logging in or signing up Seizures.Audio.2010 tom.oertel Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 572 Category: Education License: All Rights Reserved Like it (5) Dislike it (0) Added: September 15, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: marcybmoreno (1 month(s) ago) I would like to use your presentation to educate our teachers at my school. Email: morenom@ccisd.com Saving..... Post Reply Close Saving..... Edit Comment Close By: Darlafabe (10 month(s) ago) Oh man, I just noticed that the audio is not working on this PP. I will let you know if there are others. Lilia SN Saving..... Post Reply Close Saving..... Edit Comment Close By: Darlafabe (10 month(s) ago) Good PP as always, informative! Saving..... Post Reply Close Saving..... Edit Comment Close By: aedsa2004 (14 month(s) ago) Can I please have a copy of this ppt? Saving..... Post Reply Close Saving..... Edit Comment Close By: ashokanarayanan (19 month(s) ago) Can I please have a copy of this ppt? It would be of immense help to me for presenting a case. Your help is highly appreciated. Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: Seizure Disorders and Nursing Care Thomas Oertel, DNP, RN NURS 203 Definition of a seizure : Definition of a seizure "excessive, uncontrolled, paroxysmal, local discharge of a group of cerebral neurons, usually in the cortex." "Paroxysmal disorders of the nervous system that result in recurrent attacks of loss of consciousness or other types of seizures in which convulsive movements or other motor activity, sensory phenomenon or behavioral abnormalities may occur." Definition of a seizure : Definition of a seizure "Any phenomenon involving abnormal motor, sensory, or psychic activity that has an abrupt onset, short course, and is followed by a return to normal.“ (from different locations in brain) “Does my child have epilepsy?”Seizure versus epilepsy : “Does my child have epilepsy?”Seizure versus epilepsy Having a seizure does NOT necessarily mean epilepsy – there are many causes of seizures Some common causes: high fevers, electrolyte imbalances (e.g. hyponatremia), brain trauma, brain tumors, CVA – some are reversible Less than one in three children who had a febrile seizure will have another seizure Does my child have epilepsy? Seizure versus epilepsy : Does my child have epilepsy? Seizure versus epilepsy Epilepsy is a seizure disorder from an abnormal focus in the brain – different from other causes 50% have idiopathic epilepsy, i.e. no known cause Seizure as a first sign of underlying pathology : Seizure as a first sign of underlying pathology Often, the presenting sign of an intracerebral problem, e.g. a brain tumor, CVA or intracranial bleeding. Types of seizures: focal/partial versus generalizedPartial/elementary seizures – localized to a certain part of the brain without loss of consciousness Generalized: involves the whole brain with loss of consciousness : Types of seizures: focal/partial versus generalizedPartial/elementary seizures – localized to a certain part of the brain without loss of consciousness Generalized: involves the whole brain with loss of consciousness Partial/elementary seizures – localized to a certain part of the brain without loss of consciousness. : Partial/elementary seizures – localized to a certain part of the brain without loss of consciousness. a. signs and symptoms of simple, partial seizure: signs/symptoms related to that part of the brain, e.g. hearing, taste, smell, motor (isolated and localized; affecting one hand, one foot, or the face). Relates to the part of the brain that is affected. See next slide. b. Jacksonian seizures: begins in one area then “marchs” up an extremity which can then affect the brain with a full generalized seizure. All partials can possibly become generalized to full seizures. Partial/elementary seizures – examples : Partial/elementary seizures – examples a. signs and symptoms of simple, partial seizure: signs/symptoms related to that part of the brain, e.g. hearing, taste, smell, motor (isolated and localized; affecting one hand, one foot, or the face). b. Jacksonian seizures: begins in one area then “marchs” up an extremity which can then affect the brain with a full generalized seizure. All partials can possibly become generalized to full seizures. Partial/elementary seizures – Jacksonian Seizure : Partial/elementary seizures – Jacksonian Seizure Jacksonian seizures: begins in one area then “marchs” up an extremity which can then affect the brain with a full generalized seizure (tonic-clonic seizure). All partials can possibly become generalized to full seizures. Named after Andrew Jackson, the President Partial/complex seizures (temporal lobe/psychomotor seizures)A variety of signs/symptoms from the temporal lobe but usually out of touch with reality : Partial/complex seizures (temporal lobe/psychomotor seizures)A variety of signs/symptoms from the temporal lobe but usually out of touch with reality Partial/complex seizures (temporal lobe/psychomotor seizures) : Partial/complex seizures (temporal lobe/psychomotor seizures) A scary variation of the temporal lobe seizure: known as the “running fits.” b. signs and symptoms: pt begins screaming, restless, fleeing, fidgeting, but the pt is not aware of his activities or his environment. c. Actions are NOT directed towards others, not voluntary. can a partial seizures ever become a generalized (full body) seizure?? : can a partial seizures ever become a generalized (full body) seizure?? Yes. Any partial/focal seizure can proceed across the cortex and become secondarily generalized (with grand mal seizure). Generalized seizures – many typesall characterized by loss of consciousness : Generalized seizures – many typesall characterized by loss of consciousness Absence (petit mal): with and without automatisms : Absence (petit mal): with and without automatisms loss of consciousness without other visible changes, out of touch with reality. Often assumed that the person/child is “not paying attention” or “daydreaming” or staring automatisms = eyelid fluttering, chewing, lips smacking or swallowing May occur hundreds of times per day with long term cognitive changes. (Petit mal status epilepticus) Often followed by confusion Absence (petit mal) : Absence (petit mal) Other Generalized Seizures : Other Generalized Seizures myoclonic: quick jerking of arms or legs with loss of consciousness lasting a few seconds [easily missed] atonic: sudden total loss of muscle control with loss of consciousness – pt falls to the floor or has LOC behind the wheel of the car! Tonic-Clonic, “Grand Mal” Seizure : Tonic-Clonic, “Grand Mal” Seizure Electrical discharge throughout the brain affecting all cortical and motor functions Prodromal phase and aura; and what to ask pt: The time before a seizure is the prodromal phase. pt may have a warning sign an impending seizure minutes to hours; this is an aura. Auras have many forms: flashing lights, “pins and needles,” headaches, or a stomach ache, minutes or hours before the Sz. If the pt says he is having an aura, take immediate steps to protect the pt [ lie pt down and protect from harm onset of "grand mal" seizure and "epileptic cry” : onset of "grand mal" seizure and "epileptic cry” First Phase is usually tonic = full body rigidity where every voluntary muscle becomes rigid [including the arms, legs, abdomen, and diaphragm]. With tensing of the jaws, the pt can bite/lacerate the tongue, cheek, or anything else in the way [pencils, your finger!] [ABC problem] With tensing of the diaphragm and intercostals, there may be an “epileptic cry” [demonstration] and there is no effective inhalation apnea [ABC problem] With tensing of the abdomen, induces vomiting and involuntary defecation/urination. Urinary or fecal incontinence is a positive sign of the grand mal seizure. [very embarrassing: provide privacy] don't restrain patient! Don’t force anything into the person’s mouth! Onset of "grand mal“ seizures: Phases clonic = rapid jerking with possible trauma to head, back, and extremities; usually progresses from tonic phase to alternating tonic and clonic activitythere is no effective inhalation apnea [ABC problem] : Onset of "grand mal“ seizures: Phases clonic = rapid jerking with possible trauma to head, back, and extremities; usually progresses from tonic phase to alternating tonic and clonic activitythere is no effective inhalation apnea [ABC problem] Onset of "grand mal“ seizures: Phases post-ictal phase: characteristics and complications. The neurons have totally depolarized and exhausted with total relaxation of the body. Tongue may occlude airway or apnea may continue. Be prepared to ventilate and suctions when the jaws relax : Onset of "grand mal“ seizures: Phases post-ictal phase: characteristics and complications. The neurons have totally depolarized and exhausted with total relaxation of the body. Tongue may occlude airway or apnea may continue. Be prepared to ventilate and suctions when the jaws relax treatment of grand mal seizure and priorities of care/protection of pt : treatment of grand mal seizure and priorities of care/protection of pt knowing the complications and treatment of grand mal seizures, what are "seizure precautions"? When should they be instituted? “Seizure precautions" : “Seizure precautions" if a seizure may occur, e.g. pt has aura or pt has a recent history of seizures, stay with the pt or check often pad the side-rails bed in low position suction and airway equipment at the bedside saline lock in place instruct pt/family to call if the pt has an aura or feels a seizure coming have Valium or Ativan available [tongue blade = if you how/when to use it!]: prior to Sz so pt will not bite/lacerate tongue and cheeks lie the pt flat and on one side (“rescue position”) remove dentures if possible Treatment during a Seizure : Treatment during a Seizure DO NOT put anything in the mouth once the seizure has started! Could force foreign objects down airway or cause more damage! [no tongue blades, pens, fingers, etc.] lie the pt flat and on one side protect from harm, esp the head – move objects away DO NOT RESTRAIN THE PT! Fractures may occur. Suction airway through mouth or nose, as needed. Give Oxygen to elderly or respiratory pts Provide reassurance to the family and stay calm Assess and document the characteristics of the seizure: see Nursing Observations Chart (where did it start? Aura?) REMEMBER: the great majority of seizures are self-limiting [about 3 minutes] – so protect the pt and airway till it stops Post-ictal phase: characteristics and complications : Post-ictal phase: characteristics and complications The neurons have totally depolarized and exhausted with total relaxation of the body. Tongue may occlude airway or apnea may continue. Be prepared to ventilate and suctions when the jaws relax As the pt becomes more conscious, restlessness and confusion may occur, lasting minutes to hours. Realize that the pt doesn’t understands what occurred. Post-ictal confusion is to be expected! Reassure him that all is OK and that he had a seizure. Provide a non-threatening atmosphere. Be prepared for suspicious/agitated behavior and may want to pace. Have one person interact with the pt in a calm manner [family present?} and gently direct him to rest or pace in small area. DO NOT RESTRAIN Encourage sleep Provide privacy r/t incontinence Take vital signs Observe for signs of another seizure Call 911/get help Don’t allow the pt to drive! Nursing Assessment for SeizuresSee Table in Study Guide : Nursing Assessment for SeizuresSee Table in Study Guide • any warning sign or aura? • where did the seizure begin and how did it proceed? (if the seizure was witnessed) • what types of movement was noted and what body parts were involved? • did the eyes deviate and to which side? any change in pupil size? • was there urinary or bowel incontinence? • what was the duration of the entire seizure and of each phase? • was the pt unconscious throughout the seizure? • what was the behavior of the pt after the seizure? • was there any residual weakness or paralysis of the extremities after the seizure? • did the pt sleep after the seizure? Nursing Assessment for SeizuresSee Table in Study Guide : Nursing Assessment for SeizuresSee Table in Study Guide What was the patient’s level of consciousness—if consciousness was lost, at what point? What was the patient doing just before the Seizure? In what part of the body did the seizure start? Was there an epileptic cry? Were any automatisms observed such as eyelid fluttering, chewing, lip smacking, or swallowing? How long did movement last and did the location or character change (tonic to clonic); did movements involve both sides of the body or just one? Did the head and/or eyes turn to one side and, if so, which side? Were there changes in pupillary reaction? If the patient fell, did he hit his head? Was there foaming or frothing from the mouth? Did the lips or face change color? Did the patient bite his tongue or lips? Was there urinary or fecal incontinence? What happened during the post-ictal phase—lethargy, confusion, headache, muscle soreness, speech or comprehension impairment? Were they any motor alterations such as a transient hemiplegia (Todd’s paralysis)? Were the motor alterations asymmetrical? Status epilepticus: a special generalized seizure : Status epilepticus: a special generalized seizure definition of status epilepticus: 1) prolonged seizure activity OR 2) 2 or more seizures without regaining consciousness [therefore: applies to petit mal/absence as well as grand mal Seizures] Why is status epilepticus in grand mal seizures potentially deadly?: : Why is status epilepticus in grand mal seizures potentially deadly?: status epilepticus = ABC problem: Prolonged apnea with lack of oxygen to vital organs, esp. brain and heart [with hypoxemia and acidosis] People die of status epilepticus. Why is status epilepticus in petit mal seizures potentially disabling?: : Why is status epilepticus in petit mal seizures potentially disabling?: Hundreds of seizures per day can cause lack of oxygen to the young brain, with permanent cognitive loss Treatment and rationale of status epilepticus : Treatment and rationale of status epilepticus Break the status epilepticus so the pt can breathe again or so the nurse can ventilate the pt. give IV Valium or IV Ativan. Give enough to stop the seizure! What if the pt does not breathe r/t to hypoxemia and lots of Valium? Ventilate the pt. Diagnosis of Seizures : Diagnosis of Seizures 1. History: the events surrounding the loss of consciousness or abnormal sensations/movements are very important in suspecting a seizure 2. S&S: subjective and objective data 3. EEG (with evoked potentials) or sleep-deprived EEG (no sleep after 2am and fasting - trying to evoke a seizure) 4.Blood studies & CT scan (head) to rule out other causes 5. video monitoring in conjunction with continuous EEG monitoring Treatment of Epilepsy : Treatment of Epilepsy (after ruling out other causes, e.g. cerebral tumor) a. Drug therapy: critical to management, often given in combination if one doesn't work, blood tests for therapeutic levels: common many side-effects. Dilantin (phenytoin) : Dilantin (phenytoin) Family: Hydantoins Indications: Grand mal, psychomotor, focal seizures and following craniotomy (1-2 years; prophylaxis for seizures) Adult dosage: Adults: 100 mg 3 times per day (IV/PO) or 300 mg at HS Therapeutic blood level: 10-22 mg/mL Dilantin by feeding tube: must turn off the tube feeding one hour BEFORE the medication and turn on tube feeding two hours AFTER Dilantin (phenytoin) : Dilantin (phenytoin) I.V. Dilantin: Always in normal saline Complications of I.V. Dilantin: BURNS in the vein: may slow down or with lidocaine in the bag Give slowly to prevent arrhythmia Side-effects Gastric upset: give with meals. Prevent seizures: Dosage should be increased gradually to Gingival hyperplasia: Good oral hygiene and gum Problems in perception and coordination Acne (androgenic effect on hair follicles) and skin odor: skin care Toxic Signs: Nystagmus, ataxia, drowsiness, tremor, nausea, constipation. Carbamazepine (Tegretol) : Carbamazepine (Tegretol) Indications: Tonic-clonic, complex, partial and focal motor; mood stabilizer Dosage: Maximum dose for children over 15 years and adults 1200 mg. Therapeutic blood level: 4-10 g/mL Carbamazepine (Tegretol) : Carbamazepine (Tegretol) Side Effects and Precautions Baseline renal and liver function and hematologic testing should be completed before initiating treatment. Blood counts are monitored weekly for the first 3 months. Instruct clients to withhold this drug and see a physician at the first sign of bone marrow depression, genitourinary problems (frequency, retention), or cardiovascular side effect such as edema, Cyanosis, syncope. Toxic Effects: Diplopia, nausea/vomiting, dizziness, ataxia Primidone (Mysoline) : Primidone (Mysoline) Indications: Used primarily for psychomotor, autonomic, and akinetic seizures Dosage: Adults: 250 mg/day, up to 500 mg qid Therapeutic Blood Level: 5-12 g/mL Toxic Effects: Sedation, ataxia, behavioral changes, GI disturbances. Valproic acid (Depakene) : Valproic acid (Depakene) Indications: Myoclonic seizures; mood stabilizer Dosage: Initially 15 mg per kilogram of body weight per day to a maximum of 30 mg per kilogram of body weight per day; doses should be divided if total in excess of 250 mg/day Therapeutic Blood Level: 50-100 g/mL Side Effects: It should be given with meals or with large amounts of liquids. If client is also receiving phenobarbital or phenytoin, dosages need to be adjusted. Nausea, vomiting, and hepatotoxicity may occur and clients should be given appropriate instructions. Clonazepam (Clonopin) : Clonazepam (Clonopin) Indications: Absence, akinetic, and myoclonic seizures Dosage: Adults: 1.5 mg increased to 20 mg/day in divided doses Therapeutic Blood Level: 20-80 mg/mL Side Effects: Gastric Upset Drowsiness: It is not taken with alcohol or other central nervous system depressants. Hepatotoxicity Toxic Effects: Hyper- and hypoactivity, dizziness, thickened speech, drowsiness, ataxia Nonadherence with medications : Nonadherence with medications List three reasons why nonadherence is so common in pts with seizure disorders 1. Side-effects of medications [drowsiness, gum problems, etc.] Tired of taking medications, “I don’t want to do it any more.” Denial or changes in body image. Cost Others? Patient Education for the Pt with a seizure disorder: How to prevent seizures : Patient Education for the Pt with a seizure disorder: How to prevent seizures a. medications: take the medications! – the most common cause of seizures in the ER! b. good habits and things to avoid – prevent irritation of the brain 1. eat regularly – avoid hypoglycemia 2. don’t drink alcohol 3. enough sleep and rest 4. no stimulants or street drugs 5. modify stressors/emotional upset 6. identify environmental triggers for seizures (e.g. flashing lights, strobe lights, video games with strobe effect 7. call doctor if ill, esp. N/V/D, and can’t take medications Patient Education for the Pt with a seizure disorder: Healthy Habits : Patient Education for the Pt with a seizure disorder: Healthy Habits c. teach family and pt what to do if aura/prodromal signs or seizure occur, about medications, healthy lifestyle d. Medic-Alert bracelet wear it! e. dental care: care of gingival hyperplasia and regular dental exams f. child with seizures and school: teach classmates and teachers how to responds to a seizure Patient Education for the Pt with a seizure disorder: Healthy Habits : Patient Education for the Pt with a seizure disorder: Healthy Habits g. referral to community resources and support groups: Epilepsy Foundation of America h. physical activity: stay active with a positive attitude. Swim with a companion. i. occupational factors: may prevent certain jobs where person could be injured (e.g. working with heavy machinery, being a jet pilot) Surgery: if seizures are intractable to medications : Surgery: if seizures are intractable to medications 1. Good candidate: at least three anticonvulsants have been attempted without success; the seizure focus can be identified 2. Cortical resection/cryotherapy: the seizure focus is frozen 3. Corpus callosum division: very radical, where the connection between the two hemispheres is cut so that the discharge cannot generalize to the whole brain. Sometimes success in very young children. In older children/adults, the brain forms “two personalities.” Vagal nerve stimulation (VNS) : Vagal nerve stimulation (VNS) FDA approved for partial seizures in pts older than 12 years. A “pacemaker” like device is wrapped around the left vagus nerve in the chest/neck. When it senses a seizure discharge, it fires inhibiting the seizure from starting. The action of the VNS probably has NOTHING to do the parasympathetic system, but rather effects on the reticular activating system, limbic system, and other deep structures in the brain. The pt can also activate the stimulator with a magnet if the pt feels the onset of a seizure. It causes few side-effects and complications. Vagal nerve stimulation (VNS) : Vagal nerve stimulation (VNS) Caption: Picture 1. Vagus nerve stimulation. The NeuroCybernetic Prosthesis (NCP) in place in the left chest wall (Image courtesy of Cyberonics Inc) Vagal nerve stimulation (VNS) : Vagal nerve stimulation (VNS) Caption: Picture 2. Vagus nerve stimulation. The NeuroCybernetic Prosthesis (NCP) generator, with the leads that are wrapped around the left vagus nerve. http://my.webmd.com/hw/epilepsy/aa138962.asp Diet Therapy: Ketogenic Diet – Ketosis to prevent seizures in children : Diet Therapy: Ketogenic Diet – Ketosis to prevent seizures in children The ketogenic diet has been around in the medical literature for well over 70 years. It was replaced when the modern anti-convulsants became available, even though it has a very good success rate at controlling seizures. In some cases it is actually better than drugs at controlling seizures. It has a success rate of 75%. Stopping seizures in 50% and further reducing them in 25% of cases. Most kids can stay on the diet two years, get off it and never have another seizure again. The diet works best in children under ten. They are less likely to cheat and young children can maintain ketosis better than adults or older children. The diet mimics the effects of starvation. it has been known for centuries that fasting has a beneficial effects on seizure control (there is a reference to such in the New Testament). Doctors at the Mayo Clinic came up with a way to induce the effects of starvation (fat burning, ketosis and a change in blood Ph levels) by feeding the patient large quantities of fat and limiting protein and carbohydrate. the diet has to be rigidly controlled as any deviation can throw the patient out of ketosis and produce a seizure. http://www.our-kids.org/Archives/Ketogenic_diet_FAQ.html Laws Concerning Epilepsy : Laws Concerning Epilepsy a. notification to DMV of seizure disorder/epilepsy/loss of consciousness with Confidential Morbidity Form – mandatory reporting by physician for any loss of consciousness that is unexplained. Meant to protect the public so pt does not have seizure while driving! b. driving in California, per DMV regulations a driver’s license is granted in all states with evidence of a seizure-free period of 1-3 years, depending on the state medical probation: allows driving and the DMV monitors the driver. Driver must remain seizure-free for 3-6 months. suspension: if the driver’s seizures are not controlled or if the driver does not comply with the terms of the medical probation. revocation: permanently taken away. Done only when the driver’s condition is never likely to be brought under control. Nursing Diagnoses Relevant to the Patient with Seizures/epilepsy : Nursing Diagnoses Relevant to the Patient with Seizures/epilepsy Potential for Injury Ineffective Breathing Pattern Ineffective Therapeutic Regimen Denial, Ineffective You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Seizures.Audio.2010 tom.oertel Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 572 Category: Education License: All Rights Reserved Like it (5) Dislike it (0) Added: September 15, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: marcybmoreno (1 month(s) ago) I would like to use your presentation to educate our teachers at my school. Email: morenom@ccisd.com Saving..... Post Reply Close Saving..... Edit Comment Close By: Darlafabe (10 month(s) ago) Oh man, I just noticed that the audio is not working on this PP. I will let you know if there are others. Lilia SN Saving..... Post Reply Close Saving..... Edit Comment Close By: Darlafabe (10 month(s) ago) Good PP as always, informative! Saving..... Post Reply Close Saving..... Edit Comment Close By: aedsa2004 (14 month(s) ago) Can I please have a copy of this ppt? Saving..... Post Reply Close Saving..... Edit Comment Close By: ashokanarayanan (19 month(s) ago) Can I please have a copy of this ppt? It would be of immense help to me for presenting a case. Your help is highly appreciated. Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: Seizure Disorders and Nursing Care Thomas Oertel, DNP, RN NURS 203 Definition of a seizure : Definition of a seizure "excessive, uncontrolled, paroxysmal, local discharge of a group of cerebral neurons, usually in the cortex." "Paroxysmal disorders of the nervous system that result in recurrent attacks of loss of consciousness or other types of seizures in which convulsive movements or other motor activity, sensory phenomenon or behavioral abnormalities may occur." Definition of a seizure : Definition of a seizure "Any phenomenon involving abnormal motor, sensory, or psychic activity that has an abrupt onset, short course, and is followed by a return to normal.“ (from different locations in brain) “Does my child have epilepsy?”Seizure versus epilepsy : “Does my child have epilepsy?”Seizure versus epilepsy Having a seizure does NOT necessarily mean epilepsy – there are many causes of seizures Some common causes: high fevers, electrolyte imbalances (e.g. hyponatremia), brain trauma, brain tumors, CVA – some are reversible Less than one in three children who had a febrile seizure will have another seizure Does my child have epilepsy? Seizure versus epilepsy : Does my child have epilepsy? Seizure versus epilepsy Epilepsy is a seizure disorder from an abnormal focus in the brain – different from other causes 50% have idiopathic epilepsy, i.e. no known cause Seizure as a first sign of underlying pathology : Seizure as a first sign of underlying pathology Often, the presenting sign of an intracerebral problem, e.g. a brain tumor, CVA or intracranial bleeding. Types of seizures: focal/partial versus generalizedPartial/elementary seizures – localized to a certain part of the brain without loss of consciousness Generalized: involves the whole brain with loss of consciousness : Types of seizures: focal/partial versus generalizedPartial/elementary seizures – localized to a certain part of the brain without loss of consciousness Generalized: involves the whole brain with loss of consciousness Partial/elementary seizures – localized to a certain part of the brain without loss of consciousness. : Partial/elementary seizures – localized to a certain part of the brain without loss of consciousness. a. signs and symptoms of simple, partial seizure: signs/symptoms related to that part of the brain, e.g. hearing, taste, smell, motor (isolated and localized; affecting one hand, one foot, or the face). Relates to the part of the brain that is affected. See next slide. b. Jacksonian seizures: begins in one area then “marchs” up an extremity which can then affect the brain with a full generalized seizure. All partials can possibly become generalized to full seizures. Partial/elementary seizures – examples : Partial/elementary seizures – examples a. signs and symptoms of simple, partial seizure: signs/symptoms related to that part of the brain, e.g. hearing, taste, smell, motor (isolated and localized; affecting one hand, one foot, or the face). b. Jacksonian seizures: begins in one area then “marchs” up an extremity which can then affect the brain with a full generalized seizure. All partials can possibly become generalized to full seizures. Partial/elementary seizures – Jacksonian Seizure : Partial/elementary seizures – Jacksonian Seizure Jacksonian seizures: begins in one area then “marchs” up an extremity which can then affect the brain with a full generalized seizure (tonic-clonic seizure). All partials can possibly become generalized to full seizures. Named after Andrew Jackson, the President Partial/complex seizures (temporal lobe/psychomotor seizures)A variety of signs/symptoms from the temporal lobe but usually out of touch with reality : Partial/complex seizures (temporal lobe/psychomotor seizures)A variety of signs/symptoms from the temporal lobe but usually out of touch with reality Partial/complex seizures (temporal lobe/psychomotor seizures) : Partial/complex seizures (temporal lobe/psychomotor seizures) A scary variation of the temporal lobe seizure: known as the “running fits.” b. signs and symptoms: pt begins screaming, restless, fleeing, fidgeting, but the pt is not aware of his activities or his environment. c. Actions are NOT directed towards others, not voluntary. can a partial seizures ever become a generalized (full body) seizure?? : can a partial seizures ever become a generalized (full body) seizure?? Yes. Any partial/focal seizure can proceed across the cortex and become secondarily generalized (with grand mal seizure). Generalized seizures – many typesall characterized by loss of consciousness : Generalized seizures – many typesall characterized by loss of consciousness Absence (petit mal): with and without automatisms : Absence (petit mal): with and without automatisms loss of consciousness without other visible changes, out of touch with reality. Often assumed that the person/child is “not paying attention” or “daydreaming” or staring automatisms = eyelid fluttering, chewing, lips smacking or swallowing May occur hundreds of times per day with long term cognitive changes. (Petit mal status epilepticus) Often followed by confusion Absence (petit mal) : Absence (petit mal) Other Generalized Seizures : Other Generalized Seizures myoclonic: quick jerking of arms or legs with loss of consciousness lasting a few seconds [easily missed] atonic: sudden total loss of muscle control with loss of consciousness – pt falls to the floor or has LOC behind the wheel of the car! Tonic-Clonic, “Grand Mal” Seizure : Tonic-Clonic, “Grand Mal” Seizure Electrical discharge throughout the brain affecting all cortical and motor functions Prodromal phase and aura; and what to ask pt: The time before a seizure is the prodromal phase. pt may have a warning sign an impending seizure minutes to hours; this is an aura. Auras have many forms: flashing lights, “pins and needles,” headaches, or a stomach ache, minutes or hours before the Sz. If the pt says he is having an aura, take immediate steps to protect the pt [ lie pt down and protect from harm onset of "grand mal" seizure and "epileptic cry” : onset of "grand mal" seizure and "epileptic cry” First Phase is usually tonic = full body rigidity where every voluntary muscle becomes rigid [including the arms, legs, abdomen, and diaphragm]. With tensing of the jaws, the pt can bite/lacerate the tongue, cheek, or anything else in the way [pencils, your finger!] [ABC problem] With tensing of the diaphragm and intercostals, there may be an “epileptic cry” [demonstration] and there is no effective inhalation apnea [ABC problem] With tensing of the abdomen, induces vomiting and involuntary defecation/urination. Urinary or fecal incontinence is a positive sign of the grand mal seizure. [very embarrassing: provide privacy] don't restrain patient! Don’t force anything into the person’s mouth! Onset of "grand mal“ seizures: Phases clonic = rapid jerking with possible trauma to head, back, and extremities; usually progresses from tonic phase to alternating tonic and clonic activitythere is no effective inhalation apnea [ABC problem] : Onset of "grand mal“ seizures: Phases clonic = rapid jerking with possible trauma to head, back, and extremities; usually progresses from tonic phase to alternating tonic and clonic activitythere is no effective inhalation apnea [ABC problem] Onset of "grand mal“ seizures: Phases post-ictal phase: characteristics and complications. The neurons have totally depolarized and exhausted with total relaxation of the body. Tongue may occlude airway or apnea may continue. Be prepared to ventilate and suctions when the jaws relax : Onset of "grand mal“ seizures: Phases post-ictal phase: characteristics and complications. The neurons have totally depolarized and exhausted with total relaxation of the body. Tongue may occlude airway or apnea may continue. Be prepared to ventilate and suctions when the jaws relax treatment of grand mal seizure and priorities of care/protection of pt : treatment of grand mal seizure and priorities of care/protection of pt knowing the complications and treatment of grand mal seizures, what are "seizure precautions"? When should they be instituted? “Seizure precautions" : “Seizure precautions" if a seizure may occur, e.g. pt has aura or pt has a recent history of seizures, stay with the pt or check often pad the side-rails bed in low position suction and airway equipment at the bedside saline lock in place instruct pt/family to call if the pt has an aura or feels a seizure coming have Valium or Ativan available [tongue blade = if you how/when to use it!]: prior to Sz so pt will not bite/lacerate tongue and cheeks lie the pt flat and on one side (“rescue position”) remove dentures if possible Treatment during a Seizure : Treatment during a Seizure DO NOT put anything in the mouth once the seizure has started! Could force foreign objects down airway or cause more damage! [no tongue blades, pens, fingers, etc.] lie the pt flat and on one side protect from harm, esp the head – move objects away DO NOT RESTRAIN THE PT! Fractures may occur. Suction airway through mouth or nose, as needed. Give Oxygen to elderly or respiratory pts Provide reassurance to the family and stay calm Assess and document the characteristics of the seizure: see Nursing Observations Chart (where did it start? Aura?) REMEMBER: the great majority of seizures are self-limiting [about 3 minutes] – so protect the pt and airway till it stops Post-ictal phase: characteristics and complications : Post-ictal phase: characteristics and complications The neurons have totally depolarized and exhausted with total relaxation of the body. Tongue may occlude airway or apnea may continue. Be prepared to ventilate and suctions when the jaws relax As the pt becomes more conscious, restlessness and confusion may occur, lasting minutes to hours. Realize that the pt doesn’t understands what occurred. Post-ictal confusion is to be expected! Reassure him that all is OK and that he had a seizure. Provide a non-threatening atmosphere. Be prepared for suspicious/agitated behavior and may want to pace. Have one person interact with the pt in a calm manner [family present?} and gently direct him to rest or pace in small area. DO NOT RESTRAIN Encourage sleep Provide privacy r/t incontinence Take vital signs Observe for signs of another seizure Call 911/get help Don’t allow the pt to drive! Nursing Assessment for SeizuresSee Table in Study Guide : Nursing Assessment for SeizuresSee Table in Study Guide • any warning sign or aura? • where did the seizure begin and how did it proceed? (if the seizure was witnessed) • what types of movement was noted and what body parts were involved? • did the eyes deviate and to which side? any change in pupil size? • was there urinary or bowel incontinence? • what was the duration of the entire seizure and of each phase? • was the pt unconscious throughout the seizure? • what was the behavior of the pt after the seizure? • was there any residual weakness or paralysis of the extremities after the seizure? • did the pt sleep after the seizure? Nursing Assessment for SeizuresSee Table in Study Guide : Nursing Assessment for SeizuresSee Table in Study Guide What was the patient’s level of consciousness—if consciousness was lost, at what point? What was the patient doing just before the Seizure? In what part of the body did the seizure start? Was there an epileptic cry? Were any automatisms observed such as eyelid fluttering, chewing, lip smacking, or swallowing? How long did movement last and did the location or character change (tonic to clonic); did movements involve both sides of the body or just one? Did the head and/or eyes turn to one side and, if so, which side? Were there changes in pupillary reaction? If the patient fell, did he hit his head? Was there foaming or frothing from the mouth? Did the lips or face change color? Did the patient bite his tongue or lips? Was there urinary or fecal incontinence? What happened during the post-ictal phase—lethargy, confusion, headache, muscle soreness, speech or comprehension impairment? Were they any motor alterations such as a transient hemiplegia (Todd’s paralysis)? Were the motor alterations asymmetrical? Status epilepticus: a special generalized seizure : Status epilepticus: a special generalized seizure definition of status epilepticus: 1) prolonged seizure activity OR 2) 2 or more seizures without regaining consciousness [therefore: applies to petit mal/absence as well as grand mal Seizures] Why is status epilepticus in grand mal seizures potentially deadly?: : Why is status epilepticus in grand mal seizures potentially deadly?: status epilepticus = ABC problem: Prolonged apnea with lack of oxygen to vital organs, esp. brain and heart [with hypoxemia and acidosis] People die of status epilepticus. Why is status epilepticus in petit mal seizures potentially disabling?: : Why is status epilepticus in petit mal seizures potentially disabling?: Hundreds of seizures per day can cause lack of oxygen to the young brain, with permanent cognitive loss Treatment and rationale of status epilepticus : Treatment and rationale of status epilepticus Break the status epilepticus so the pt can breathe again or so the nurse can ventilate the pt. give IV Valium or IV Ativan. Give enough to stop the seizure! What if the pt does not breathe r/t to hypoxemia and lots of Valium? Ventilate the pt. Diagnosis of Seizures : Diagnosis of Seizures 1. History: the events surrounding the loss of consciousness or abnormal sensations/movements are very important in suspecting a seizure 2. S&S: subjective and objective data 3. EEG (with evoked potentials) or sleep-deprived EEG (no sleep after 2am and fasting - trying to evoke a seizure) 4.Blood studies & CT scan (head) to rule out other causes 5. video monitoring in conjunction with continuous EEG monitoring Treatment of Epilepsy : Treatment of Epilepsy (after ruling out other causes, e.g. cerebral tumor) a. Drug therapy: critical to management, often given in combination if one doesn't work, blood tests for therapeutic levels: common many side-effects. Dilantin (phenytoin) : Dilantin (phenytoin) Family: Hydantoins Indications: Grand mal, psychomotor, focal seizures and following craniotomy (1-2 years; prophylaxis for seizures) Adult dosage: Adults: 100 mg 3 times per day (IV/PO) or 300 mg at HS Therapeutic blood level: 10-22 mg/mL Dilantin by feeding tube: must turn off the tube feeding one hour BEFORE the medication and turn on tube feeding two hours AFTER Dilantin (phenytoin) : Dilantin (phenytoin) I.V. Dilantin: Always in normal saline Complications of I.V. Dilantin: BURNS in the vein: may slow down or with lidocaine in the bag Give slowly to prevent arrhythmia Side-effects Gastric upset: give with meals. Prevent seizures: Dosage should be increased gradually to Gingival hyperplasia: Good oral hygiene and gum Problems in perception and coordination Acne (androgenic effect on hair follicles) and skin odor: skin care Toxic Signs: Nystagmus, ataxia, drowsiness, tremor, nausea, constipation. Carbamazepine (Tegretol) : Carbamazepine (Tegretol) Indications: Tonic-clonic, complex, partial and focal motor; mood stabilizer Dosage: Maximum dose for children over 15 years and adults 1200 mg. Therapeutic blood level: 4-10 g/mL Carbamazepine (Tegretol) : Carbamazepine (Tegretol) Side Effects and Precautions Baseline renal and liver function and hematologic testing should be completed before initiating treatment. Blood counts are monitored weekly for the first 3 months. Instruct clients to withhold this drug and see a physician at the first sign of bone marrow depression, genitourinary problems (frequency, retention), or cardiovascular side effect such as edema, Cyanosis, syncope. Toxic Effects: Diplopia, nausea/vomiting, dizziness, ataxia Primidone (Mysoline) : Primidone (Mysoline) Indications: Used primarily for psychomotor, autonomic, and akinetic seizures Dosage: Adults: 250 mg/day, up to 500 mg qid Therapeutic Blood Level: 5-12 g/mL Toxic Effects: Sedation, ataxia, behavioral changes, GI disturbances. Valproic acid (Depakene) : Valproic acid (Depakene) Indications: Myoclonic seizures; mood stabilizer Dosage: Initially 15 mg per kilogram of body weight per day to a maximum of 30 mg per kilogram of body weight per day; doses should be divided if total in excess of 250 mg/day Therapeutic Blood Level: 50-100 g/mL Side Effects: It should be given with meals or with large amounts of liquids. If client is also receiving phenobarbital or phenytoin, dosages need to be adjusted. Nausea, vomiting, and hepatotoxicity may occur and clients should be given appropriate instructions. Clonazepam (Clonopin) : Clonazepam (Clonopin) Indications: Absence, akinetic, and myoclonic seizures Dosage: Adults: 1.5 mg increased to 20 mg/day in divided doses Therapeutic Blood Level: 20-80 mg/mL Side Effects: Gastric Upset Drowsiness: It is not taken with alcohol or other central nervous system depressants. Hepatotoxicity Toxic Effects: Hyper- and hypoactivity, dizziness, thickened speech, drowsiness, ataxia Nonadherence with medications : Nonadherence with medications List three reasons why nonadherence is so common in pts with seizure disorders 1. Side-effects of medications [drowsiness, gum problems, etc.] Tired of taking medications, “I don’t want to do it any more.” Denial or changes in body image. Cost Others? Patient Education for the Pt with a seizure disorder: How to prevent seizures : Patient Education for the Pt with a seizure disorder: How to prevent seizures a. medications: take the medications! – the most common cause of seizures in the ER! b. good habits and things to avoid – prevent irritation of the brain 1. eat regularly – avoid hypoglycemia 2. don’t drink alcohol 3. enough sleep and rest 4. no stimulants or street drugs 5. modify stressors/emotional upset 6. identify environmental triggers for seizures (e.g. flashing lights, strobe lights, video games with strobe effect 7. call doctor if ill, esp. N/V/D, and can’t take medications Patient Education for the Pt with a seizure disorder: Healthy Habits : Patient Education for the Pt with a seizure disorder: Healthy Habits c. teach family and pt what to do if aura/prodromal signs or seizure occur, about medications, healthy lifestyle d. Medic-Alert bracelet wear it! e. dental care: care of gingival hyperplasia and regular dental exams f. child with seizures and school: teach classmates and teachers how to responds to a seizure Patient Education for the Pt with a seizure disorder: Healthy Habits : Patient Education for the Pt with a seizure disorder: Healthy Habits g. referral to community resources and support groups: Epilepsy Foundation of America h. physical activity: stay active with a positive attitude. Swim with a companion. i. occupational factors: may prevent certain jobs where person could be injured (e.g. working with heavy machinery, being a jet pilot) Surgery: if seizures are intractable to medications : Surgery: if seizures are intractable to medications 1. Good candidate: at least three anticonvulsants have been attempted without success; the seizure focus can be identified 2. Cortical resection/cryotherapy: the seizure focus is frozen 3. Corpus callosum division: very radical, where the connection between the two hemispheres is cut so that the discharge cannot generalize to the whole brain. Sometimes success in very young children. In older children/adults, the brain forms “two personalities.” Vagal nerve stimulation (VNS) : Vagal nerve stimulation (VNS) FDA approved for partial seizures in pts older than 12 years. A “pacemaker” like device is wrapped around the left vagus nerve in the chest/neck. When it senses a seizure discharge, it fires inhibiting the seizure from starting. The action of the VNS probably has NOTHING to do the parasympathetic system, but rather effects on the reticular activating system, limbic system, and other deep structures in the brain. The pt can also activate the stimulator with a magnet if the pt feels the onset of a seizure. It causes few side-effects and complications. Vagal nerve stimulation (VNS) : Vagal nerve stimulation (VNS) Caption: Picture 1. Vagus nerve stimulation. The NeuroCybernetic Prosthesis (NCP) in place in the left chest wall (Image courtesy of Cyberonics Inc) Vagal nerve stimulation (VNS) : Vagal nerve stimulation (VNS) Caption: Picture 2. Vagus nerve stimulation. The NeuroCybernetic Prosthesis (NCP) generator, with the leads that are wrapped around the left vagus nerve. http://my.webmd.com/hw/epilepsy/aa138962.asp Diet Therapy: Ketogenic Diet – Ketosis to prevent seizures in children : Diet Therapy: Ketogenic Diet – Ketosis to prevent seizures in children The ketogenic diet has been around in the medical literature for well over 70 years. It was replaced when the modern anti-convulsants became available, even though it has a very good success rate at controlling seizures. In some cases it is actually better than drugs at controlling seizures. It has a success rate of 75%. Stopping seizures in 50% and further reducing them in 25% of cases. Most kids can stay on the diet two years, get off it and never have another seizure again. The diet works best in children under ten. They are less likely to cheat and young children can maintain ketosis better than adults or older children. The diet mimics the effects of starvation. it has been known for centuries that fasting has a beneficial effects on seizure control (there is a reference to such in the New Testament). Doctors at the Mayo Clinic came up with a way to induce the effects of starvation (fat burning, ketosis and a change in blood Ph levels) by feeding the patient large quantities of fat and limiting protein and carbohydrate. the diet has to be rigidly controlled as any deviation can throw the patient out of ketosis and produce a seizure. http://www.our-kids.org/Archives/Ketogenic_diet_FAQ.html Laws Concerning Epilepsy : Laws Concerning Epilepsy a. notification to DMV of seizure disorder/epilepsy/loss of consciousness with Confidential Morbidity Form – mandatory reporting by physician for any loss of consciousness that is unexplained. Meant to protect the public so pt does not have seizure while driving! b. driving in California, per DMV regulations a driver’s license is granted in all states with evidence of a seizure-free period of 1-3 years, depending on the state medical probation: allows driving and the DMV monitors the driver. Driver must remain seizure-free for 3-6 months. suspension: if the driver’s seizures are not controlled or if the driver does not comply with the terms of the medical probation. revocation: permanently taken away. Done only when the driver’s condition is never likely to be brought under control. Nursing Diagnoses Relevant to the Patient with Seizures/epilepsy : Nursing Diagnoses Relevant to the Patient with Seizures/epilepsy Potential for Injury Ineffective Breathing Pattern Ineffective Therapeutic Regimen Denial, Ineffective