently. Their seizures are often caused by problems around the time of birth, including injuries during birth or infections.The types of seizures that children experience are different from those in adults and may be associated with an epileptic syndrome.Slide56

Infantile Spasms Infantile spasms are an age-specific disorder beginning during the first 2 years of life

. Peak age of onset is between 4 and 6 months. Approximately 90% of infantile spasms begin before 12 months of age.Rare for infantile spasms to begin during the first 2 weeks of life or after 18 months.Slide57

Febrile Seizures

Febrile seizures involve contractions

in the child’s

muscles—either mild (such as stiffening of

the child’s

limbs) or severe

(tonic-

clonic

).

Triggered

by fever.

Fairly

common: About 2 to 5 percent of children in the United States experience a febrile

seizure.

Usually

happen in children between 6 months and 5 years of age. Children who have febrile seizures often have a family history of this type of

seizure.Slide58

***Neonatal Seizures***Neonatal period is the most vulnerable period of life for developing seizures.

Neonatal epileptic seizures often constitute a neurological emergency demanding urgent diagnosis and management. Neonatal seizures are paroxysmal, repetitive, and stereotyped events. They are usually clinically subtle. There is no recognizable post-ictal state.

Generalized

tonic-

clonic

seizures probably do not occur. Slide59

Benign Familial Neonatal SeizuresThe

diagnosis of this syndrome in a child with seizures is based on five criteria: normal neurologic examinationnegative evaluation for another etiology of the seizuresnormal developmental and intellectual

outcome

positive

family history of newborn or infantile seizures with benign

outcome

onset

of seizures during the neonatal or early infantile period)

Slide60

Neonatal SeizuresThere are 5 main types of neonatal seizures: Subtle seizures (50%)

Tonic seizures (5%)Clonic seizures (25%)Myoclonic seizures (20%)Non-paroxysmal repetitive behaviorsSlide61

Neonatal SeizuresSevere causes are usually the cause.Hypoxic-ischemic encephalopathy is the most common cause (80% of all seizures in the first 2 days of life

). Previously common acute metabolic disturbances such as electrolyte and glucose abnormalities are now unusual causes.Slide62

Benign Rolandic Epilepsy

Classified as an idiopathic, localization-related epileptic syndrome. It is characterized by:nocturnal generalized seizures, probable focal onsetdiurnal partial seizures arising from the lower rolandic area

Both daytime and nighttime seizures may occur, although in most children the seizures usually occur during sleep.

The

disorder always begins during childhood.

Age

range is from 3 to 13 years, with the peak incidence occurring between the 7th and 8th year of life

.

Somewhat

more common in boys than in girls

.

Most

affected children have normal intelligence and normal findings on the neurologic

examination.

The

disorder is usually familial

.

(http

://professionals.epilepsy.com/page/syndromes_benign.html

2013)Slide63

Benign childhood focal seizures The

most common pediatric seizure. 25% of children with non-febrile seizures. Seizures are infrequent, usually nocturnal, and remit within 1 to 3 years from onset. Brief or prolonged seizures, even status epilepticus, may be the only clinical event of the patient’s lifetime.

Ictal

autonomic

manifestations are

frequent and may occasionally appear in isolation as in pure autonomic seizures. Slide64

Nursing Care for pediatricsNursing care for children is the same but should include:

Safety should include the rails of the crib, or bed so the child does not roll out.Children’s brain cannot recover from status well. Medications should be given ASAP.Rectal benzodiazepines may be used for seizure control. Slide65

For school age and adolescents, the school should know the type of seizure and what to expect from the child.

Parental/Caregiver support is a must!Some young girls may experience seizures in conjunction with puberty and their menstrual cycle. Hormones play a large part in seizure activity.Slide66

Questions1. In teaching family members how to care for a patient during a seizure, the nurse should include which of these measures?

a. Begin cardiac compressions b. Sit the client in an upright position c. Do not force anything into the patient’s mouth d. Hold the patient down so not to injure himself Slide67

Question #2An ictal assessment should include the following: (Select all that apply)

a. Name, address b. Time the event started c. Movement of extremities d. Vocalizations

e. Cognition during the eventSlide68

Question #3One out of ten people will experience a seizure at least once in their life.

TrueFalseSlide69

Question #4Upon entering the patient’s room at the end of the seizure, the patient can tell the nurse everything that happened during the seizure. The nurse realizes that this patient experienced a:

a. Complex Partial Seizure b. Generalized Tonic-Clonic c. Myoclonic Seizure d. Simple Partial SeizureSlide70

Question #5Status Epilepticus is a: (select all that apply)

a. an medical emergency b. Name for a generalized seizure c. Continuous seizure lasting for longer that 5 minutes d. A possible fatal conditionSlide71

ReferencesEpilepsy Foundation

www.epilepsyfoundation.orgIgnatavicius, Donna (2010) Medical-Surgical Nursing, Patient-Centered Collaborative Care. Elsevier St. Louis, Missouri.Hickey, Joanne (2009) The Clinical Practice of Neurological and Neurosurgical Nursing

6

th

ed. , Lippincott, Williams, & Wilkins, Philadelphia, PA.

KSA

competencies

for pre-licensure (2013)

qsen.org.

EEG,

Vagus

Nerve Stimulator

http

://www.nlm.nih.gov/medlineplus/seizures.html