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Managing Students with Seizures

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Title: Managing Students with Seizures


1
Managing Students with Seizures
  • Recognizing Seizure and Their Impact
  • Current Treatment Options
  • Seizure First Aid
  • Seizure Action Plans
  • Training Teachers Other School Personnel

2
Role of School Nurse
  • Recognize seizure activity and its impact on
    students
  • Train teachers and other personnel to recognize
    and manage seizures
  • Help create an environment in which the child
    continues to achieve educational goals
  • Coordinate with student, parents, the school, and
    the healthcare team.







3
Where it all begins
  • Recognizing
  • Observing
  • Documenting
  • This can be challenging symptoms are often
  • Subtle
  • Difficult to detect
  • Occur without warning
  • Confused with other behavioral or psychological
    problems



4
What is Epilepsy?
  • A disorder characterized by the tendency to have
    recurrent unprovoked seizures
  • Recurrent 2 or more
  • Epilepsy is also called a
  • SEIZURE DISORDER

5
Epilepsy is a Common Problem
  • About 2.7 million Americans have epilepsy
  • Affects more than 315,000 students in the United
    States
  • More than 45,000 new cases are diagnosed annually
    in students
  • 1 in 100 people develop epilepsy
  • 1 in 10 will have a seizure in their lifetime
  • Epilepsy is more common than Cerebral Palsy,
    Multiple Sclerosis and Parkinsons disease
    combined.

6
What Causes Epilepsy?
  • For approximately 70 of students who are
    diagnosed with epilepsy the cause is either
  • Cryptogenic (of unknown cause) or
  • Idiopathic (presumed to be genetic)
  • For the remaining 30, the causes are generally
    the same as those for symptomatic seizures

7
Causes of Symptomatic Seizures
  • Brain trauma
  • Brain lesions (i.e. tubers)
  • Poisoning
  • Infections of the brain (i.e. meningitis,
    encephalitis, measles)
  • High fever
  • Brain injury at birth
  • Congenital malformations

8
Risk Factors for Childhood Onset Epilepsy
  • Seizures at an early age (starting before age 1
    is highest)
  • Prior provoked seizures
  • Neurodevelopmental delays
  • Mental retardation and cerebral palsy

9
Students with Epilepsy
  • Students often outgrow epilepsy and are seizure-
    free as adults
  • Majority of seizures are not emergencies but a
    part of daily life
  • Some students have more than one type of seizure
  • Many students have complete or almost complete
    seizure control when they take medication as
    prescribed

10
Seizure Triggers and Precipitants
  • Flashing lights and hyperventilation can trigger
    seizures in some
  • students with epilepsy
  • Factors that might increase the likelihood of a
    seizure in a student with
  • epilepsy include
  • Missed or late medication (1 reason)
  • Stress/anxiety
  • Lack of sleep/fatigue
  • Hormonal changes
  • ETOH or recreational drugs
  • Drug interactions
  • Overheating/overexertion
  • Poor diet/missed meals

11
Seizure Classification
  • Generalized Seizures
  • Involves whole brain
  • Convulsions, staring, muscle spasms,
  • and falls
  • Most common are absence tonic-clonic
  • Partial Seizures (focal)
  • Involves only part of brain
  • Simple complex forms
  • Symptoms relate to the part of the brain
    effected

12
Tonic-Clonic Seizure
  • A sudden hoarse cry
  • Loss of consciousness
  • A fall
  • Rigidity
  • Convulsions (stiffening of arms and legs followed
    by rhythmic jerking)
  • Shallow breathing and drooling may occur
  • Possible loss of bowel or bladder control
  • Occasionally skin, nails, lips may turn blue
  • Generally lasts 1 to 3 minutes
  • Usually followed by confusion, headache,
    tiredness, soreness, speech difficulty

13
Absence Seizures
  • Pause in activity with blank stare
  • Brief lapse of awareness
  • Possible chewing or blinking motion
  • Usually Lasts 1-10 seconds
  • May be confused with
  • Daydreaming
  • Inattentiveness
  • ADD

14
Simple Partial Seizures
  • Consciousness is not impaired
  • Involuntary movements (isolated twitching of
    arms, face, legs)
  • Sensory symptoms (tingling, weakness, sounds,
    smells, tastes, visual distortions)
  • Psychic symptoms (déjà vu, hallucinations, fear,
    anxiety, a feeling they cant explain)
  • Duration is usually less than 1 minute
  • May be confused with acting out, mystical
    experience, mental illness or psychosomatic
    illness

15
Complex Partial Seizures
  • Altered awareness
  • Blank stare/dazed look
  • AUTOMATISMS (picking at clothes, lip smacking,
    chewing)
  • Nonsensical speech or lip smacking
  • Clumsy or disoriented movements
  • Aimless walking
  • Picking things up
  • Often lasts 1 to 3 minutes
  • Often followed by tiredness, headache or nausea
  • May be confused with
  • Drunkenness or drug abuse
  • Aggressive behavior

16
Secondarily Generalized Seizures
  • Partial seizure spreads to involve entire brain
  • Begins with simple or complex partial seizure
  • May spread rapidly or occur after a typical
    partial seizure
  • Generalized seizure may be
  • Tonic-Clonic
  • Atonic
  • Tonic

17
Intractability in Epilepsy
  • Students with intractable seizures
  • Fail to respond to standard antiepileptic drug
    therapy or other treatment modalities
  • May have underlying structural brain or
    neurological conditions
  • Pose the greatest challenge for the school nurse

18
Status Epilepticus
  • Medically defined as 30 minutes of uninterrupted
    seizure activity and may include
  • one prolonged seizure or
  • multiple seizures without recovery to baseline
  • Is a medical emergency and requires immediate
    action to stop the seizure activity
  • Every students Seizure Action Plan should
    clearly define what constitutes a seizure
    emergency and detail an emergency response plan

19
Non-Epileptic Seizures
  • Events that look like epileptic seizures but on
    EEG monitoring have no correlate
  • Also called psychogenic seizures or
    pseudoseizures
  • Video-EEG monitoring is the most effective way of
    diagnosing
  • Can be caused by a variety of psychological
    factors

20
Factors that Impact the Student with Seizures
  • Affect
  • Learning
  • Behavior
  • Self-concept
  • Stigma
  • Psychosocial development
  • Overall quality of life
  • Factors
  • Seizures
  • Medication side effects
  • Underlying brain abnormalities

21
Impact on Learning
  • Most students with epilepsy have IQs within the
    normal range
  • Risk of learning problems is 3x greater than
    average
  • Students with epilepsy may have difficulty with
    memory, attention and concentration
  • Students may be eligible for special education
    and related services
  • Students who achieve seizure control quickly,
    with few medication side effects, have the best
    chance for normal educational achievement

22
Impact on Psychosocial Development
  • There is an association between seizures/epilepsy
    and the following
  • Impaired self-image/self-confidence
    (Shame/embarrassment)
  • Low self-esteem
  • Anxiety
  • Delayed social development
  • Once seizures are under control, the psychosocial
    impact may outweigh the medical impact.

23
Factors that May Increase the Risk of Learning,
Behavioral and Psychosocial Problems
  • Early age of onset
  • Multiple lifetime seizures
  • High seizure frequency
  • Seizures in school
  • Memory deficit
  • Slowed motor speed

24
Strategies for Reducing Stigma (1)
  • Incorporate epilepsy education into health
    curricula for all students include seizure
    first aid
  • Appreciate the spectrum of epilepsy hidden
    nature and uniqueness of individual experiences
  • Be aware of cultural differences
  • Support student involvement in extracurricular
    activities
  • Look beyond the seizures assess the impact.
    Coordinate a team approach
  • Help the student and family understand any
    limitations that the doctor may put on the
    student

25
Strategies for Reducing Stigma (2)
  • Educate all school personnel to assist with
    minimizing stigma (myths, first aid, support
    strategies)
  • Prevent bullying and teasing when possible
  • Teach coping strategies for managing life and
    school
  • Help enhance independence address parental
    over-protectiveness if necessary
  • Be a resource. Put the family in contact with the
    Epilepsy Foundation affiliate and any other
    resource that may be helpful

26
When to Refer to an Epileptologist?
  • Uncontrolled seizures and status epilepticus
  • When not already under the care of a specialist
  • Significant mood and anxiety disturbances
  • Major memory and learning deficits
  • Sudden change in seizure type
  • Signs of medication toxicity or allergy

27
Show DVD
  • Seizure Disorders and the School

28
Treatment Options
  • Antiepileptic Drugs (AEDs)
  • PRN medications (acute seizures and seizure
    emergencies)
  • Surgery
  • Ketogenic Diet
  • Vagus Nerve Stimulation (VNS) Therapy

29
Effectiveness of Antiepileptic Drugs (AEDs)
  • Before 1993, drug choices for epilepsy were
    limited
  • Since 1993, many new products have been
    introduced
  • More than 50 of those with newly-diagnosed
    epilepsy become seizure free on medication
  • About 75 of those with epilepsy have seizures
    that are well-controlled by medication

30
Medications (newer drugs)
  • Felbatol (felbamate)
  • Gabatril (tiagabine)
  • Keppra (levetiracetam)
  • Lamictal (lamotrigine)
  • Neurontin (gabapentin)
  • Trileptal (oxcarbazepine)
  • Topamax (topiramate)
  • Zonegran (zonisamide)
  • Lyrica (pregabalin)

31
Side Effects of AEDs Overview
  • AED side effects can be unpredictable. Some are
    dose dependent, while others occur regardless of
    dose
  • Newer medications generally have fewer cognitive
    side effects
  • Long term effects are unclear, but even mild side
    effects can have a significant impact
  • Behavior and mood changes from AEDs are often
    difficult to sort out and are not necessarily
    dose-related

32
Common AED Side Effects
  • Dose-related/toxic
  • Diplopia, blurry vision
  • Dizziness, lightheadedness
  • Sedation
  • Slowed thinking
  • Feels drunk
  • Coordination problems
  • Unsteady walking
  • Drug-related
  • Cognitive problems
  • Fatigue
  • Weight gain or loss
  • Cosmetic acne, excessive hairiness or hair loss
  • Hyperactivity, slowed movements
  • Personality changes
  • Mood changes, depression

33
Drug Reaction Warning Signs
  • Rash
  • Prolonged fever
  • Severe sore throat
  • Mouth ulcers
  • Easy bruising
  • Weakness
  • Excessive fatigue
  • Swollen glands
  • Lack of appetite
  • Increased seizures
  • THESE ARE SERIOUS BUT NOT COMMON!

Contact Childs Healthcare Provider
34
Surgery for Seizures
  • Considered after failing AED therapy
  • Surgical evaluation includes inpatient video/EEG
    monitoring
  • Other tests may include MRI, SPECT scan, PET
    scan, and neuropsychological testing
  • Procedures include focal resection, temporal
    lobectomy, lesionectomy, hemispherectomy and
    corpus callosotomy
  • Post-surgical seizure-free rates vary
  • Patients usually go home after a short stay at
    the hospital and will likely miss several weeks
    or months of school

35
Transient Surgical Side Effects
  • Headaches
  • Dizziness and unsteadiness
  • Aching jaw
  • Swelling or bruising of head and face
  • Blurred vision
  • Depression or mood changes, which are usually
    temporary
  • Sensation changes, especially numbness around the
    operation site

36
Ketogenic Diet
  • Introduced in the 1920s as a treatment for
    intractable seizures
  • Produces ketotic state using diet high in fat and
    low in protein and carbohydrates
  • Used mostly with children
  • Effective for all seizure types
  • May require 2 to 3 days fasting followed by
    strict diet
  • Compliance may be problematic
  • Side effects can include renal calculi, weight
    loss, cardiomyeopathy and blood abnormalities
  • Researchers still dont know exactly how it works

37
Vagus Nerve Stimulation (VNS) Therapy
  • A programmable pulse generator implanted
    subcutaneously in upper left chest
  • Electrode wrapped around the left vagus nerve
  • Exact mechanism of action not known
  • Side effects may include hoarseness, coughing and
    shortness of breath and occur during stimulation
    only

38
VNS Magnet Use
  • Typically worn on wrist or belt
  • If the student has a seizure warning sign (aura)
    he/she or a trained observer may swipe the
    magnet over the VNS device to activate it and
    help abort a seizure
  • Magnet may be swiped during an actual seizure to
    shorten seizure length
  • Magnet may be used as often as needed with at
    least a minute between swipes
  • For a free video and more information visit
    www.vnstherapy.com

39
PRN Medications for Seizures
  • Sometimes AEDs are prescribed for students who
    tend to have seizure clusters or status
    epilepticus. Two of these include
  • Lorazepam
  • Diazepam rectal gel

40
Diazepam Rectal Gel Administration in Schools
  • Approved by the FDA for treatment of prolonged
    and clustered seizures
  • Approved by the FDA for use by family members and
    other non-medical caregivers
  • Often referred to as a seizure rescue
    medication
  • Primary concerns expressed by other school nurses
    include privacy, ability to assess when to
    administer, and respiratory depression
  • Despite concerns, respiratory depression is NOT a
    common side effect!

41
Diazepam Rectal Gel Administration in Schools
(continued)
  • State nurse practice acts and local school
    districts may have specific regulations regarding
    administration
  • If prescribed by a physician, regulations and
    impact on the student must be discussed with
    parents to come to a workable solution
  • For more information and a free video on the
    administration of diazepam rectal gel, visit
    www.diastat.com

42
Delegation Issues Laws and Mandates
  • Applicable Federal laws or mandates that may
    impact
  • delegation include
  • Section 504 of the Rehabilitation Act of 1973
  • Americans with Disabilities Act (ADA)
  • Individuals with Disabilities in Education Act
    (IDEA)
  • Local and state laws, such as nurse practice acts
    and
  • school district policies, generally govern
    the administration
  • of medications in schools
  • What do the regulations in your state or school
    district say
  • about the delegation of medication
    administration?

43
Tips for Effectively Managing Delegation
  • Know state nurse practice act and school district
    policies
  • Bring parents and school personnel together to
    attempt to find a workable solution
  • Explain to all parties that you are obligated to
    put the health, safety and welfare of the student
    first
  • Know applicable state and federal mandates and
    laws

44
More Tips for Effectively Managing Delegation
  • When a school nurse delegates a task under
    his/her nursing license the nurse is responsible
    for the following
  • Insuring that the delegate is appropriate
  • Providing training and ongoing assessment and
    documentation of the competence of a delegate
  • Ongoing assessment of the student's health
    outcome

45
Routine First Aid Care and Comfort
  • Most seizures are not medical emergencies
  • Basic first aid has many common elements, but
    varies depending whether there is
  • No change in consciousness
  • Altered awareness
  • Loss of consciousness

46
No change in Consciousness (Simple Partial
Seizure)
  • Stay calm
  • Time seizure
  • Reassure student that he or she is safe
  • Explain to others if necessary
  • Protect students privacy

47
Altered Awareness (Complex Partial Seizure)
  • Speak softly and calmly
  • Guide away from potentially harmful objects such
    as tables, chairs and doors
  • Allow for wandering in a contained area
  • If lasts 5 minutes beyond what is routine for
    that student or another seizure begins before
    full awareness is regained, follow emergency
    protocol
  • DO NOT restrain or grab (may result in
    combativeness)
  • DO NOT shout or expect verbal instructions to be
    obeyed

48
Loss of Consciousness (Generalized Tonic-Clonic
Seizure)
  • Protect from potentially harmful objects
  • Observe and time events
  • Ensure airway is unobstructed
  • Cushion and protect head
  • Turn student on one side
  • Remain with student until fully conscious
  • Follow the students Seizure Action Plan
  • DO NOT put anything in mouth
  • DO NOT restrain

49
When is a Seizure an Emergency?
  • First time seizure
  • Convulsive seizure lasting more than 5 minutes
  • Repeated seizures without regaining consciousness
  • More seizures than usual or change in type
  • Student has diabetes or is pregnant
  • Seizure occurs in water
  • Student is injured
  • Parents request emergency evaluation
  • Follow the seizure emergency definition and
    protocol as defined by healthcare provider and
    included in the Seizure Action Plan

50
Use of PRN Medications
  • Prescribed for seizure clusters and prolonged
    seizures
  • Emergency protocol should include
  • Medication name
  • Details about exactly when it should be given
  • Specific administration instructions
  • Monitor responses and side effects
  • Follow Seizure Action Plan emergency response
    protocol

51
Tonic-Clonic Seizure in a Wheelchair
  • Do not remove from wheelchair unless absolutely
    necessary
  • Secure wheelchair to prevent movement
  • Fasten seatbelt (loosely) to prevent student from
    falling from wheelchair
  • Protect and support head
  • Ensure breathing is unobstructed and allow
    secretions to flow from mouth
  • Pad wheelchair to prevent injuries to limbs
  • Follow relevant seizure first aid protocol

52
Tonic-Clonic Seizure on a School Bus
  • Safely pull over and stop bus
  • Place the student on one side across seat facing
    away from the seat back (or in the aisle if
    necessary)
  • Follow standard seizure first aid protocol until
    the seizure abates and child regains
    consciousness
  • Continue to the destination or follow school
    policy

53
Tonic-Clonic Seizure in Water
  • Support head so that both the mouth and nose are
    always above the water
  • Remove the student from the water as soon as it
    can be done safely
  • If the student is not breathing, begin rescue
    breathing
  • Always transport the child to the emergency room
    even if he/she appears fully recovered

54
Seizure Action Planning
  • Assess student needs and gather information
  • Customize a Seizure Action Plan
  • Teach school personnel and tailor interventions
    as needed

55
Questionnaire for Parent of a Student with
Seizures
  • Can be difficult to get parent(s) to complete
    this form and may take persistence
  • May require you to interview the parent(s) to
    clarify information
  • Update annually or when any changes occur
  • Seizure Observation Record
  • To be completed by school personnel when
    reporting a seizure(s)
  • Helps to identify seizure triggers, patterns
    precautions

56
Seizure Observation Record
  • To be completed by school personnel when
    reporting a seizure(s)
  • Helps to identify seizure triggers, patterns and
    precautions

57
Seizure Action Plan
  • To be completed by the school nurse
  • Provides basic information about students
    seizures, seizure first aid and emergency
    response
  • Distribute to relevant school personnel at the
    beginning of a school year, when a diagnosis is
    made or when a change in health status occurs
  • Should generally be signed and approved by the
    treating physician

58
Assessment Information Gathering
  • Have parent or guardian complete and sign a
    Parent Questionnaire
  • Gather seizure history and treatment information
  • Speak with the students medical team to clarify
    treatment and emergency response protocol
  • Observe and document any in-school seizures
  • Speak with teachers and other school personnel
    about
  • Possible seizure precipitants (triggers)
  • Observed or perceived impact on learning and
    behavior

59
Assessment Information Gathering contd
  • Consider transportation issues
  • Complete a school safety assessment
  • Identify activities that may need to be modified
    or necessitate special precautions
  • Some students may need a safety helmet
  • Determine best method to communicate with parents
    and medical team

60
Communication Tips
  • Set up a log for communicating with
    parents/guardians on a daily or weekly basis
  • Be a liaison for parents and teachers regarding
    any status changes
  • Have teachers regularly note physical, emotional
    or cognitive changes
  • Create a substitute teacher folder with the
    Seizure Action Plan and other relevant
    information and keep this folder in a secure
    location

61
Training School Personnel is Important
  • Helps enlist the full cooperation of school
    personnel
  • Optimizes ability to manage seizures and
    consequences
  • Helps insure full integration of the student in
    school activities
  • Minimizes stigma

62
Goal of Training for School Personnel
  • School personnel should be able to
  • Recognize seizures and consequences
  • Provide appropriate first aid
  • Recognize when a seizure is a medical emergency
  • Provide appropriate social and academic support
  • Understand the Seizure Action Plan

63
Essential Training Topics
  • What is a seizure? What is epilepsy?
  • Who has epilepsy?
  • What do seizures look like?
  • What are common myths about epilepsy?
  • What is appropriate first aid for seizures?
  • When is a seizure an emergency?
  • What causes seizures?

64
More Essential Training Topics
  • What are common seizure triggers?
  • What can be done to prevent stigma?
  • What is a Seizure Action Plan? How is it best
    used?

65
Optional Topics to Consider as Appropriate
  • Seizures outside the classroom (playground, field
    trips, etc.)
  • Seizures in a wheelchair
  • Seizures on a school bus
  • Seizures in the water
  • Special issues in treatment
  • Use of the Ketogenic diet
  • Use of the vagus nerve stimulator magnet
  • Use of rescue medication, including rectal
    diazepam

66
Resources
  • Seizure Training for School Personnel Toolkit
  • Brochures, videos, pamphlets, fact sheets,
    posters
  • Seizures and You Take Charge of the Facts. (An
    Epilepsy Awareness Program for Teens)
  • Managing Students with Seizures A Quick
    Reference Guide for School Nurses
  • To review the product catalogue online, go to
    www.epilepsyfoundation.org and visit the Epilepsy
    Foundations Marketplace
  • Materials may be ordered through the local
    Epilepsy Foundation affiliate sponsoring this
    program or by calling 1 (866) 330-2718

67
www.epilepsyfoundation.org/schoolnurse
  • Seizure Action Planning forms (customizable)
  • Downloadable fact sheets on key subjects of
    interest to school nurses
  • Links to other useful Websites
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