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definition of a seizure
- a seizure represents an abnormal behavior caused by an electrical discharge from neurons in the cerebral cortex
- uncontrolled physiological response to abnormal electrical discharges in the CNS
- usually indicative of neuronal hyperexcitability
- symptom rather than a disease
- starts w/one hyper exitable and spreads
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seizures
- are generated/initiated by synchronous high frequency discharge from a group of abnormal hyperexcitable neurons (focus), spread to adjacent tissues
- - focus can be the result of congenital defect, hypoxia, head trauma, tumor, meds
- - sometimes unknown (electrical imb)
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two different causes
- two different causes
- idiopathic causes: genetic, development (febrile)
- Acquired: from other things happening to the body
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outward manifestation of a seizure depends on
- location of the seizure focus (where)
- Neuronal connections to the focus and adjacent neurons- where does it spread
- - rate, extent and direction of the spread of abnormal electrical discharges
- - think of the parts of the brain and function
- tonic-clonic- larger one
- simple- one place r/t one part of the brain
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parts of the brain
- temporal- ears, balance, emotions, panic, fear
- frontal- confusion, behavioral, speech, movement
- parietal- sensory, parenthesia
- occipatal- eyes visual changes
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seizure threshold
- the nervous system normally exhibits a basal level of excitability
- whenever the degree of excitability exceeds a certain threshold (seizure threshold), abnormal discharges can occur in the CNS
- in seizure disorders, the threshold is low or multiple areas are stimulated
- we all have different threshold- normal, abnormal will bypass this, lower threshold (bypass this too)
- seizure meds- will raise seizure threshold
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seizures are classified into two types
- partial or focal seizure- one part of the brain
- generalized seizure- both hemispheres
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partial seizures
simple partial
- simple partial:
- involves one hemisphere
- intact consciousness- aware but can't control abnormal action
- may have prodrome/aura symptom- can feel it before it comes
- during seizure: movement of one extremity
- focal
- last for 1-1 1/2 min
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simple partial seizure s/s
- motor, vision, hearing impaired
- Autonomic (SNS)- tachycardia, flushing, diaphorectic
- automastism- grimacing, smacking of the lips- repetitive non purposeful movement
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partial seizures
complex partial
- also called temporal lobe/psychomotor seizure
- prodrome/aura
- initially begins in a localized area
- can progress to both hemisphere
- impairment of consciousness- not loss but can follow commands- may not remember
- cognitive s/s
- sensory/motor
- autonomic s/s
- automatisms
- fear, feeling of detachment (confusion)
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Generalized seizure
- loss of consciousness
- involves both hemispheres
- subdivided into 6 types:
- - absence seizures
- - myoclonic
- - tonic-clonic
- - clonic
- - tonic
- - atonic
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Absence seizure
- petit mal
- seizure of sudden onset and termination
- seen in children
- impairment of conscious, brief staring, automatisms
- usually labs < 20 secs
- affects school
- usually doesn't occur after puberty
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generalized seizure
tonic-clonic **
- last for 2-5 mins
- begins with tonic (stiffing of rigidity of mus. mostly of arms/legs f/b LOC)
- clonic phase- rhythmic jerking of all extremities follows- person may bit tongue, incont of both urine/feces
- fatigue, acute confusion, lethargy may last for 1 hr following seizure
- tonic-clonic seizures: occasionally, only clonic or tonic movement may occur
- tonic- stiffiness
- clonic- jerky
- vague, warning or awareness
- watch airway b/c muscle in airway (constrict)
- neuro, safety
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atonic seizures (akinetic- w/ot movement)
- sudden loss of muscle ton, lasting seconds
- f/b postictal confusion- not sure what happen
- incr risk for falls
- drop attack- loss muscle time- falls
- this type is most resistant to the drug therapy
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myoclonic (muscle jerk)
- small % of population
- sudden. brief involuntary muscle 'jerking'
- - rapid brief contractions of muscle contractions
- can involve one body part (mild) or whole body
- no loss of consciousness
- (bright lights, strobe lights, fatigue, dehydration)
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epilepsy
- defined as: two or more seizures experienced by a person 3% of pop
- chronic disorder in which repeated unprovoked seizure activity occurs
- may be caused by abnormality of electrical neural activity, an imb of neurotransmitters
- chx of neuro transmission, birth, trauma, sepsis, meds, alchol and drug withdrawl
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Status epilepticus
- seizure lasting longer than 5 mins or
- repeated seizures over the course of 30 mins
- potential complication of all seizures
- medical emergency!!!!!!
- seizure > 10 mins- death, airway
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different phases of seizures
- pre ictal phase- pressence of an aura before the seizures
- ictal- seizure activity occurs
- post- ictal phase-recovery, amnesia
- drowsy, sleeping, fatigue, confusion-agitation
- breathing- airway, safety- decision making not good..like getting up to use batheroom
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assessment: seizure
- determine the type of seizures:
- frequently, length of time- when, where did it start from
- description, movement, sequence patterns
- precipating factor- aura
- after seizure
- history
- pre existing injury- head, fam hx, alcohol and drug use, AED, meds (antiseizure
- seizure diary**
- - track aura
- - percipating factors
- - fam can document what happened
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diagnostics for seizure
- pt hx
- PE and description of seizures
- EEG- best within 2 hr of seizure
- dx tests: to rule out other causes
- - CT, MRI, chem studies, drug levels
- - ie brain tumor, mass, lytes imb, infection (sepsis)
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nursing management
- priorities
- assessments
- nursing and medical care
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Nx care during seizure activity
- Protect pt from injury:
- maintain airway:
- - airway protection
- - nothing in pt's mouth
- - positioning- on side
- - monitor respiratory and cardiac status
- Maintain safe environment:
- - protect the head, loosen clothes ie tie
- - lower the head of bed, pad rails
- - do not restrain
- guide movements
- p 1961
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nx care during seizure activity 2
- assessment and documentation
- - seizure- movements, time, LOC
- Support pt/fam
- - provide privacy
- Medication administration
- - IV access- IV meds benzon diazpems
- - rectal- diastat (diazpams)
- - nasal spray- benzodiazepine (clinical trials)
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nc care of during seizure activity 3
meds
- Benzodiazepine- rescue medication:
- IV lorazepam (ativan), diazepam (valium)
- - incre GABA, suppresses foci and movement
- s/e: CNS, hypotension, respiratory chx
- NI: assess VS, RR
- check IV push rate and compatiblity
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nx care of a pt after seizure
- airway/breathing
- assessments: VS, respiratory, cardiac, neuro
- safety
- positioning - on side, head slightly elev
- support/privacy
- - basic care needs
- side rails up, help with incontinence
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medical manage of seizure meds
- mainstay of seizure management
- choice: seizure type, EEG, indivi pt, safety and PMH
- objective: seizure control w/minimal side effects- balance but helping s/e
- single drug therapy: initial
- - monitor s/e
- - drug level
- - compliance
- see pharm notes
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how do anticonvulsants work to dec seizure activity
- decre discharge of neurons within the seizure focus- decr foci
- suppress propagation of seizure activity from the focus to other areas of the brain - stop movement
- incre seizure threshold
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Four basic mechanisms of action for AED
- decr NA influx- nerve transmission
- decr Ca influx- same
- incr GABA
- inhibit glutamate- dec neuronal activity
- *** decr neuronal stim***
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medical management w/drugs
- start with one dryg and if not working try another one
- Phenytoin (dilantin)- dec Na reflux, raises seizure threshold, 10-20 small theura range, CNS, ginival hyperplasia
- valproate (depakote)- , CNS, resp
- lamtrigine (lamictal)-
- keppra (levetiracetam)
- ativan-
- look at sheet
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Nx dx and teaching 1
Knowledge deficient
- knowledge deficit:
- - medication therapy
- - educate pt/fam
- - seizure diary- aura
- - driving after a seizure- usually 6m
- - community resources
- - ID bracelet
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NX dx and teaching 2
fear
- emotional support
- collab w/heathcare team- emotional, occupational, financial
- education
- community resources, support groups
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nx dx and teaching 3
risk for injury
- prevention of seizure:
- meds as prescribed- same time each day
- drugs levels
- reduce risk
- healthy diet, exercise, and sleep (help prevent- cause poor nutrition, lack of sleep and exercise can make it happen)
- f/u care
- Safe environment--
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SUDEP
- sudden unexpected death in epilepsy
- respiratory arrest..
- young adults
- genetic predisposition
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Status Epilecticus and nursing management
- medical emergency!!!!
- treat promptly and aggressively- airway
- stop seizure as quickly as possible- ativan- tonic-clonic worry about airway
- - airway
- - safety
- - IV AED to stop seizure
- - assess airway, breathing, VS, neuro, seizures
- - blood- Chem (lytes and BS) CBC (infection, bleeding), drug levels (ellicit drugs/alcohol)
- - positioning- side
- - support- neuro
- - f/u with neuro, daily AED
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