Epilepsy edited

Epilepsy
Presented by:
Major Lavanya L V
DNN student(2019-2020)
NIMHANS,Bangalore

Demographic data
Name of the patient Mr Sabarinathan
Age/Sex 25 years/Male
Religion Hindu
Education Primary
Occupation Coolie
Marital Status Single
Family Income 40000/year
MRD Seq No N 896278
Address Nathakkattanoor village, Thoramangalam(PO),
Salem,Tamilnadu
Date of admission
Diagnosis
17/07/2019
Epilepsy

Present medical history:
• Patient admitted with the c/o seizures, jerks of upper and
lower extremities since 10 years, difficulty in holding
objects. Also reported 3-4 episode of seizures within
last 2 wks.Reported normal till 15 years of age.
• Had first episode of GTCS followed by occasional upper
limb dominant myoclonus at the age of 15 years.
Gradually increased frequency and had daily jerks. Had
dropped out school as he could not unite jerk
movements on action and walking.
• Currently on medication:Valproate,500mg BD, tab
Clonazepam,0.25mg HS,tab Amoxyclav,625mg BD,tab
Diclofenac 50mg BD, tab Rantac 150mg BD

Seizures Vs Epilepsy?
seizures
• abnormal, sudden,
excessive, uncontrolled
electrical discharge of
neurons within the brain
that may result in alteration
in consciousness, motor or
sensory ability, and/or
behavior.
• No known reason.
• Pathologic condition of
the brain.
epilepsy
• Is a chronic disorder
characterized by recurrent,
unprovoked seizure activity.
• Abnormality in electrical
neuronal activity.
• Imbalance in
neurotransmitters.
• Combination of both

Definition
Epilepsy is a chronic
disorder of abnormal,
recurrent, excessive
and self-terminating
discharge of electrical
impulses from
neurons (Hicky 2007).

Anatomy and physiology of nerve cells

Properties of neurons which helps in
neurotransmission:
Irritability
Conductivity

How common is epilepsy?
• Most common serious neurological disorder
• Affects 1/200 people worldwide.
• Could be as much as 1/100 in developing
nations like India due to following reasons:
poor antenatal care and perinatal injury,
infections(tuberculosis,cysticercosis,road
traffic accidents)

Incidence of Epilepsy by Age
Hauser WA. Epilepsia. 1992;33:S6-S14.

Causes of Epilepsy
Degenerative
(3.5%)
Infection
(2.5%)
Neoplastic
(4.1%)
Vascular
(10.9%)
Trauma
(5.5%)
Congenital
(8.0%)
Idiopathic/
cryptogenic
(65.5%)
Annegers JF. The epidemiology of epilepsy. In: Wyllie E, ed. The Treatment of Epilepsy: Principles and Practice. 2001:131-138

Etiology
Etiology
Primary or
Idiopathic
Secondary
Brain lesion
Metabolic Disorders
Acute alcohol withdrawal
Electrolyte Imbalance
Heart Diseases

Causes of Epilepsy by Age
• Infancy and Childhood
- Birth injury
- Inborn errors of metabolism
- Congenital malformations
• Childhood and Adolescence
- Idiopathic-Cryptogenic/genetic
- CNS infection

Causes of Epilepsy by Age
• Adolescence and Young Adult
- Head trauma
- Drug intoxication/withdrawal (acute seizure)
• Older Adult
- Stroke
- Brain tumor
- Acute metabolic disturbances (acute seizure)

Post-Traumatic Epilepsy
• Epilepsy arising as a result of head trauma
• Head trauma may be subtle or severe
• Extent & location of injury may increase
likelihood of developing seizures
– 2 types of seizures -early/acute & delayed
onset
• Early treatment with anti-epileptic drugs (AEDs)
may not affect the development of seizures later
on

Epilepsy Risk Factors
• Intellectual or other
developmental
disability
• Cerebral Palsy
• Anoxia
• Autism
• Stroke
• Major head trauma
• CNS hemorrhage
• CNS infection,
neurocystercosis
• Dementia
• Brain tumor, tubers
• Family history
• Birth injury

Seizure Triggers
• Non-adherence
• Sleep deprivation
• Stress (good or bad)
• Accident/injury
• Concurrent illness (fever)
• Menses or hormonal changes
• Alcohol/drugs
• Specific stimuli (photosensitivity, reflex epilepsy)

Mortality
• Risk of death higher in people with epilepsy
– 10 years of life lost for people with known cause of
seizures
– 2 years of life lost for those with unknown cause of
seizures
• Approximately 42,000 deaths are caused by epilepsy
annually
• Mortality rate associated with seizures lasting  30
minutes may be as high as 19%
– Vast majority of deaths occur in people with seizure
in the context of an acute brain insult, hypoxia,
trauma, etc.
.

Additional Causes of Death in Epilepsy
• Life-threatening injuries
• Drowning
• Status epilepticus
• Sudden unexplained death in epilepsy (SUDEP)
• Suicide

Sudden Death in Epilepsy (SUDEP)
• SUDEP
– applies to a sudden death in someone known to
have epilepsy, in the absence of an obvious cause
for the death
• Numbers vary
– 1 in 10,000 of newly diagnosed
– 9 of 1,000 candidates for epilepsy surgery

A Spectrum of Severity
Uncomplicated epilepsy,
Seizures controlled with
medication
Seizures not completely controlled by treatment;
Epilepsy lowers standard of living due to social,
emotional, and educational problems
Seizures refractory to
treatment; Epilepsy is disabling
due to frequent seizures
and other problems
Increase risk of SUDEP

Types of seizures
• Generalized
Seizures
• Partial Seizures
• Unclassified
Seizures

Partial/focal/local
seizures
Simple
Complex
Generalized
seizures
Tonic-
Clonic
Tonic
Clonic
Absence
Myocloni
c
Atonic
Unclasssified

Generalized seizures
Tonic-Clonic Seizure
• Last for 2-5 minutes.
• TONIC phase is characterized by stiffening or
rigidity on the muscles, particularly of the
arms and legs, and immediate loss of
consciousness.
• CLONIC phase or rhythmic jerking of all
extremeties follows it.
• Biting of tongue, incontinent urine or feces,
fatigue, confusion and lethargy.

Tonic Seizures
Characterized by an abrupt increase in muscle
tone, loss of consciousness, and loss of
autonomic signs lasting from 30 seconds to
several minutes.

Clonic Seizures
Characterized by muscle contraction and
relaxation lasting for several minutes.

Absence Seizure
• More common in
children and tends to be
hereditary.
• With brief periods of loss
of consciousness and
blank staring, as though
the person is
daydreaming.
• Returns to baseline
immediately after.

Myoclonic Seizure
• Characterized by brief
jerking or stiffening of
the extremeties, which
may occur singly or in
groups.
• May be symmetric or
asymmetric.

Atonic Seizure
Characterized by
sudden loss of muscle
tone, lasting for
seconds, followed by
postictal confusion

Partial seizures
• Known as focal or local seizures, begin in a
part of one cerebral hemisphere.
• Complex Partial Seizure
• Simple Partial Seizure

Complex Partial Seizures
• Cause loss of consciousness or “black out” for
1-3 minutes.
• Automatism may occur such as lip smacking,
patting, picking at clothes, amnesia.
• Affects the temporal lobe so also known
Psychomotor or temporal lobe seizure.

Simple Partial Seizures
• Client remains conscious.
• Aura – “deja vu”, offensive smell, sudden
onset of pain.
• Unilateral movement of extremity, unusual
sensations, autonomic or psychic motors such
as changes in heart rate, skin flushing and
epigastric discomfort.

UNCLASSIFIED SEIZURES
• Unclassified or Idiopathic
• Occur for no known reason and do not fit into
the generalized or partial classifications.

STATUS EPILEPTICUS
• Characterized by prolonged seizures lasting more
than 5 minutes or repeated seizures over the
course of 30 minutes.
• Sudden withdrawal from AEDs
• Infections
• Acute alcohol withdrawal
• Head trauma
• Cerebral Edema
• Metabolic disturbances
• It is a Neurologic Emergency.

Diagnostic tests
Along with history taking and physical examination
 Blood tests: CBC, electrolytes, glucose, Calcium,
Magnesium, phosphate, hepatic and renal function
 Lumbar puncture only if meningitis or encephalitis
suspected and potential for brain herniation is ruled out
 Blood or urine screen for drugs
• EEG
• CT Scan
• MRI
• PET
• Laboratory studies to determine metabolic or genetic
disorders.

EEG Abnormalities
Look for:
– Spikes
– Sharp waves
– Spike-wave complexes
 May be focal, lateralized,generalized

Pharmacotherapy
• Major component of management.
• Introduces one drug at a time to achieve
seizure control.
• Dosage of medications are adjusted to achieve
therapeutic blood levels without causing
major side effects.

Surgical management
• Resective Surgery: In this the focal area of the
seizures activity is excised.
• Callosotomy: Include the separation of the
connection between the two hemispheres of the
brain and is used in some generalized seizures.
• Vagus nerve stimulation and deep brain
stimulation:- It uses an implantable device that
reduces seizure in individuals who have not had
effective control with drug therapy.

NURSING MANAGEMENT
Aims:
• To control seizures
• Protecting the person from injury
• To determine and to treat the
underlying cause.
• To prevent and to treat medial
complications
• To provide accurate data based on
observation of the patient

• To rehabilitate and to teach the patient and his
family.
Immediate care:
• The patient experiencing a seizure demands
immediate attention.
• Airway management and safety are the top two
priorities.

Before and during a seizure:
 If the patient is seated when a major seizure
occurs, ease him or her to the floor if
possible.
 If the patient experiences an aura, have him
to lie down to prevent injury.
 Move person away from danger e.g. Fire,
water, furniture , machinery etc.

 Provide privacy by pulling the bed curtains,
screen or closing the door.
 Remove patient’s eyeglasses
 Loosen any constricting clothing
 Do not try to force anything into the mouth
 Remove objects that may obstruct breathing
or cause injury to patient.

 Avoid tongue biting by inserting spoon or a
piece of wood wrapped with cloth
 Use a naso pharyngeal airway if needed.
Forcing a tongue blade or airway into the
mouth may break teeth or hamper breathing
efforts
 Never insert your fingers into patients’ mouth
during a seizure. Turn patient on his side to
provide for drainage of oral secretions

 Don’t forcibly restrain patient during
seizures
 Protect patient head from injury by putting
a pillow or folded blanket under the
patients head.
 Guide the movements to prevent injuries
 Inform the doctor and carry out the orders
 Stay with the patient throughout the
seizure to ensure safety

Essential steps to ensure safety:
Keep bed flat and patient turned on his side.
The side rails of the bed should be up and
padded.
Suction and airway should be made
available.
Room lighting should be dim and noise to be
kept to a minimum

check vital signs immediately.
check lips, tongue and inside of
mouth for injuries.
if patient is incontinent, change
clothing and bedding.
check the seizure prone patients
temperature with a rectal
thermometer.

After a seizure:
• Position the patient on the side.
• Provide adequate ventilation.
• Suctioning may be necessary.
• Allow the patient to sleep after the seizure.
• On awakening, orient the patient

Nursing assessment and documentation
Collecting data
Observations
Verbal reinforcement

CONTROLLING SEIZURES
Patients should be put on anti-convulsant
drugs.
Assess the effectiveness of the drug.
Observe for any signs of toxicity to the drug.
Attend to the oral hygiene.

DRUG NURSING INTERVENTIONS
Divalproex (Depakote)
Valproic Acid
(Depakene)
Monitor for hairloss, tremor, increased liver enzymes,
bruising and N/V.
Monitor CBC, PT, PTT and AST
Gabapentin (Neurontin) Watch for increased appetite and weight gain.
Monitor for ataxia, irritability, dizziness and fatigue.
Phenobarbital Note that this is less desirable than other AEDs
because of sedation.
Overdose can be fatal.
Monitor for drowsiness, sleep disturbances, cognitive
impairment and depression.
Phenytoin Monitor for gastric distress, gingival hyperplasia,
anemia, ataxia, and nystagmus.
Check CBC and Calcium levels.
For IV, Flush catheter with saline before and after
administration.

PATIENT EDUCATION AND
REHABILITATION

 Make regular follow-up.
 Visit the doctor as suggested .
 No food restriction.
 Continue all routine work.
 Make use of proper support and give
encouragement to client.

Do’s:
• Take prescribed medicines regularly
• Eat regularly – patient should not fast
• Rest regularly as lack of sleep or tiredness can
precipitate an attack.
• Take tablets regularly for 3-5 years

Do’s:
• They can go to school
• They can play
• They can work like others except near the machines
or electrical installations.
• They can marry but there must be at least a year fit
free period before marrying.

References
• Joyce M Black, M.S.N.R.N. Nursing specialist, “Medical –Surgical
Nursing”, fifth edition, W.B. Saunders company, pages-834-835.
• Hickey Joanne, “the clinical practice of neurological, neurosurgical
nursing”, fifth edition, published in London-2003, pages-612-618.
• Luckmann and sovensons, “Medical and surgical nursing”, fourth
edition, printed in London, W.B.S Saunders company-1996, pages-
106-108.
• T.P.Prema, K.F.Graicy, “essentials of neurological and neurosurgical
nursing”, Jaypee brothers, pages-155-157.
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