Seizure Disorders (Epilepsy) Nursing Care Management

Epilepsy is recurrent, unprovoked seizures from abnormal cortical electrical activity. At the bedside your job is concrete: protect the airway and the head during a seizure, prevent injury, document what you saw accurately because your observation drives the diagnosis, and keep the child and family on a medication regimen they cannot safely stop on their own.

What are Seizure Disorders?

Seizure disorders, also called epilepsy, are a diverse group of neurological conditions caused by abnormal electrical activity in the brain, producing recurrent seizures that vary in type and intensity. They affect all ages and arise from head injury, genetic factors, or underlying medical conditions. Epilepsy is a brain disorder marked by an enduring predisposition to generate seizures along with the neurobiological, cognitive, psychological, and social consequences that follow.

A seizure is an abnormal, unregulated electrical discharge in the cortical gray matter that transiently interrupts normal brain function, causing altered awareness, abnormal sensations, focal involuntary movements, or convulsions (widespread violent involuntary contraction of voluntary muscles). One of the earliest descriptions of a secondary generalized tonic-clonic seizure was recorded over 3000 years ago in Mesopotamia and attributed to the moon god. Hippocrates wrote the first book on epilepsy almost 2500 years ago, rejecting divine causation and attributing it to excessive phlegm.

Classification

Seizures are generalized or partial. In generalized seizures the discharge diffusely involves the entire cortex of both hemispheres from onset, consciousness is usually lost, and the cause is most often metabolic and sometimes genetic. In partial seizures the discharge starts in one cerebral cortex and most often reflects a structural abnormality; revised terminology calls partial seizures focal seizures.

Pathophysiology

Seizures are paroxysmal manifestations of cortical electrical properties. A seizure occurs when the balance between excitatory and inhibitory forces in the cortical neuronal network shifts toward sudden-onset net excitation. The clinical picture maps to the cortex involved; a discharge in the visual cortex produces visual phenomena. The mechanisms of focal-onset and generalized-onset seizures differ: cellular excitability is increased in both, but synchronization mechanisms differ substantially between the two types.

Statistics and Incidences

Hauser and collaborators found the annual incidence of recurrent nonfebrile seizures in Olmsted County, Minnesota, was about 100 cases per 100,000 persons aged 0 to 1 year, 40 per 100,000 aged 39 to 40 years, and 140 per 100,000 aged 79 to 80 years. By age 75, cumulative incidence of epilepsy is 3400 per 100,000 men (3.4%) and 2800 per 100,000 women (2.8%). Several developed countries show incidence and prevalence similar to the United States.

Causes

In a substantial number of cases the cause is unknown. Several genetic syndromes cause seizures. Chromosomal 22q deletion syndrome is a spectrum caused by a deletion on chromosome 22q11.2; seizures occur in 7% of these patients. Many metabolic disorders cause seizures, some through disturbances such as hypoglycemia or acidosis and some as a primary manifestation. Mitochondrial disorders are underdiagnosed and often involve seizures; mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS) syndrome is associated with seizures, often as the presenting feature. Single-gene mutations are also responsible: autosomal dominant nocturnal frontal lobe epilepsy is caused by mutations in the CHRNA4, CHRNB2, or CHRNA2 genes and presents with nocturnal motor seizures. Many cases remain idiopathic.

Phases

Seizure activity moves through prodromal, aural, ictal, and postictal phases. The prodromal phase brings mood or behavior changes hours to days before a seizure. The aura is a premonition of impending seizure activity and may be visual, auditory, or gustatory. The ictal stage is the seizure itself, usually musculoskeletal. The postictal stage is the confusion, somnolence, and irritability that follows.

Clinical Manifestations

Clinical diagnosis rests on the history from the patient and, most importantly, from observers. An aura precedes seizures in about 20% of people with a seizure disorder. Almost all seizures are brief, from a few seconds to a few minutes; most last 1 to 2 minutes. When a seizure stops, the postictal state brings headache, sore muscles, unusual sensations, confusion, and profound fatigue. In some people one side of the body is weak and the weakness outlasts the seizure (Todd paralysis). Visual hallucinations (unformed images) occur if the occipital lobe is involved. A convulsion (jerking and spasms throughout the body) occurs when large areas of both hemispheres are affected.

Assessment and Diagnostic Findings

The American Academy of Neurology recommends a serum prolactin assay measured 10 to 20 minutes after a suspected event to help differentiate generalized tonic-clonic or complex partial seizure from psychogenic nonepileptic seizure in adults and older children. Judicious serum levels of antiepileptic drugs (AEDs) can improve care, though many newer AEDs lack established levels. Brain MRI or head CT may reveal a structural cause. Interictal epileptiform discharges or focal abnormalities on EEG strengthen the diagnosis and help with prognosis. Video-EEG monitoring is the criterion standard for classifying seizure type or syndrome and for diagnosing pseudoseizures. Lumbar puncture (rarely done) detects abnormal CSF pressure and signs of infection or bleeding (subarachnoid, subdural hemorrhage) as a cause.

Medical Management

The goal is a seizure-free status without adverse effects. Monotherapy is preferred: it reduces adverse effects, avoids drug interactions, and is often less expensive, since many older anticonvulsants induce hepatic enzymes that lower serum levels of concomitant drugs and force higher doses. Anticonvulsant medication is the mainstay, and the drug of choice depends on accurate diagnosis of the epileptic syndrome because response varies by syndrome. After a patient has been seizure free for typically 2 to 5 years, the physician may consider discontinuing medication; many children outgrow their epileptic syndromes and no longer need anticonvulsants.

The ketogenic diet relies heavily on fat such as hydrogenated vegetable oil shortening and has a role in severe childhood epilepsy; it is effective in some refractory cases but hard to maintain, and fewer than 10% of patients continue it after a year. A modified Atkins (low-carbohydrate) diet mimics the ketogenic approach without restricting protein, calories, and fluids; small studies of children with intractable epilepsy have shown seizure reductions of more than 50% within 3 months, particularly with carbohydrate limits of 10 g per day. Vagal nerve stimulation (VNS) is a palliative technique using a surgically implanted stimulating device, FDA-approved for medically refractory focal-onset epilepsy in patients older than 12 years. The NeuroPace RNS System is implanted into the cranium, senses and records electrocorticographic patterns, and delivers short trains of current pulses to interrupt ictal discharges.

In a randomized controlled trial of surgery in 80 patients with temporal lobe epilepsy, 58% randomized to anterior temporal lobe resection were free from awareness-impairing seizures at 1 year, versus 8% with anticonvulsant treatment alone. At the 66th Annual Meeting of the American Epilepsy Society, investigators suggested that in select pediatric patients smaller lesionectomy resections may be as effective as larger ones while sparing functional and developmental deficits. Because the next seizure is unpredictable, discuss precautions around driving, heights, fire or cooking, power tools and dangerous equipment, unsupervised baths, and swimming. In 2018 the FDA cleared the first smartwatch for seizure tracking, the Embrace, which identifies convulsive seizures and alerts caregivers by text and phone while recording sleep, rest, and activity; in a study of 135 patients its algorithm detected 100% of seizures.

Pharmacologic Management

Anticonvulsants prevent seizure recurrence and terminate clinical and electrical seizure activity, and are reserved for patients at increased risk of recurrence. Barbiturates, like benzodiazepines, bind the GABA receptor and enhance GABA by extending GABA-mediated chloride channel openings, allowing neuronal hyperpolarization. Benzodiazepines bind the GABA receptor to enhance GABA action. Succinimides reduce current in T-type calcium channels. Neuronal potassium channel openers stabilize neuronal KCNQ (Kv7) channels in the open position, increasing the stabilizing membrane current and preventing bursts of action potentials during sustained depolarizations. Hydantoins stabilize sodium channels and prevent their return to the active state.

Nursing Management

Nursing Assessment

The diagnosis is made by analyzing a detailed clinical history plus confirmatory tests. Someone who has witnessed the events is usually the best historian, but the patient supplies key detail about auras, preservation of consciousness, and postictal states. A physical exam helps identify syndromes with abnormal findings, such as neurocutaneous syndromes (Sturge-Weber, tuberous sclerosis); patients with years of intractable generalized tonic-clonic seizures often carry injuries requiring stitches.

Nursing Diagnosis

Based on assessment data, the major nursing diagnoses are:

• Risk for trauma or suffocation related to loss of large or small muscle coordination.
• Risk for ineffective airway clearance related to neuromuscular impairment.
• Situational low self-esteem related to the stigma of the condition.
• Deficient knowledge related to information misinterpretation.
• Risk for injury related to weakness, balance difficulty, cognitive limitations, or altered consciousness.

Nursing Care Planning and Goals

The patient or caregiver will understand the factors that raise the risk of trauma and suffocation and act to correct them, identify what to do when a seizure occurs, identify and correct environmental risk factors, adopt behaviors and lifestyle changes that reduce risk and protect from injury, modify the environment for safety, maintain a treatment regimen that controls or eliminates seizures, recognize when help is needed to prevent injury, maintain a patent airway with aspiration prevented, restore positive self-esteem, and understand the disorder and the stimuli that may potentiate seizure activity.

Nursing Interventions

Prevent trauma and injury: teach the support person the warning signs and how to care for the patient during and after a seizure; avoid breakable thermometers and use a tympanic thermometer when needed; enforce strict bedrest if prodromal signs or an aura appear; turn the head to the side and suction the airway as indicated; support the head, place the patient on a soft area or assist to the floor if out of bed; do not restrain; monitor and document AED levels, side effects, and seizure frequency. Promote airway clearance: keep the patient lying flat, turn the head to the side during activity, loosen clothing at the neck, chest, and abdomen, suction as needed, and provide supplemental oxygen or bag ventilation postictally. Improve self-esteem: assess the situation, avoid overprotecting the patient, encourage supervised activity, gauge the support person's attitudes and capabilities, and help the patient see their feelings as normal while making clear that guilt and blame do not help. Enforce education: review the pathology and prognosis and the lifelong need for treatment, discuss trigger factors (flashing lights, hyperventilation, loud noises, video games, TV), stress good oral hygiene and regular dental care, and review the medication regimen, the need to take drugs as ordered, not stopping therapy without physician supervision, and what to do for a missed dose.

Evaluation

Goals are met when the patient or caregiver understands and acts on trauma and suffocation risks, knows what to do during a seizure, identifies and corrects environmental risks, adopts protective behaviors and lifestyle changes, modifies the environment for safety, maintains the treatment regimen, recognizes the need for assistance, maintains a patent airway with aspiration prevented, restores positive self-esteem, participates in treatment, and understands the disorder and its triggers.

Documentation Guidelines

Document individual findings (factors affecting the patient, interactions, nature of social exchanges, specifics of behavior), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and attainment or progress toward the desired outcome.