Seizure Disorder - PowerPoint PPT Presentation


Title: Seizure Disorder


1
Seizure Disorder
  • Not the Cause, but the Symptom

http//www.epilepsy.com/
2
Is it the same as Epilepsy?
  • Epilepsy is recurrent unprevoked seizures due to
    underling dysfunction of the brain
  • Does our patient have Epilepsy?
  • Can not be determined
  • She did have a hemorhagic stroke
  • She is still on Phyntonin
  • How would you determine if she had epilepsy?

3
Does our Patient have Eclampsia?
  • Near birth time ??
  • History of HTN??
  • HELLP?

4
Basal Ganglion Hematoma
5
Types of Seizures
  • Generalized-both hemispheres
  • Partial-localized to specific area of one
    hemisphere
  • Simple-No loss of consciousness
  • Complete -Loss of consciousness
  • Status epilepticus
  • Non-epileptic seizures

6
Types/Phases of Seizures
  • Absence
  • Myoclonic-rapid jerks
  • Atonic - Flaccid
  • Tonic- 10 to 20 sec. rigid legs extended elbows
    abducted
  • Clonic- 1 to 2 min. Tremors
  • Tonic-Clonic - alternating

7
Nerve Transduction
  • Action potential
  • Open Ca Gates
  • Na flows out all or nothing
  • ATP required to repolarize via Na/K pumps
  • Neurotransmitters released into synapse
  • Receptors
  • Threshold effects

8
Pathophysiology
  • 3 different mechanisms
  • (1) hyperexcitable cortex has abnormal response
    of to initially normal thalamic input,
  • (2) primary subcortical trigger, and
  • (3) abnormal cortical innervation from
    subcortical structures.

9
PathophysiologyAdapted from Cavazos et al 2007
  • A seizure results from erratic electrical
    discharge of susceptible hyper-excitable neurons
    within an area of the brain (Focus).
  • That, for unknown reasons, remain in a state of
    partial depolarization.
  • Eventually neighboring GABA- inhibtory neuron are
    overcome and the firing spread.

10
Pathophysiology
  • Animal models implicate brainstem structures
  • (1) a lateral geniculate body
  • (2) ascending pathways through the mamillary
    bodies and anterior thalamus and
  • (3) the substantia nigra,

11
http//en.wikipedia.org/wiki/ImageConstudoverbrai
n.gif
12
Phases of Seizure
  • Preictal (Prodromal)-Prior to
  • Ictal-During
  • Postictal-After

13
Preictal
  • Aura-similar of onset of migraine
  • Visual
  • Bright lights, zig zag lines, tunnel vision,
    spots
  • Auditory
  • Hallucinations, modification of sounds
  • Olfactory
  • Burning rubber, electrical smell
  • Tactile
  • Numbness, weakness, separation from body
  • Psychological

14
Ictal
  • Dependent on seizure type
  • Absence (Petit mal) blank stares-muscle in
    complex
  • Eye blinks, rubbing fingers, tasting movements of
    mouth
  • Last 10-20 seconds
  • Patient may not know they had one
  • Can be differentiated from day dreaming

15
Ictal-Clonic/Tonic
  • Teeth clenching/grinding , Tongue biting
  • Eyelid fluttering
  • Eyes rolling up
  • Falling down
  • Foot stomping
  • Hand waving
  • Inability to move
  • Incontinence
  • Convulsion
  • Difficulty talking
  • Drooling
  • Shaking
  • Staring
  • Stiffening
  • Swallowing
  • Sweating
  • Rigitity

16
PostictalCan range from none to
  • Memory loss
  • Writing difficulty
  • Confusion
  • Depression and sadness
  • Fear
  • Frustration
  • Embarrassment
  • Bruising
  • Difficulty talking
  • Injuries
  • Sleeping
  • Exhaustion
  • Headache
  • Nausea
  • Pain
  • Thirst
  • Weakness
  • Urge to urinate/defecate

17
Treatment
  • Diet-Ketogenic diet investigated in 1921 and
    studied extensively in 1930 (Barborka, 1930)
  • Thought to be due to chemical changes in the
    brain due to starvation (Temlock, 2002)
  • Medication
  • Nerve stimulation
  • Implantation of a electrical device that
    stimulated the vagus nerve
  • UCLA is working on trigeminal nerve stimulator
    (Page, 2006)

18
Classic Types of Medication
  • GABA agonist
  • GABA inhibits/ controls nerve transduction
  • Benzodiazepines
  • Diazepam (Valium)
  • Clonazapam (Klonopin)
  • Lorazapam (Ativan)

19
Classic Types of Medication
  • Blocks Na/Ca
  • Phenobarbital (Luminal)-
  • Valproic acid (Depakote, Depakene)
  • Phenytoin (Dilantin)
  • Carbamazepine (Tegretol)

20
Pharmaceuticals
  • Depakote (divalproex sodium )
  • absence, generalized tonic-clonic, simple/complex
    partial, myoclonic
  • SA- pancreatitis, liver failure, hair loss,
    tremor
  • Diastat (viscous solution of diazepam)
  • status or repeated seizures
  • Rectal application
  • SA-respiratory depression (rare)

21
Pharmaceuticals
  • Dialantin (phenytoin)
  • simple/complex partial, generalized tonic-clonic
  • SA Stevens-Johnson rash, body hair increase, gum
    overgrowth, termor, anemia
  • Klonopin (clonazepam)
  • absence (petit mal), atonic, myoclonic
  • SA-abrupt withdrawl causes seizures
  • may precipitate tonic-clonic seizures

22
Steven-Johnson
  • Facial swelling
  • Tongue swelling
  • Hives
  • Skin pain
  • A red or purple skin rash that spreads
  • Blisters on your skin and mucous membranes,
    especially in your mouth, nose and eyes
  • Shedding (sloughing) of your skin

23
Newer Meds
  • Keppra (levitiracetam)
  • Partial and generalized tonic-clonic
  • MOA ???
  • Midazolam
  • Nasal or buccual
  • Rescue like Diastat (Rectal)
  • Lorazapam
  • Nasal microcrystals

24
What to do?
  • Stay calm
  • Time the seizure
  • On one side
  • Protect the head
  • Nothing in mouth
  • Loosen ties/shirts
  • Area Clear
  • Stay with the person untill
  • Seizure stops
  • Offer to call taxi, friend, or relative if
    disoriented

25
Incidence Prevalence
  • The lifetime likelihood of experiencing at least
    1 epileptic seizure is about 9, and the lifetime
    likelihood of receiving a diagnosis of epilepsy
    is almost 3. However, the prevalence of active
    epilepsy is only about 0.8.

26
Evaluation
  • Make a phone call with 1 week to check on
    progress of Safe Parenting Plan
  • Talk with husband in two weeks to determine
    confort with parenting by G.H.
  • Talk with PT/OT on G.H.s progress on ADL
  • Arange for a home visit in one mounth to assess
    progress.

27
(No Transcript)
28
Status Epilepticus
  • two or more sequential seizures without full
    recovery of consciousness between seizures, or
    more than 30 minutes of continuous seizure
    activity
  • The most serious complication of epilepsy
  • A neurologic emergency associated with high
    mortality and long-term disability
  • Can involve any type of seizure
  • (Lewis et al, 2007)
  • (http//www.aafp.org/afp/20030801/469.html)

29
Mortality Rate
30
Status Epilepticus
  • During repeated seizures the brain uses more
    energy than can be supplied. Neuron become
    exhausted and cease to function
  • Tonic-clonic status epilepticus is the most
    dangerous because it can cause ventilatory
    insufficiency, hypoxemia, cardiac arrhythmias,
    hyperthermia, and systemic acidosis, all of which
    can be fatal
  • (Lewis, et al 2007 )

31
Some data about SE
  • An estimated 152,000 cases occur per year in the
    USA
  • 42,000 deaths per year
  • An inpatient cost of 3.8 to 7 billion per year
  • An incidence of 86 per 100,000 persons per year
    among patients older than 60
  • 69 percent of episodes in adults and 64 percent
    of episodes in children were partial onset
  • generalized status epilepticus in 43 percent of
    adults and 36 percent of children
  • http//www.aafp.org/afp/20030801/469.html

32
Common causes
  • Withdrawal from medication or noncompliance with
    the regimen
  • Most common in the very young and the very old.
    The lowest incidence at age 15-40
  • In very young, febrile seizures are a leading
    cause
  • Later in life, stroke is a common cause
  • In adults, the major causes are low level of
    antiepileptic drugs (34) and cerebrovascular
    disease (22)
  • http//www.aafp.org/afp/20030801/469.html
  • http//www.epilepsyfoundation.org/about/types/type
    s/statusepilepticus.cfm

33
Diagnostic test
  • Complete neuro exam
  • EEG
  • Skull x-rays
  • CT, MRI
  • CBC, lytes, BUN, glucose
  • EKG

34
Nursing Care
  • Airway management
  • Ensure IV access patent
  • Protect from injury, DO NOT RESTRAIN
  • Loosen restrictive clothing
  • Provide emotional support, orientation
  • Administer prescribed medications
  • If EEG, wash hair before and after

35
Case Study
  • You are the nurse on a medical unit taking care
    of a 40-year-old man, T.Z., who has been admitted
    with peptic ulcer disease (PUD) secondary to
    chronic alcoholism. You enter T.Z.s room and
    find him having a generalized convulsive
    (tonic-clonic) seizure.
  • 1. List five things you would do

36
Case study
  • Protect from injury. Clear the area of furniture
    or other objects that may cause injury.
  • Turn the person to the side
  • Position the head to prevent the tongue from
    blocking the airway
  • Loosen restrictive clothing
  • Ensure IV access patent
  • Time the seizure
  • Dont hold the person down or try to stop his
    movements
  • Providing emotional support
  • (http//www.nlm.nih.gov/medlineplus/ency/article/0
    00695.htm)

37
Case study
  • Placing any objects, including an airway, into
    the patients mouth at this point is
    contraindicated because of the possibility of
    patient or caregiver harm.
  • T.A.s seizure activity does not appear to be
    subsiding, and he is becoming cyanotic. The
    physician is notified and orders lorazepam
    (Ativan) 4mg IV over 2 to 5 minutes, repeat once
    in 1- to 15 minutes prn (as needed)
  • 2. What is rationale for giving T.Z. lorazepam?

38
Case study
  • Lorazepam is a benzodiazepines which is one of
    the most effective drugs in the treatment of
    acute seizures and status epilepticus
  • Lorazepam acts rapidly enough to interrupt
    seizures quickly
  • It has a more prolonged anticonvulsant effect
  • http//professionals.epilepsy.com/page/managing_lo
    ra.html

39
Case study
  • 3. What is status epilepticus?
  • two or more sequential seizures without full
    recovery of consciousness between seizures, or
    more than 30 minutes of continuous seizure
    activity
  • (http//www.aafp.org/afp/20030801/469.html)

40
Case study
  • 4. List one thing you would be particularly alert
    for when giving lorazepam intravenously.
  • Lorazepam can cause excessive sedation which can
    cause respiratory distress. So make sure airway
    is patent
  • (http//en.wikipedia.org/wiki/Lorazepam)

41
Case study
  • By the time the physician arrives, T.Zs seizure
    activity has not subsided. The physician
    administers an additional 4mg lorazepam, without
    effect. Fifteen minutes have elapsed since you
    found T.Z. having seizure activity.
  • 5. What is the significance of this?
  • T.Z. may has Tonic-clonic status epilepticus
    which is the most dangerous SE because it can
    cause ventilatory insufficiency, hypoxemia,
    cardiac arrhythmias, hyperthermia, and systemic
    acidosis, all of which can be fatal

42
Case study
  • The physician decides to administer
    succinylcholine (Anectine) and intubate T.Z. to
    protect his airway
  • 6. What is succinylcholine, and why is it being
    administered to T.Z.?
  • Succinylcholine is a muscle relaxant. It is
    usually used to relax muscle during surgery or
    when using a breathing machine (ventilator). T.Z.
    uses this drug because he will be intubated.
  • (http//www.drugs.com/cdi/succinylcholine.html)

43
Case study
  • T.Z. has been intubated the physician orders a
    phenytoin (Dilantin) 20mg/kg IV loading dose and
    transport to ICU.
  • 7. What is the rationale behind giving phenytoin?
  • Phenytoin is one of the most effective drugs for
    treating acute seizures and status epilepticus.
    The main advantage of phenytoin is the lack of a
    sedating effect.
  • (http//www.aafp.org/afp/20030801/469.html)

44
Case study
  • 8. List two problems related to T.Z.s care.
  • T.Z. is cyanotic. At the beginning, maintaining
    oxygenation and circulation are necessary. So
    oxygen should be administrated to prevent hypoxia
  • Phenytoin is contraindicated to alcohol. T.Z. is
    a chronic alcoholism.

45
Case study
  • 9. Given T.Z.s history, state at least two
    possible causes for his grand mal seizure.
  • Chronic alcoholism
  • Peptic ulcer disease (PUD) which can cause
    electrolytes imbalances
  • Nutritional deficiencies- from PUD
  • Kidney problems which can cause toxic
    accumulation of wastes-from chronic alcoholism
  • (http//www.nlm.nih.gov/medlineplus/ency/article/0
    00695.htm)

46
Case study
  • T.Zs seizure is successfully treated with
    lorazepam and phenytoin, and he has no further
    seizure activity. As you are writing up his
    discharge papers, you overhear T.Z. telling his
    girlfriend to have his car brought to the
    hospital so he can drive home.
  • 10. How should you respond to this situation

47
Case study
  • The nurse should inform T.Z. the side effects of
    lorazepam. It can cause severe sedation. The side
    effects of phenytoin are dizziness, drowsiness,
    difficulty focusing (vision). Although his
    seizure is treated, he may has recurrent seizure
    when he is on the way home. For all these
    reasons, T.Z. should not drive car by his own.

48
Nursing Diagnosis
  • Diagnosis Risk for injury r/t uncontrolled
    movements during seizure, falls
  • Outcome Patient has no injury in the next 8
    hours
  • Nursing Intervention
  • 1. Protect from injury. Clear the area of
    furniture or other objects that may cause injury
  • 2. Avoid moving or restraining patient during
    a seizure to prevent bone or soft tissue injury
  • 3. Assess for trauma to mouth, cheek,
    tongue, lips abrasions, bruises broken bones
    burns because these injuries may occur during
    seizure activity
  • Lewis, Heitkemper Dirksen

49
Nursing Diagnosis
  • Diagnosis Ineffective breathing pattern r/t
    neuromuscular impairment secondary to prolonged
    tonic phase of seizure or during postictal period
    AEB abnormal respiratory rate, rhythm or depth.
  • Outcome patient will have appropriate rate,
    rhythm and depth of respirations in the next 8
    hours
  • Nursing Intervention
  • 1. Loosen constricting clothing to avoid
    restricting breathing
  • 2. Turn the person to the side if patient
    has vomiting to prevent aspiration
  • 3. Position the head to prevent the tongue
    from blocking the airway
  • 4. Provide oxygen when necessary to prevent
    hypoxia
  • 5. Assess breathing pattern, observing for
    labored respiration, tachypnea, bradypnea,
    dyspnea, and apnea to determine presence and
    extent of problem and to initiate appropriate
    interventions
  • (Lewis et al ,2007)

50
Nursing Diagnosis
  • Diagnosis Risk for injury r/t uncontrolled
    movements during seizure, falls
  • Outcome Patient has no injury in the next 8
    hours
  • Nursing Intervention
  • 1. Protect from injury. Clear the area of
    furniture or other objects that may cause injury
  • 2. Avoid moving or restraining patient during
    a seizure to prevent bone or soft tissue injury
  • 3. Assess for trauma to mouth, cheek,
    tongue, lips abrasions, bruises broken bones
    burns because these injuries may occur during
    seizure activity
  • (Lewis et al ,2007)

51
Nursing Diagnosis
  • Diagnosis Ineffective therapeutic regimen
    management r/t lack of knowledge about management
    of seizure disorder AEB verbalization of lack of
    knowledge, inaccurate perception of health
    status, noncompliance with prescribed heath
    behavior
  • Outcome Patient will have therapeutic drug level
    of antiseizure medication and be compliance with
    therapeutic regimen in one week
  • Nursing Intervention
  • 1. Providing teaching to patient and family
    about seizure activity and therapeutic management
    including diagnosis, treatment, lifestyle, and
    community resources so that patient and family
    can make necessary lifestyle modifications to
    manage a chronic disease.
  • Lewis, Heitkemper Dirksen

52
Nursing Diagnosis
  • Knowledge deficit r/t seizures, nerological
    impairment and childcare AEB husbands fear of
    allowing J.G to care for child.

53
Interventions
  • Assist J.G./Husband to create a Safe Parenting
    Plan
  • Use creditable web resoruce to increse
    prepairedness
  • Work with J.G./Husband to develop a system to
    ensure compliance with medications
  • Consult with PT/OT to adapt environment as needed.

54
Outcomes
  • For J.G. not to exibit signs that pose risk to
    her or her baby and do notfoster distrust of
    capibilitys form husband
  • For J.G. to remain seizure free for next year
  • For J.G. to continue with PT until ability
    reaches plataeu state
  • For J.G and husband to develop a Safe Parenting
    Plan (Rousseau, 2008)

55
Nursing Diagnosis
  • Ineffective coping r/t perceived loss of control
    and denial of diagnosis
  • Social isolation r/t unpredictability of
    seizures, community-imposed stigma
  • Risk for disturbed thought process r/t effects of
    anticonvulsant medications
  • Ackley Ladwig

56
References
  • Stevens-Johnson-Syndrome http//www.mayoclinic.com
    /health/stevens-johnson-yndrome/DS00940/DSECTION2
    updated Feb 8, 2008 Accessed 5/10/08
  • Kossoff, E. 2008 Do ketogenic diets work for
    adults with epilepsy? Yes!
  • Barborka CJ. Epilepsy in adults results of
    treatment by ketogenic diet in one hundred cases.
    Arch Neurol 19306904-914.
  • Vining EPG, Freeman JM, Ballaban-Gil K, et. al. A
    multicenter study of the efficacy of the
    ketogenic diet. Arch Neurol 1998551433-1437.
  • TEMLOCK, A 2002. THE KEY INTO KETOGENIC DIETS.
    http//www.vanderbilt.edu/ans/psychology/health_ps
    ychology/ketogenic_diets.htm Accessed 5-10-08
  •  Axon, M. 2007 Epilepsy, learning disabilities
    and the nurse prescriber Nurse Prescribing 511,
    481-484. 2007.
  • Shafer, P.O. Schachter S. C., SEIZURES AND
    TEENSUsing Technology to Develop Seizure
    Preparedness. 66 November 2007 EP MAGAZINE/
    www.eparent.com Accessed 5/10/08
  • Eskandar E. N Epilepsy Surgery for Tumors,
    Vascular Malformations, Trauma and
    Cerebrovascular Disease. Http//neurosurgery.mgh.h
    arvard.edu/functional/EpilepsySurgery.htm. May
    11, 2005 Accessed 5/10/2008
  • http//www.ilae-epilepsy.org/
  • Cavazos, J.E Lum,F. Spitz, M . Seizures and
    Epilepsy Overview and Classification
    http//www.emedicine.com/neuro/TOPIC415.HTM.
    updated Nov 30, 2007 accessed 5/10/2008.
  • Lewis, S.L., Heirkemper, M.m., Dirkson, S.R.,
    Obrain, P.G., Bucher, L. (2007) Medical-surgical
    Nursing, Assessment and Management of Clinical
    Problems. Mosby 2007.
  • http//www.nlm.nih.gov/medlineplus/ency/article/00
    0695.htm
  • http//professionals.epilepsy.com/page/managing_lo
    ra.html
  • http//www.aafp.org/afp/20030801/469.html
  • http//en.wikipedia.org/wiki/Lorazepam
  • http//www.drugs.com/cdi/succinylcholine.html
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Seizure Disorder

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Title: Seizure Disorder


1
Seizure Disorder
  • Not the Cause, but the Symptom

http//www.epilepsy.com/
2
Is it the same as Epilepsy?
  • Epilepsy is recurrent unprevoked seizures due to
    underling dysfunction of the brain
  • Does our patient have Epilepsy?
  • Can not be determined
  • She did have a hemorhagic stroke
  • She is still on Phyntonin
  • How would you determine if she had epilepsy?

3
Does our Patient have Eclampsia?
  • Near birth time ??
  • History of HTN??
  • HELLP?

4
Basal Ganglion Hematoma
5
Types of Seizures
  • Generalized-both hemispheres
  • Partial-localized to specific area of one
    hemisphere
  • Simple-No loss of consciousness
  • Complete -Loss of consciousness
  • Status epilepticus
  • Non-epileptic seizures

6
Types/Phases of Seizures
  • Absence
  • Myoclonic-rapid jerks
  • Atonic - Flaccid
  • Tonic- 10 to 20 sec. rigid legs extended elbows
    abducted
  • Clonic- 1 to 2 min. Tremors
  • Tonic-Clonic - alternating

7
Nerve Transduction
  • Action potential
  • Open Ca Gates
  • Na flows out all or nothing
  • ATP required to repolarize via Na/K pumps
  • Neurotransmitters released into synapse
  • Receptors
  • Threshold effects

8
Pathophysiology
  • 3 different mechanisms
  • (1) hyperexcitable cortex has abnormal response
    of to initially normal thalamic input,
  • (2) primary subcortical trigger, and
  • (3) abnormal cortical innervation from
    subcortical structures.

9
PathophysiologyAdapted from Cavazos et al 2007
  • A seizure results from erratic electrical
    discharge of susceptible hyper-excitable neurons
    within an area of the brain (Focus).
  • That, for unknown reasons, remain in a state of
    partial depolarization.
  • Eventually neighboring GABA- inhibtory neuron are
    overcome and the firing spread.

10
Pathophysiology
  • Animal models implicate brainstem structures
  • (1) a lateral geniculate body
  • (2) ascending pathways through the mamillary
    bodies and anterior thalamus and
  • (3) the substantia nigra,

11
http//en.wikipedia.org/wiki/ImageConstudoverbrai
n.gif
12
Phases of Seizure
  • Preictal (Prodromal)-Prior to
  • Ictal-During
  • Postictal-After

13
Preictal
  • Aura-similar of onset of migraine
  • Visual
  • Bright lights, zig zag lines, tunnel vision,
    spots
  • Auditory
  • Hallucinations, modification of sounds
  • Olfactory
  • Burning rubber, electrical smell
  • Tactile
  • Numbness, weakness, separation from body
  • Psychological

14
Ictal
  • Dependent on seizure type
  • Absence (Petit mal) blank stares-muscle in
    complex
  • Eye blinks, rubbing fingers, tasting movements of
    mouth
  • Last 10-20 seconds
  • Patient may not know they had one
  • Can be differentiated from day dreaming

15
Ictal-Clonic/Tonic
  • Teeth clenching/grinding , Tongue biting
  • Eyelid fluttering
  • Eyes rolling up
  • Falling down
  • Foot stomping
  • Hand waving
  • Inability to move
  • Incontinence
  • Convulsion
  • Difficulty talking
  • Drooling
  • Shaking
  • Staring
  • Stiffening
  • Swallowing
  • Sweating
  • Rigitity

16
PostictalCan range from none to
  • Memory loss
  • Writing difficulty
  • Confusion
  • Depression and sadness
  • Fear
  • Frustration
  • Embarrassment
  • Bruising
  • Difficulty talking
  • Injuries
  • Sleeping
  • Exhaustion
  • Headache
  • Nausea
  • Pain
  • Thirst
  • Weakness
  • Urge to urinate/defecate

17
Treatment
  • Diet-Ketogenic diet investigated in 1921 and
    studied extensively in 1930 (Barborka, 1930)
  • Thought to be due to chemical changes in the
    brain due to starvation (Temlock, 2002)
  • Medication
  • Nerve stimulation
  • Implantation of a electrical device that
    stimulated the vagus nerve
  • UCLA is working on trigeminal nerve stimulator
    (Page, 2006)

18
Classic Types of Medication
  • GABA agonist
  • GABA inhibits/ controls nerve transduction
  • Benzodiazepines
  • Diazepam (Valium)
  • Clonazapam (Klonopin)
  • Lorazapam (Ativan)

19
Classic Types of Medication
  • Blocks Na/Ca
  • Phenobarbital (Luminal)-
  • Valproic acid (Depakote, Depakene)
  • Phenytoin (Dilantin)
  • Carbamazepine (Tegretol)

20
Pharmaceuticals
  • Depakote (divalproex sodium )
  • absence, generalized tonic-clonic, simple/complex
    partial, myoclonic
  • SA- pancreatitis, liver failure, hair loss,
    tremor
  • Diastat (viscous solution of diazepam)
  • status or repeated seizures
  • Rectal application
  • SA-respiratory depression (rare)

21
Pharmaceuticals
  • Dialantin (phenytoin)
  • simple/complex partial, generalized tonic-clonic
  • SA Stevens-Johnson rash, body hair increase, gum
    overgrowth, termor, anemia
  • Klonopin (clonazepam)
  • absence (petit mal), atonic, myoclonic
  • SA-abrupt withdrawl causes seizures
  • may precipitate tonic-clonic seizures

22
Steven-Johnson
  • Facial swelling
  • Tongue swelling
  • Hives
  • Skin pain
  • A red or purple skin rash that spreads
  • Blisters on your skin and mucous membranes,
    especially in your mouth, nose and eyes
  • Shedding (sloughing) of your skin

23
Newer Meds
  • Keppra (levitiracetam)
  • Partial and generalized tonic-clonic
  • MOA ???
  • Midazolam
  • Nasal or buccual
  • Rescue like Diastat (Rectal)
  • Lorazapam
  • Nasal microcrystals

24
What to do?
  • Stay calm
  • Time the seizure
  • On one side
  • Protect the head
  • Nothing in mouth
  • Loosen ties/shirts
  • Area Clear
  • Stay with the person untill
  • Seizure stops
  • Offer to call taxi, friend, or relative if
    disoriented

25
Incidence Prevalence
  • The lifetime likelihood of experiencing at least
    1 epileptic seizure is about 9, and the lifetime
    likelihood of receiving a diagnosis of epilepsy
    is almost 3. However, the prevalence of active
    epilepsy is only about 0.8.

26
Evaluation
  • Make a phone call with 1 week to check on
    progress of Safe Parenting Plan
  • Talk with husband in two weeks to determine
    confort with parenting by G.H.
  • Talk with PT/OT on G.H.s progress on ADL
  • Arange for a home visit in one mounth to assess
    progress.

27
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28
Status Epilepticus
  • two or more sequential seizures without full
    recovery of consciousness between seizures, or
    more than 30 minutes of continuous seizure
    activity
  • The most serious complication of epilepsy
  • A neurologic emergency associated with high
    mortality and long-term disability
  • Can involve any type of seizure
  • (Lewis et al, 2007)
  • (http//www.aafp.org/afp/20030801/469.html)

29
Mortality Rate
30
Status Epilepticus
  • During repeated seizures the brain uses more
    energy than can be supplied. Neuron become
    exhausted and cease to function
  • Tonic-clonic status epilepticus is the most
    dangerous because it can cause ventilatory
    insufficiency, hypoxemia, cardiac arrhythmias,
    hyperthermia, and systemic acidosis, all of which
    can be fatal
  • (Lewis, et al 2007 )

31
Some data about SE
  • An estimated 152,000 cases occur per year in the
    USA
  • 42,000 deaths per year
  • An inpatient cost of 3.8 to 7 billion per year
  • An incidence of 86 per 100,000 persons per year
    among patients older than 60
  • 69 percent of episodes in adults and 64 percent
    of episodes in children were partial onset
  • generalized status epilepticus in 43 percent of
    adults and 36 percent of children
  • http//www.aafp.org/afp/20030801/469.html

32
Common causes
  • Withdrawal from medication or noncompliance with
    the regimen
  • Most common in the very young and the very old.
    The lowest incidence at age 15-40
  • In very young, febrile seizures are a leading
    cause
  • Later in life, stroke is a common cause
  • In adults, the major causes are low level of
    antiepileptic drugs (34) and cerebrovascular
    disease (22)
  • http//www.aafp.org/afp/20030801/469.html
  • http//www.epilepsyfoundation.org/about/types/type
    s/statusepilepticus.cfm

33
Diagnostic test
  • Complete neuro exam
  • EEG
  • Skull x-rays
  • CT, MRI
  • CBC, lytes, BUN, glucose
  • EKG

34
Nursing Care
  • Airway management
  • Ensure IV access patent
  • Protect from injury, DO NOT RESTRAIN
  • Loosen restrictive clothing
  • Provide emotional support, orientation
  • Administer prescribed medications
  • If EEG, wash hair before and after

35
Case Study
  • You are the nurse on a medical unit taking care
    of a 40-year-old man, T.Z., who has been admitted
    with peptic ulcer disease (PUD) secondary to
    chronic alcoholism. You enter T.Z.s room and
    find him having a generalized convulsive
    (tonic-clonic) seizure.
  • 1. List five things you would do

36
Case study
  • Protect from injury. Clear the area of furniture
    or other objects that may cause injury.
  • Turn the person to the side
  • Position the head to prevent the tongue from
    blocking the airway
  • Loosen restrictive clothing
  • Ensure IV access patent
  • Time the seizure
  • Dont hold the person down or try to stop his
    movements
  • Providing emotional support
  • (http//www.nlm.nih.gov/medlineplus/ency/article/0
    00695.htm)

37
Case study
  • Placing any objects, including an airway, into
    the patients mouth at this point is
    contraindicated because of the possibility of
    patient or caregiver harm.
  • T.A.s seizure activity does not appear to be
    subsiding, and he is becoming cyanotic. The
    physician is notified and orders lorazepam
    (Ativan) 4mg IV over 2 to 5 minutes, repeat once
    in 1- to 15 minutes prn (as needed)
  • 2. What is rationale for giving T.Z. lorazepam?

38
Case study
  • Lorazepam is a benzodiazepines which is one of
    the most effective drugs in the treatment of
    acute seizures and status epilepticus
  • Lorazepam acts rapidly enough to interrupt
    seizures quickly
  • It has a more prolonged anticonvulsant effect
  • http//professionals.epilepsy.com/page/managing_lo
    ra.html

39
Case study
  • 3. What is status epilepticus?
  • two or more sequential seizures without full
    recovery of consciousness between seizures, or
    more than 30 minutes of continuous seizure
    activity
  • (http//www.aafp.org/afp/20030801/469.html)

40
Case study
  • 4. List one thing you would be particularly alert
    for when giving lorazepam intravenously.
  • Lorazepam can cause excessive sedation which can
    cause respiratory distress. So make sure airway
    is patent
  • (http//en.wikipedia.org/wiki/Lorazepam)

41
Case study
  • By the time the physician arrives, T.Zs seizure
    activity has not subsided. The physician
    administers an additional 4mg lorazepam, without
    effect. Fifteen minutes have elapsed since you
    found T.Z. having seizure activity.
  • 5. What is the significance of this?
  • T.Z. may has Tonic-clonic status epilepticus
    which is the most dangerous SE because it can
    cause ventilatory insufficiency, hypoxemia,
    cardiac arrhythmias, hyperthermia, and systemic
    acidosis, all of which can be fatal

42
Case study
  • The physician decides to administer
    succinylcholine (Anectine) and intubate T.Z. to
    protect his airway
  • 6. What is succinylcholine, and why is it being
    administered to T.Z.?
  • Succinylcholine is a muscle relaxant. It is
    usually used to relax muscle during surgery or
    when using a breathing machine (ventilator). T.Z.
    uses this drug because he will be intubated.
  • (http//www.drugs.com/cdi/succinylcholine.html)

43
Case study
  • T.Z. has been intubated the physician orders a
    phenytoin (Dilantin) 20mg/kg IV loading dose and
    transport to ICU.
  • 7. What is the rationale behind giving phenytoin?
  • Phenytoin is one of the most effective drugs for
    treating acute seizures and status epilepticus.
    The main advantage of phenytoin is the lack of a
    sedating effect.
  • (http//www.aafp.org/afp/20030801/469.html)

44
Case study
  • 8. List two problems related to T.Z.s care.
  • T.Z. is cyanotic. At the beginning, maintaining
    oxygenation and circulation are necessary. So
    oxygen should be administrated to prevent hypoxia
  • Phenytoin is contraindicated to alcohol. T.Z. is
    a chronic alcoholism.

45
Case study
  • 9. Given T.Z.s history, state at least two
    possible causes for his grand mal seizure.
  • Chronic alcoholism
  • Peptic ulcer disease (PUD) which can cause
    electrolytes imbalances
  • Nutritional deficiencies- from PUD
  • Kidney problems which can cause toxic
    accumulation of wastes-from chronic alcoholism
  • (http//www.nlm.nih.gov/medlineplus/ency/article/0
    00695.htm)

46
Case study
  • T.Zs seizure is successfully treated with
    lorazepam and phenytoin, and he has no further
    seizure activity. As you are writing up his
    discharge papers, you overhear T.Z. telling his
    girlfriend to have his car brought to the
    hospital so he can drive home.
  • 10. How should you respond to this situation

47
Case study
  • The nurse should inform T.Z. the side effects of
    lorazepam. It can cause severe sedation. The side
    effects of phenytoin are dizziness, drowsiness,
    difficulty focusing (vision). Although his
    seizure is treated, he may has recurrent seizure
    when he is on the way home. For all these
    reasons, T.Z. should not drive car by his own.

48
Nursing Diagnosis
  • Diagnosis Risk for injury r/t uncontrolled
    movements during seizure, falls
  • Outcome Patient has no injury in the next 8
    hours
  • Nursing Intervention
  • 1. Protect from injury. Clear the area of
    furniture or other objects that may cause injury
  • 2. Avoid moving or restraining patient during
    a seizure to prevent bone or soft tissue injury
  • 3. Assess for trauma to mouth, cheek,
    tongue, lips abrasions, bruises broken bones
    burns because these injuries may occur during
    seizure activity
  • Lewis, Heitkemper Dirksen

49
Nursing Diagnosis
  • Diagnosis Ineffective breathing pattern r/t
    neuromuscular impairment secondary to prolonged
    tonic phase of seizure or during postictal period
    AEB abnormal respiratory rate, rhythm or depth.
  • Outcome patient will have appropriate rate,
    rhythm and depth of respirations in the next 8
    hours
  • Nursing Intervention
  • 1. Loosen constricting clothing to avoid
    restricting breathing
  • 2. Turn the person to the side if patient
    has vomiting to prevent aspiration
  • 3. Position the head to prevent the tongue
    from blocking the airway
  • 4. Provide oxygen when necessary to prevent
    hypoxia
  • 5. Assess breathing pattern, observing for
    labored respiration, tachypnea, bradypnea,
    dyspnea, and apnea to determine presence and
    extent of problem and to initiate appropriate
    interventions
  • (Lewis et al ,2007)

50
Nursing Diagnosis
  • Diagnosis Risk for injury r/t uncontrolled
    movements during seizure, falls
  • Outcome Patient has no injury in the next 8
    hours
  • Nursing Intervention
  • 1. Protect from injury. Clear the area of
    furniture or other objects that may cause injury
  • 2. Avoid moving or restraining patient during
    a seizure to prevent bone or soft tissue injury
  • 3. Assess for trauma to mouth, cheek,
    tongue, lips abrasions, bruises broken bones
    burns because these injuries may occur during
    seizure activity
  • (Lewis et al ,2007)

51
Nursing Diagnosis
  • Diagnosis Ineffective therapeutic regimen
    management r/t lack of knowledge about management
    of seizure disorder AEB verbalization of lack of
    knowledge, inaccurate perception of health
    status, noncompliance with prescribed heath
    behavior
  • Outcome Patient will have therapeutic drug level
    of antiseizure medication and be compliance with
    therapeutic regimen in one week
  • Nursing Intervention
  • 1. Providing teaching to patient and family
    about seizure activity and therapeutic management
    including diagnosis, treatment, lifestyle, and
    community resources so that patient and family
    can make necessary lifestyle modifications to
    manage a chronic disease.
  • Lewis, Heitkemper Dirksen

52
Nursing Diagnosis
  • Knowledge deficit r/t seizures, nerological
    impairment and childcare AEB husbands fear of
    allowing J.G to care for child.

53
Interventions
  • Assist J.G./Husband to create a Safe Parenting
    Plan
  • Use creditable web resoruce to increse
    prepairedness
  • Work with J.G./Husband to develop a system to
    ensure compliance with medications
  • Consult with PT/OT to adapt environment as needed.

54
Outcomes
  • For J.G. not to exibit signs that pose risk to
    her or her baby and do notfoster distrust of
    capibilitys form husband
  • For J.G. to remain seizure free for next year
  • For J.G. to continue with PT until ability
    reaches plataeu state
  • For J.G and husband to develop a Safe Parenting
    Plan (Rousseau, 2008)

55
Nursing Diagnosis
  • Ineffective coping r/t perceived loss of control
    and denial of diagnosis
  • Social isolation r/t unpredictability of
    seizures, community-imposed stigma
  • Risk for disturbed thought process r/t effects of
    anticonvulsant medications
  • Ackley Ladwig

56
References
  • Stevens-Johnson-Syndrome http//www.mayoclinic.com
    /health/stevens-johnson-yndrome/DS00940/DSECTION2
    updated Feb 8, 2008 Accessed 5/10/08
  • Kossoff, E. 2008 Do ketogenic diets work for
    adults with epilepsy? Yes!
  • Barborka CJ. Epilepsy in adults results of
    treatment by ketogenic diet in one hundred cases.
    Arch Neurol 19306904-914.
  • Vining EPG, Freeman JM, Ballaban-Gil K, et. al. A
    multicenter study of the efficacy of the
    ketogenic diet. Arch Neurol 1998551433-1437.
  • TEMLOCK, A 2002. THE KEY INTO KETOGENIC DIETS.
    http//www.vanderbilt.edu/ans/psychology/health_ps
    ychology/ketogenic_diets.htm Accessed 5-10-08
  •  Axon, M. 2007 Epilepsy, learning disabilities
    and the nurse prescriber Nurse Prescribing 511,
    481-484. 2007.
  • Shafer, P.O. Schachter S. C., SEIZURES AND
    TEENSUsing Technology to Develop Seizure
    Preparedness. 66 November 2007 EP MAGAZINE/
    www.eparent.com Accessed 5/10/08
  • Eskandar E. N Epilepsy Surgery for Tumors,
    Vascular Malformations, Trauma and
    Cerebrovascular Disease. Http//neurosurgery.mgh.h
    arvard.edu/functional/EpilepsySurgery.htm. May
    11, 2005 Accessed 5/10/2008
  • http//www.ilae-epilepsy.org/
  • Cavazos, J.E Lum,F. Spitz, M . Seizures and
    Epilepsy Overview and Classification
    http//www.emedicine.com/neuro/TOPIC415.HTM.
    updated Nov 30, 2007 accessed 5/10/2008.
  • Lewis, S.L., Heirkemper, M.m., Dirkson, S.R.,
    Obrain, P.G., Bucher, L. (2007) Medical-surgical
    Nursing, Assessment and Management of Clinical
    Problems. Mosby 2007.
  • http//www.nlm.nih.gov/medlineplus/ency/article/00
    0695.htm
  • http//professionals.epilepsy.com/page/managing_lo
    ra.html
  • http//www.aafp.org/afp/20030801/469.html
  • http//en.wikipedia.org/wiki/Lorazepam
  • http//www.drugs.com/cdi/succinylcholine.html
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