Seizures are characterized by sudden, uncontrolled electrical disturbances in the brain. These disruptions can manifest in various ways, affecting muscle control, sensation, behavior, memory, and consciousness. It’s important to note that not all seizures are indicative of epilepsy. They can be triggered by a range of acute conditions such as high fever, sleep deprivation, and withdrawal from substances like alcohol or benzodiazepines. Electrolyte imbalances and hypoglycemia can also provoke seizures. Furthermore, underlying medical conditions such as traumatic brain injuries, stroke, and brain tumors are recognized causes of seizure activity.
Epilepsy, on the other hand, is a chronic neurological disorder defined by recurrent, unprovoked seizures. It can emerge at any age and is typically diagnosed after an individual experiences two or more unprovoked seizures. While there is currently no definitive cure for epilepsy, some children may naturally outgrow the condition, and many individuals achieve seizure freedom through consistent, long-term management.
Seizure Classifications
Seizures are classified based on their onset, further categorized by their motor components:
Generalized Onset Seizures: These seizures involve abnormal electrical activity originating simultaneously across both hemispheres of the brain. Examples include:
- Tonic-Clonic Seizures: Characterized by muscle stiffening (tonic phase) followed by jerking movements (clonic phase).
- Absence Seizures: Involve brief lapses of consciousness, often appearing as staring spells.
- Atonic Seizures: Marked by a sudden loss of muscle tone, potentially leading to falls.
Focal Onset Seizures: These seizures begin with abnormal electrical activity in a specific area of one brain hemisphere. They are further divided into:
- Focal Onset Aware Seizures (Simple Partial Seizures): The individual remains conscious and aware during the seizure.
- Focal Onset Impaired Awareness Seizures (Complex Partial Seizures): Consciousness is altered, and the individual may be confused or unaware of their surroundings.
It’s crucial to note that a focal seizure, starting in one hemisphere, can spread to both sides of the brain, evolving into a focal to bilateral tonic-clonic seizure. Patients often report experiencing an aura, a sensory warning, before such generalized seizures.
Unknown Onset Seizures: This classification is used when the seizure onset is unclear or details are lacking. Further investigation and information gathering may lead to a more specific diagnosis.
Nursing Process for Seizure Management
In nursing care, patient safety is paramount during and after a seizure. For patients with a known seizure history or diagnosis, implementing seizure precautions is essential. This includes ensuring the bed is in the lowest position, side rails are padded, and suction equipment is readily available. Long-term seizure control relies heavily on patient education and strict adherence to prescribed treatment plans, areas where nurses play a crucial supportive and educational role.
Nursing Assessment for Seizures
The nursing assessment is the foundational step in providing care. It involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic. This section focuses on subjective and objective data collection relevant to seizures.
Review of Health History
1. Elicit General Symptoms: Seizure symptoms are diverse and depend on the seizure type. Inquire about the patient’s recollection of events before, during, and after the seizure. Some individuals experience a prodrome or aura as a pre-seizure warning.
Common seizure symptoms include:
- Vocalization at onset (cry or noise)
- Sudden altered consciousness
- Unresponsiveness to stimuli
- Rhythmic motor activity (tonic-clonic seizures)
- Fixed gaze
- Involuntary limb movements
- Urinary incontinence
- Tongue biting
- Muscle weakness or limpness
- Muscle twitching
- Clapping
- Lip smacking
Postictal state symptoms (following the seizure) can include:
- Transient altered consciousness
- Unusual perceptions
2. Identify Potential Causes: Determine if seizures are provoked or unprovoked. For epilepsy patients, identify potential seizure triggers:
- Sleep deprivation
- Illness
- Flashing lights
- Alcohol or drug use
- Stress
- Menstrual cycle fluctuations
- Certain medications
- Excessive caffeine intake
3. Medical History Review: Explore possible underlying causes of epilepsy, even if idiopathic in some cases:
- Brain infections
- Autoimmune disorders
- Genetic predisposition
- Brain structural abnormalities
4. Head Trauma History: Inquire about past head injuries, as acute trauma can trigger seizures and lower the seizure threshold.
5. Medication Review: Assess medication adherence in epilepsy patients, as non-adherence to antiseizure medications is a significant risk factor for breakthrough seizures.
6. Observer Interviews: For seizures involving loss of consciousness, interview witnesses (family, bystanders) to gather information about pre-seizure events (provocation), seizure characteristics, and postictal state.
Physical Assessment
1. Assess ABCs: Immediately evaluate Airway, Breathing, and Circulation during and post-seizure. Respiratory depression is a common post-seizure concern, necessitating continuous ABC monitoring.
2. Note Seizure Characteristics: Document motor manifestations like tonic-clonic phases, lip smacking, or blank stares (absence seizures).
3. Assess Postictal Consciousness: Evaluate changes in consciousness, behavior, or perceptions post-seizure. The postictal period can last from minutes to hours, presenting with confusion, fatigue, headache, and speech or vision difficulties.
4. Neurological and General Assessment: Conduct a thorough neurological exam to identify deficits or injuries from the seizure. Monitor vital signs frequently.
5. Inquire About Aura: Ask about auras – warning signs preceding seizures. Auras are focal seizure manifestations and can include deja vu, tingling, tastes, smells, fear, joy, sounds, colors, or a sense of impending doom.
Diagnostic Procedures
1. Initial Lab Tests: For new-onset seizures without epilepsy history, expect labs to rule out secondary causes like electrolyte imbalances, substance use, or hypoglycemia.
2. Serum Medication Levels: For certain antiseizure drugs (e.g., valproic acid), monitor serum levels to ensure therapeutic range. Subtherapeutic levels may indicate non-adherence.
3. Lumbar Puncture Consideration: Consider lumbar puncture for febrile seizures, immunocompromised patients, or signs of CNS infection.
4. Neuroimaging Anticipation: Brain MRI or CT scans are often indicated to identify structural abnormalities causing seizures.
5. Brain Activity Assessment (EEG): Electroencephalography (EEG) is crucial for diagnosing and classifying seizures by assessing brain electrical activity.
Alt Text: A medical professional performs an electroencephalogram (EEG) test on a patient to diagnose seizures by monitoring brain activity with electrodes attached to the scalp.
Nursing Interventions for Seizures
Nursing interventions are vital for patient safety and recovery during and after seizures.
1. Stay with the Patient During a Seizure: If a seizure occurs:
- Record the seizure start time.
- Loosen restrictive clothing.
- Clear the surrounding area.
- Do not restrain the patient.
- Never insert anything into the mouth.
- Monitor airway and breathing.
- Remain with the patient until seizure cessation.
- Place in recovery position post-seizure.
- Assess for injuries after the seizure.
2. Stabilize Patient Condition: Prioritize airway, breathing, and circulation. Administer benzodiazepines (lorazepam, midazolam, diazepam) as prescribed for ongoing seizures. Manage generalized convulsive status epilepticus with advanced airway interventions.
3. Institute Seizure Precautions: For hospitalized patients with seizure risk:
- Pad bed rails.
- Keep bed in lowest position.
- Ensure bedside suction and resuscitation equipment.
- Remove environmental hazards.
4. Manage Alcohol Withdrawal: Monitor for recurrent seizures in alcohol withdrawal and treat preventatively with lorazepam.
5. Administer Antiseizure Medications: Combination therapy is often more effective than monotherapy. Common antiseizure drug classes include:
- GABA receptor agonists (Benzodiazepines, Barbiturates)
- Sodium channel blockers (Carbamazepine, Oxcarbazepine, Phenytoin, Lamotrigine, Lacosamide, Zonisamide)
- GABA reuptake inhibitors (Tiagabine)
- GABA transaminase inhibitors (Vigabatrin, Valproic acid)
- Glutamate antagonists (Topiramate, Felbamate, Perampanel)
- Synaptic vesicle protein 2A binders (Levetiracetam, Brivaracetam)
- Multiple mechanism drugs (Gabapentin, Pregabalin)
6. Ensure Rescue Medication Access: Provide rescue medications (benzodiazepines, often via buccal, nasal, rectal, or sublingual routes) for seizure exacerbations.
7. Educate on Implanted Devices: For medication-refractory epilepsy, discuss neuromodulation options:
- Deep Brain Stimulation (DBS)
- Responsive Neurostimulation (RNS)
- Vagus Nerve Stimulation (VNS)
8. Discuss Surgical Options: Consider epilepsy surgery for uncontrolled seizures. Procedures may involve removing seizure-generating brain tissue or disconnecting seizure pathways. Surgery can be curative or reduce seizure frequency/severity.
9. Encourage Diet Modification: Adjunctive dietary therapies include:
- Ketogenic diet (high-fat, low-carb, primarily for children)
- Modified Atkins diet (less restrictive ketogenic variant)
10. Educate on Safety Precautions: Advise epilepsy patients on safety measures:
- Medical alert bracelet
- Helmet use during cycling
- Supervised swimming/bathing
- Caution around heat/fires
For uncontrolled seizures:
- Avoid unsupervised stair climbing
- Avoid working at heights or using power tools/heavy machinery
- Avoid high-risk activities (rock climbing, scuba diving)
Driving laws vary by state, often requiring seizure-free periods (3-12 months) for licensure.
11. Seizure Action Plan Development: Create a personalized action plan including patient information, medications, healthcare contacts, and emergency protocols. Ensure the patient carries it and shares copies with caregivers and schools.
12. Discuss Complementary Therapies: Address patient interest in complementary therapies (herbal remedies, acupuncture, massage, meditation) and discuss potential benefits and risks.
13. Epilepsy Center Referral: For uncontrolled epilepsy, consider referral to specialized epilepsy centers for advanced diagnostics (video EEG) and tailored treatment plans.
Alt Text: A visual guide outlining seizure first aid steps: protect the person, cushion their head, loosen tight clothes, turn them to their side, time the seizure, and stay until it ends and they are fully awake.
Nursing Care Plans for Seizures
Nursing care plans prioritize assessments and interventions based on identified nursing diagnoses, guiding short- and long-term care goals. Examples for seizure care include:
Caregiver Role Strain
Caregiver role strain can affect individuals caring for someone with epilepsy or those with epilepsy managing caregiver responsibilities.
Nursing Diagnosis: Caregiver Role Strain
Related Factors:
- Chronic seizures
- Seizure unpredictability
- Lack of family support
- Financial strain
- Resource scarcity
Evidenced By:
- Increased stress levels
- Anxiety, depression
- Sleep disturbances
- Transportation limitations due to inability to drive
- Employment difficulties
- Challenges in childcare
- Social isolation
Expected Outcomes:
- Caregiver will identify support resources.
- Patient will report improved caregiver role perception with seizure control.
- Caregiver will verbalize realistic self-expectations.
Assessments:
- Caregiver Role Assessment: Evaluate caregiver responsibilities for individuals with or without epilepsy.
- Support System Assessment: Determine available support systems, especially for those unable to work or drive.
- Perception of Epilepsy Impact: Assess patient’s views on epilepsy control, independence, and potential isolation.
Interventions:
- Epilepsy Center Recommendation: Refer to epilepsy centers for comprehensive care, especially for complex cases.
- Delegation and Coordination Encouragement: Promote task delegation to reduce caregiver burden.
- Resource Provision: Connect with epilepsy support groups and financial aid resources.
- Case Management Referral: Utilize nurse case managers for education, stress management, and care coordination.
Deficient Knowledge
Lack of knowledge regarding seizures can hinder seizure control.
Nursing Diagnosis: Deficient Knowledge
Related Factors:
- Limited understanding of seizure causes and triggers
- Disinterest in seizure information
- Impaired recall of education
Evidenced By:
- Medication non-adherence
- Increased seizure frequency
- Seizure-related injuries
Expected Outcomes:
- Patient will verbalize understanding of seizure type and symptoms.
- Patient will identify personal seizure triggers.
- Patient will demonstrate medication adherence for 30 days.
Assessments:
- Seizure Knowledge Assessment: Evaluate understanding of seizure types, auras, and modifiable risk factors.
- Activity Restriction Adherence: Assess understanding and adherence to safety precautions like driving restrictions and high-risk activity avoidance.
- Medication Adherence Review: Assess understanding of medication regimen importance.
Interventions:
- Seizure Diary Instruction: Teach patients to maintain a seizure log (date, time, duration, aura, triggers) to identify patterns.
- Trigger Review: Educate on common triggers like stress, sleep deprivation, flashing lights, and hormonal changes.
- Warning Sign Recognition: Help patients recognize individual auras or pre-seizure symptoms for preparedness.
- Action Plan Provision: Develop a comprehensive action plan with medication lists, contacts, and seizure details for emergency preparedness and care continuity.
Ineffective Airway Clearance
Airway compromise can occur during seizures.
Nursing Diagnosis: Ineffective Airway Clearance
Related Factors:
- Retained secretions
- Airway obstruction (tongue)
- Neuromuscular impairment
- Respiratory depression
- Loss of reflexes
Evidenced By:
- Ineffective cough
- Excessive sputum
- Hypoxia
- Altered respiratory rhythm
- Cyanosis
- Abnormal breath sounds
- Tachypnea
Expected Outcomes:
- Maintain patent airway.
- Demonstrate effective airway clearance and clear breath sounds.
Assessments:
- Respiratory Status Monitoring: Assess rate, rhythm, depth, and effort of breathing.
- Obstructive Sleep Apnea Assessment: Evaluate for sleep disorders that can worsen seizures.
- Oxygen Saturation Monitoring: Continuously monitor SpO2, especially post-seizure, due to respiratory depression risk.
- Cough and Swallow Ability: Assess effectiveness of cough and swallow reflexes for secretion clearance.
Interventions:
- Supplemental Oxygen Administration: Provide oxygen (non-rebreather mask) as needed to prevent desaturation.
- Recovery Position: Position patient on their side (recovery position) during and after seizures to maintain airway patency and drainage.
- Clothing Loosening: Loosen restrictive clothing around neck and chest.
- Suctioning: Suction oral secretions cautiously during and after seizures, avoiding oral insertion during active seizure.
Risk for Aspiration
Aspiration risk is elevated during and after seizures.
Nursing Diagnosis: Risk for Aspiration
Related Factors:
- Ineffective airway clearance
- Airway obstruction
- Loss of gag reflex
- Neuromuscular impairment
- Decreased consciousness
Evidenced By:
- (Risk diagnosis – no defining signs/symptoms)
Expected Outcomes:
- Maintain patent airway and clear lungs.
- Remain free from aspiration complications (pneumonia, respiratory distress).
Assessments:
- Secretion/Vomitus Assessment: Monitor for secretions, blood, or vomitus during seizures.
- Oxygen Saturation Monitoring: Monitor SpO2 for late-onset drops indicating aspiration pneumonia.
- High-Risk Patient Identification: Identify infants, elderly, and developmentally delayed patients at higher aspiration risk.
Interventions:
- Nothing per Mouth During Seizure: Avoid placing objects in the mouth during a seizure.
- Dentures Removal: Instruct patients to remove dentures when not needed.
- Suctioning as Needed: Suction oral cavity when safe to remove secretions.
- NPO Until Fully Alert: Keep patient NPO post-seizure until fully alert to prevent aspiration.
Risk for Injury
Seizures increase injury risk due to loss of control and awareness.
Nursing Diagnosis: Risk For Injury
Related Factors:
- Loss of muscle control
- Falls
- Loss of consciousness
- Altered sensations
- Convulsions
- Impaired swallowing/airway clearance
Evidenced By:
- (Risk diagnosis – no defining signs/symptoms)
Expected Outcomes:
- Remain safe and injury-free during seizures.
- Modify environment for seizure safety.
- Patient/family will verbalize seizure safety measures.
Assessments:
- Seizure Pattern Exploration: Identify seizure triggers and patterns to anticipate and prevent injuries.
- Caregiver Availability Assessment: Assess support systems and ensure caregivers understand seizure safety protocols.
Interventions:
- Patent Airway Maintenance: Position patient on side, loosen clothing, avoid oral objects, administer oxygen if needed.
- Hazard Removal: Remove furniture and sharp objects, keep bed low.
- No Restraints, Close Monitoring: Avoid restraints, provide padding, and closely monitor during seizures.
- Activity Restriction Education: Counsel on precautions for activities like swimming, driving, and working at heights.
- Medical Alert Bracelet Recommendation: Encourage medical identification for emergency situations.
