Epilepsy is a paroxysmal neurological disorder and is characterized by recurrent episodes of convulsive movements or other motor activity, loss of consciousness, sensory disturbances, and other behavioral abnormalities. Because epilepsy occurs in more than 50 diseases, it is considered a syndrome rather than a disease. Each year approximately 180,000 new cases of epilepsy occur.
Convulsive seizures are the most common forms of attacks of epilepsy. Seizures occur with abnormal electrical discharges from brain cells, and these discharges are caused by the movement of ions across the cell membrane. Although seizures are the dominant manifestation of epilepsy, patients can have a seizure and not have epilepsy. The current classification for seizures that is commonly used was redefined in the 1980s (Table 1). The characteristics of the seizure vary and depend on the focus or location of brain involvement. Seizures can vary from almost imperceptible alterations in the level of consciousness to a sudden loss of consciousness with tonic-clonic convulsions of all extremities accompanied by urinal and fecal incontinence and amnesia for the event.
Status epilepticus is defined as more than 30 minutes of unconsciousness with continuous or intermittent convulsive seizure activity. Usually, status epilepticus results when more than six seizures occur in 24 hours or when the patient progresses from one seizure to the next without resolution of the postictal period. Pseudoseizures are the physical appearance of seizure activity without the cerebral electrical activity.
Seizures may be caused by primary central nervous system (CNS) disorders, metabolic or systemic disorders, or idiopathic origins. Primary CNS disorders include any potential mass effect (tumor, abscess, atrioventricular malformation [AVM], aneurysm, or hematoma) and all types of strokes, especially those that are embolic. Metabolic and systemic causes include acute overdose, acute drug withdrawal (especially CNS depressants, alcohol, benzodiazepines, and barbiturates), febrile states, hypoxia, hyperosmolarity, hypertensive encephalopathy, hyperthermia, and a multitude of electrolyte disturbances.
Nursing care plan assessment and physical examination
Obtain a thorough history of past illnesses and surgeries. Lifestyle changes, medications or vaccinations, and history of past head injury may be significant. Obtain data about the age of onset and the frequency, duration, and severity of the seizures. Ask the patient if she or he experiences any type of aura or prodromal symptoms before the seizure or if there are any precipitating factors such as dizziness, palpitations, flashing lights, or fatigue. A history of seizure activity is crucial from both the patient and a significant other who has witnessed the activity. Elicit information about eye movements, body movements, level of consciousness, and presence of urinary or fecal incontinence. Ask the family to describe the patient’s postictal state.
A thorough neurological exam includes assessing changes in mental status, cranial nerve function, muscular tone and strength, sensations, reflexes, and gait. Describe in detail any seizure activity that may occur during the physical examination. Assess the initial manifestations, motor activity, pupil size, gaze, incontinence, and duration of the seizure. Assess what the patient is like in the postictal state. Since the patient may bite his or her tongue during the seizure, assess the patient for mouth and tongue injury.
When it is poorly controlled, epilepsy may be seriously debilitating. Seizure activity in public is embarrassing and poorly understood by the public. Mobility is frequently disturbed because of the inability to drive. Attending school or going to work may be a serious trial to the poorly controlled epileptic.
Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to clonic-tonic motor activity and tongue obstruction.
Nursing care plan intervention and treatment
In general, the management of seizures is done pharmacologically. The patient with status epilepticus is considered a medical emergency. Airway management is critical, often endotracheal intubation is needed, and intravenous medications are administered. If there is a delay in treatment, or if the patient is unresponsive to treatment, irreversible brain damage, coma, or death can occur.
Surgery, an extensive and expensive alternative, is considered as a last resort to control the seizures. Only 5% of all patients with epilepsy undergo surgery. Surgical removal of the epileptic focus is appropriate only for the patient who is uncontrolled with medication, has a single identifiable focus firing at least 80% of the seizure initiations, has no underlying medical problems, and has a focus lying in nonessential tissue.
The most important nursing interventions are to maintain adequate airway, breathing, and circulation during the seizure and to prevent injury. Have an oral airway and suction apparatus at the bedside at all times. A patient who begins a seizure should not be left alone. Use the call light to obtain assistance, and if the patient is upright, gently ease her or him to the floor. Position her or him to maintain the airway, but do not force anything into the patient’s mouth if the teeth are clenched. If the patient’s mouth is open, protect the patient’s tongue by placing a soft cloth or a well-padded tongue blade between the teeth. Help the patient to a lying position, remove constricting clothing, and place a pillow or sheet under the patient’s head to cushion her or him from injury. Clear the area of objects that are hard or sharp. Do not restrain the patient’s movement during the seizure. Assist the patient with hygiene and linen changes, should incontinence occur during the seizure.
To lower the risk of injury, provide a safe environment at all times. Pad and raise the side rails, but do not use pillows for padding because of the possibility of suffocation. Take axillary rather than oral temperatures, and remove breakable objects such as water glasses from the area. The extent of seizure precautions should be consistent with the type of seizures. Good oral hygiene is important. Also observe for signs of infection if there is any damage to the tongue and oral mucosa.
Educate the patient and family about providing care during a seizure, the medication schedule and side effects, and the importance of regular follow-up. Involve the family as much as possible in patient care. Use patient and family teaching to dispel any myths and misconceptions
about epilepsy. Assure the family that most patients can control the syndrome if they follow the prescribed routine. Since epilepsy can be a debilitating, restrictive disease, provide support and encouragement. Refer patients to national organizations (Epilepsy Foundation of America) and local support groups.
Nursing care plan discharge and home health care guidelines
Be sure that the patient understands all medications, including the dosage, route, action, adverse effects, and need for routine laboratory monitoring of AEDs. Stress the need for taking medications as prescribed, even if seizure activity is under control. Ensure that the patient has basic epilepsy safety information, such as no tub baths, no swimming, and no driving without seizure control for at least 1 year. Family members should be able to verbalize what to do during a seizure. The patient should wear jewelry identifying him or her as having epilepsy.