Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for seizures
- Describe the diagnostics and laboratory values in seizures
- Apply nursing concepts and plan associated nursing care for the patient with seizures
- Evaluate the efficacy of nursing care for the patient with seizures
- Describe the medical therapies that apply to the care of seizures
A seizure occurs when some of the brain’s neurons experience sudden and uncontrolled electrical activity, sending incorrect messages between brain cells. Electrical bursts may cause changes in consciousness or may cause the body to react with involuntary movements and behavior.
Seizures come in several types and have various causes. Some patients experience seizures because they have epilepsy, an incurable neurological disease that causes recurring seizures. This section provides an overview of seizures, including epilepsy, and explains the nursing care that is needed to help patients with seizures.
Pathophysiology
When the brain’s neurons function normally, they produce chemical and electrical signals that interact with other neurons, as well as the body’s muscles and organs, to create each person’s feelings, thoughts, and behaviors. During a seizure, the neurons send signals at a much greater speed, and multiple neurons may send signals at the same time, creating overlapping neuron communication that is too rapid. The body responds with seizures.
Seizures can be triggered by a variety of factors, including high fever, brain tumors, strokes, head trauma, heart attacks, and infections such as encephalitis and meningitis. Patients who have diabetic hypoglycemia may experience a seizure if their glucose level drops too low. Diseases, such as Alzheimer disease, can cause seizures, and seizures have been linked to alcoholism. Any condition or disease that deprives the brain of oxygen or causes the brain to become inflamed has the potential to cause a seizure. In addition, seizures can be triggered by physical problems such as stress, sleep deprivation, hormonal changes, and dehydration. Certain medications, such as atypical antipsychotic drugs and opioids, may lower a patient’s seizure threshold, which is the likelihood that a patient will have a seizure.
Some patients have seizures because of epilepsy, which is a neurological disorder that causes surges of electrical activity in the brain, resulting in recurring seizures. Epileptic seizures are unprovoked, and doctors typically diagnose epilepsy in patients with seizures when they have two unprovoked seizures.
Types of Seizures
Seizures are categorized as either focal or generalized, and each category includes several different subtypes of seizures:
- focal seizure—As the name implies, a focal seizure begins in one area of the brain. Focal seizures include the following types:
- onset awareness—The patient is awake and aware throughout the seizure, which may begin with twitching or stiffness in a specific part of the body, such as the hand; as the twitching and/or stiffness spreads, the patient may experience a range of emotions including happiness, fear, or depression, and they may have déjà vu accompanied by nausea; they may also have hallucinations and see flashing lights.
- onset impaired awareness—The patient is confused and not fully aware during the seizure; they may lose consciousness and have uncontrolled movements such as lip smacking and bicycling legs.
- generalized seizure—A generalized seizure affects both sides of the brain at the same time. Generalized seizures include the following types:
- absence generalized seizure—The patient stares into space and may have slight twitching.
- atonic generalized seizure —The patient loses normal muscle tone, which may cause them to involuntary drop their head or fall down.
- clonic generalized seizure —The patient has repetitious jerking movements on both sides of their body
- myoclonic generalized seizure —The patient has twitches and/or jerks in the arms, upper body, or legs.
- tonic generalized seizure —The patient’s muscles stiffen, typically in the arms, legs, and/or back.
- tonic-clonic generalized seizure —The patient has a combination of reactions that may include repetitious jerking, stiffening, and/or a loss of consciousness.
Each type of seizure may have three phases. The prodrome phase occurs before the seizure actually begins and includes warning signals—such as a headache, dizziness, racing thoughts, or disorientation—that indicate a seizure is going to happen. Prodrome may occur hours, or even days, before a seizure ensues. The ictal phase begins with the first symptom of the seizure and lasts until the seizure ends. The postictal phase is the recovery period after a seizure ends. During the postictal phase, which may last minutes or hours, patients may be confused, scared, frustrated, and anxious. They may have memory lapses and may struggle to do things such as walk or write. They may also experience physical symptoms, such as a headache, muscle weakness, and loss of bladder control.
Clinical Manifestations
The symptoms of seizures vary and can be mild or severe. Common symptoms include confusion, staring, uncontrollable twitching or jerking of the arms and legs, sudden falls, body spasms, tense and/or stiffened muscles, weakened muscles, loss of awareness or consciousness, anxiety and fear, and a feeling of déjà vu. Patients may also experience strange sensations and emotions and feel that they have an aura when a seizure begins. An aura may include a sense of déjà vu and/or a sudden feeling of intense emotion such as fear or happiness.
If seizures are caused by factors such as hypoglycemia, infection, or head trauma that can be treated and resolved, treating the cause should also stop the patient’s seizures. If seizures are caused by factors that cannot be cured, including epilepsy, the patient will need health care focused on minimizing and managing the seizures.
Assessment and Diagnostics
Seizures are assessed and diagnosed with a physical examination and tests. The physical examination should assess the patient’s cognitive functioning, behavior, and motor abilities, as well as gather the patient’s medical history. This should include information about illnesses and medications that could be a factor in the patient’s seizures, and details about a family history of seizures.
Diagnostics and Laboratory Values
Tests for patients with seizures may include blood tests, lumbar puncture electroencephalogram (EEG), stereoelectroencephalography (SEEG), MRI, CT, PET, and single-photon emission computed tomography (SPECT).
Blood tests will show if the patient has genetic conditions or infections that can cause seizures. Lumbar punctures also show infections that can cause seizures. An EEG shows the brain’s electrical activity and can reveal abnormal patterns that cause seizures. A SEEG involves surgically implanting electrodes in the brain to track brain activity and determine where seizures originate. MRIs and CTs show abnormal changes in the brain, such as brain tumors and cysts, which may be the cause of seizures. PET scans track abnormal chemical changes in the brain that may cause seizures. PET scans also show areas of the brain that have abnormal metabolism, which indicates the area of the brain that is the focus of a seizure after it is over. SPECT tracks the brain’s blood flow during a seizure. SPECT blood flow tracers should be injected during periods of seizure and compared to periods when the patient is not having a seizure. During a seizure, the seizure onset area will show a higher blood flow, identifying where the seizure originates.
Nursing Care of the Patient with Seizures
Nursing care for patients with seizures should focus on keeping patients safe while controlling symptoms. Hazards, such as footstools and other things that could cause patients to fall if they have a seizure, should be removed. If patients are in bed, they should have guard rails, and during a seizure, their head should be supported with a pillow. Tight clothing should be removed, and some patients may need oxygen to support breathing. Nurses should provide education to help patients and their families learn to live with and manage seizures. This may include eating a healthier diet and avoiding triggers for seizures, such as bright lights and sleep deprivation.
Link to Learning
Every seizure causes neurological dysfunction, making the treatment of seizures critical for patient well-being. Patients with seizures need early therapy and preventative measures to minimize the possibility of recurring seizures.
Recognizing Cues and Analyzing Cues
The cues of seizures will be found in the patient’s physical examination and test results. Patients and their family members should be able to tell the nurse if the patient has had seizures. Even if the patient does not have a seizure during the examination, the physical examination may still yield cues of seizures if the patient exhibits symptoms such as confusion, weakened muscles, and anxiety. If the patient is under observation and has a seizure, the cues may include uncontrollable twitching or jerking of the arms and legs, body spasms, tense muscles, and loss of awareness or consciousness. Other cues, which the provider will use for diagnosis, will come from the patient’s test results. Blood tests and lumbar punctures may show infections that are causing the seizures. Imaging may show cues such as brain tumors and cysts that can cause seizures. Results of EEGs, SEEGs, PETs, and SPECTs will show additional cues by providing information about the brain’s blood flow, electrical activity, and chemical activity.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Seizures should be prioritized based on the severity of symptoms. Severe symptoms, particularly for frequent seizures, should be a higher priority than infrequent seizures and/or seizures with mild symptoms. In particular, severe seizures that jeopardize patients’ safety, and possibly even put them at risk of death, must be prioritized over mild seizures that cause more minor issues, such as mild twitching and muscle weakness. Nurses should work with patients’ health-care team members to generate solutions. The nursing interventions appropriate for patients with seizures may include those in Table 17.15.
| Nursing Care | Rationale |
|---|---|
| Complete focused neurological assessments. | Twitching, muscle weakness, staring, confusion, anxiety, and other related symptoms are cues of seizures. |
| Care during seizures. | During a seizure, remove hazards, particularly sharp objects, and allow the patient’s body to move freely. Place a pillow under their head and turn the patient on their side to keep their tongue from blocking the airway. If the patient is wearing eyeglasses and/or necklaces or other items around their neck, remove these if possible. Never attempt to place your fingers into a mouth of a patient who is seizing, and do not attempt to put a barrier between the teeth of a patient having a seizure. After the seizure, provide emotional support and check the patient’s vital signs, including awareness levels. Apply supplemental oxygen and provide suction to prevent the patient from aspirating. Ask the patient questions, such as, What is your name? Where are you? Documentation of a seizure includes time of onset, duration of the active seizure, and the length of the postal state. It also includes assessing if the patient experienced an aura before the seizure onset. If the seizure lasts more than five minutes, it is an emergency, and the provider should be called. |
| Monitor vital signs. | Changes in the patient’s vital signs such as heart rate and blood pressure may indicate health problems. |
| Administer medications specifically for seizures. | The appropriate medicine for each patient depends on the type of seizure and frequency, patient’s lifestyle and age, and other factors such as other medications the patient is taking and whether the patient is pregnant. Medications that may be considered include brivaracetam, cannabidiol oral solution, cenobamate, clonazepam, and divalproex sodium. |
| Administer other medications. | Patients with seizures may need medications to control other problems that may occur as a result of their seizures. For example, patients who develop a headache following a seizure may need pain medication, and patients who have trouble sleeping may benefit by taking a sedative. |
| Prepare for surgery and aftercare. | Some patients may need surgery to stop seizures. Nurses should help prepare patients for surgery and should provide surgery aftercare, such as dressing the patient’s surgical wound(s). Options for surgical procedures that can help patients with seizures include the following:
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| Assist with electrical stimulation. | Nurses may assist providers as they conduct electrical stimulation, which includes the options of vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation to implant devices that send signals to the brain to stop seizures. |
| Consult with a dietician for nutrition issues. | Some patients with seizures, particularly those with epilepsy, may need to change their diet to eat foods that are high in protein and fat, while low in carbohydrates. |
| Assist with mental health support. | Patients with seizures, particularly those with epilepsy, and their families may need consultation with a mental health professional to help them cope with the challenges of living with seizures. Some patients may need prescription medications to help with issues such as anxiety and depression. |
Evaluation of Nursing Care for Patients with Seizures
The desired outcome for patients with seizures is a cure if their seizures are caused by a factor that can be cured, such as infection. If patients with seizures cannot be cured, their condition should be controlled, and they should experience few or no seizures even if they still have an incurable condition, such as epilepsy, that triggers seizures. Patients with seizures should also understand the risks associated with seizures, and they should exercise safety protocols to minimize the dangers posed by seizures. They should also understand the importance of medications in treating seizures and should be committed to taking the appropriate medications as needed.
Medical Therapies and Related Care
The medical therapies used to treat patients with seizures typically include antiepileptic drugs (AEDs), which are categorized as either broad-spectrum or narrow-spectrum. Broad-spectrum AEDs treat various seizure types and are often used initially, particularly if the patient’s diagnosis has not determined seizure type. Broad-spectrum AEDs include clobazam, clonazepam, lamotrigine, levetiracetam, perampanel, rufinamide, topiramate, valproic acid, and zonisamide. Narrow-spectrum AEDs generally are used to treat focal seizures and include carbamazepine, ezogabine, gabapentin, lacosamide, oxcarbazepine, phenytoin, pregabalin, and vigabatrin.
Some patients with seizures may benefit from surgery, such as corpus callosotomy, a procedure that involves cutting the connection between the right and left sides of the brain to slow electrical activity between the hemispheres. Laser interstitial thermal therapy uses computer navigation to find and destroy lesions in a patient’s brain that cause seizures. Stereotactic radiosurgery relies on 3D imaging to locate and destroy misfiring nerve cells.
Electrical stimulation benefits some patients with seizures. In this procedure, a neurostimulator is placed inside the patient’s skull and connected to electrodes that continuously monitor the patient’s brain activity. When a seizure is detected, the electrodes emit an electrical signal that attempts to stop the seizure.
Nutrition can also be a vital part of helping patients with seizures. Patients with seizures need a balanced diet that includes proteins, fats, and carbohydrates along with sufficient fluid intake to prevent dehydration.