Seizures, characterized by sudden, uncontrolled electrical disturbances in the brain, can manifest in various ways, affecting muscle control, sensation, behavior, memory, and consciousness. These neurological events are not always indicative of epilepsy; they can arise from a multitude of underlying conditions such as high fever, sleep deprivation, and substance withdrawal, including from alcohol and benzodiazepines. Electrolyte imbalances and hypoglycemia are also significant metabolic triggers. Furthermore, seizures can be a consequence of medical conditions like traumatic brain injuries, stroke, and brain tumors. Understanding the risk factors and implementing appropriate nursing care are crucial for patient safety and well-being.
Epilepsy, defined as a chronic neurological disorder, is marked by recurrent, unprovoked seizures. It can emerge at any stage of life and is typically diagnosed after an individual experiences two or more unprovoked seizures. While epilepsy remains a lifelong condition for many, some children may outgrow it, and others may achieve seizure freedom through consistent treatment.
This article delves into the nursing diagnosis of “risk for seizures,” providing a comprehensive guide for healthcare professionals. We will explore the classification of seizures, essential nursing assessments, targeted interventions, and effective care plans to mitigate risks and optimize patient outcomes.
Classifications of Seizures
Seizure classification is primarily based on the onset of abnormal electrical activity in the brain and further categorized by the motor components exhibited during the seizure. The International League Against Epilepsy (ILAE) classifies seizures into three main categories based on where they begin in the brain:
Generalized Onset Seizures: These seizures originate simultaneously in networks involving both sides of the brain. Generalized onset seizures can be further categorized, including:
- Tonic-Clonic Seizures: Characterized by muscle stiffening (tonic phase) followed by rhythmic jerking movements (clonic phase). This is what is often thought of as a ‘grand mal’ seizure.
- Absence Seizures: Often brief, these seizures involve a sudden lapse of awareness, sometimes accompanied by subtle body movements like eye blinking or lip smacking. Formerly known as petit mal seizures, they are more common in children.
- Atonic Seizures: Involve a sudden loss of muscle tone, which can cause falls or head drops. These are also known as drop attacks.
Focal Onset Seizures: These seizures begin in a specific area or network on one side of the brain. Focal seizures are further classified by the patient’s level of awareness:
- Focal Onset Aware Seizures: Previously known as simple partial seizures, the individual remains conscious and aware throughout the seizure, although they may experience unusual sensations, emotions, or movements.
- Focal Onset Impaired Awareness Seizures: Formerly known as complex partial seizures, these seizures involve a change or loss of consciousness or awareness. The person may stare blankly, make repetitive movements (automatisms), and be confused after the seizure.
It is important to note that a focal seizure can evolve into a bilateral tonic-clonic seizure. This occurs when the abnormal electrical activity spreads from one side of the brain to both hemispheres. Patients may report experiencing an aura, a sensory warning sign, before the onset of a focal to bilateral tonic-clonic seizure.
Unknown Onset Seizures: When the beginning of a seizure is not known, it is classified as unknown onset. With more detailed observation and information, these seizures may be reclassified as generalized or focal onset.
Nursing Process for Patients at Risk for Seizures
For individuals identified as being at risk for seizures, the nursing process is paramount. The immediate nursing priority during a seizure event is to ensure patient safety. This includes implementing seizure precautions for patients with a known history or diagnosis of seizures. These precautions typically involve ensuring the bed is in the lowest position, padding side rails, and having suction equipment readily available at the bedside. Long-term management involves patient education and promoting strict adherence to prescribed treatment plans, which nurses play a vital role in supporting and reinforcing.
Nursing Assessment for Risk for Seizures
The initial step in nursing care is a comprehensive nursing assessment. This process involves gathering subjective and objective data related to the patient’s risk for seizures, including physical, psychosocial, emotional, and diagnostic information.
Review of Health History
1. Elicit a detailed history of seizure symptoms. Symptoms vary widely depending on the type of seizure. Nurses should ask patients about their recollections of events preceding, during, and following a seizure. Prodromal symptoms or auras may precede a seizure in some individuals.
Common seizure symptoms include:
- Vocalization at onset (e.g., a cry or moan)
- Sudden alteration or loss of consciousness
- Unresponsiveness to verbal or painful stimuli
- Tonic-clonic motor activity (rhythmic muscle contractions and relaxation)
- Sustained eye gaze
- Involuntary movements of limbs
- Urinary or bowel incontinence
- Tongue or cheek biting
- Muscle weakness or limpness
- Muscle twitching (myoclonic jerks)
- Repetitive behaviors like clapping or lip smacking (automatisms)
Postictal symptoms, occurring after the seizure, may include:
- Transient confusion or altered consciousness
- Unusual perceptions or sensory disturbances
2. Identify potential causes and triggers. Determining whether a seizure was provoked or unprovoked is crucial. For patients with known epilepsy or at risk for seizures, identify potential triggers such as:
- Sleep deprivation
- Acute illnesses, especially infections with fever
- Sensory stimuli like flashing lights
- Substance use or withdrawal (alcohol, drugs)
- Elevated stress levels
- Hormonal fluctuations (menstrual cycle)
- Certain medications that lower the seizure threshold
- Excessive caffeine intake
3. Obtain a comprehensive medical history. While some cases of epilepsy have no identifiable cause, potential underlying medical conditions should be explored:
- Central nervous system infections (meningitis, encephalitis)
- Autoimmune disorders
- Genetic predispositions or family history of seizures
- Pre-existing structural brain abnormalities
4. Inquire about head trauma history. Both acute and past traumatic brain injuries can provoke seizures. Brain damage from injury or stroke lowers the threshold for seizure activity.
5. Review medication history. For patients with epilepsy, medication non-adherence is a significant risk factor. Failure to take prescribed antiseizure medications consistently lowers the seizure threshold and increases seizure risk.
6. Interview seizure observers. Patients who experience loss of consciousness or impaired awareness during seizures may not accurately recall events. Gathering information from observers, family members, or caregivers is essential. Inquire about events preceding the seizure (potential triggers), seizure characteristics, and the patient’s postictal state.
Alt text: A nurse attentively reviews a patient’s chart and medication list, focusing on details relevant to seizure risk factors during a health assessment.
Physical Assessment
1. Prioritize ABC assessment. During and immediately after a seizure, the nurse’s first action is to assess and ensure the patient’s airway, breathing, and circulation (ABCs). Respiratory depression is a common postictal complication, requiring continuous monitoring of ABCs.
2. Document seizure characteristics. Observe and document the specifics of the seizure. In tonic-clonic seizures, note the progression from stiffening (tonic phase) to jerking (clonic phase). Document any other motor manifestations like automatisms (lip smacking, hand movements). Recognize that not all seizures involve motor symptoms; absence seizures, for example, manifest as a blank stare.
3. Evaluate postictal consciousness. Assess the patient’s level of consciousness and neurological status following a seizure. Any alteration in consciousness, unusual behavior, or sensory perception may indicate the postictal state, which can last from minutes to hours. Patients may present with confusion, fatigue, headache, and difficulties with vision or speech.
4. Conduct a thorough neurological and general physical exam. Perform a focused neurological exam to identify any deficits or injuries sustained during the seizure. Obtain vital signs frequently to monitor for postictal changes.
5. Determine if an aura is present. Inquire if the patient experiences an aura, a warning sign preceding some focal seizures. Auras can manifest as a deja vu sensation, tingling, unusual tastes or smells, intense emotions (fear, joy), sounds, visual phenomena, or a sense of impending doom. While considered part of the seizure itself, auras can be valuable in identifying seizure onset and type.
Diagnostic Procedures
1. Anticipate initial laboratory studies. For patients presenting with new-onset seizures and no prior epilepsy diagnosis, laboratory investigations are essential to identify potential secondary causes. Common labs include:
- Electrolyte panel to rule out imbalances (sodium, calcium, magnesium, glucose)
- Blood glucose to exclude hypoglycemia
- Toxicology screen to detect alcohol or drug use
2. Monitor serum medication levels. For patients taking antiseizure medications, especially drugs like valproic acid or phenytoin, monitor serum levels to ensure therapeutic ranges are achieved. Subtherapeutic levels in patients with known epilepsy may indicate medication non-adherence and increased seizure risk.
3. Consider lumbar puncture (spinal tap). Lumbar puncture may be indicated in specific situations, such as:
- Febrile seizures in infants and young children to rule out meningitis
- Patients with immunocompromise or signs of central nervous system infection (fever, nuchal rigidity, altered mental status)
4. Prepare for neuroimaging studies. Brain MRI or head CT scans are typically recommended to evaluate for structural brain abnormalities that may be causing seizures, such as tumors, vascular malformations, or evidence of prior stroke or trauma.
5. Electroencephalography (EEG). EEG is a primary diagnostic test for seizures and epilepsy. It measures brain electrical activity and helps to:
- Diagnose epilepsy
- Classify seizure type
- Localize seizure onset zone
- Monitor effectiveness of antiseizure medication
Nursing Interventions for Patients at Risk for Seizures
Effective nursing interventions are crucial for managing patients at risk for seizures and ensuring their safety and well-being.
1. Provide immediate care during an active seizure. When a seizure occurs:
- Stay with the patient and call for assistance.
- Note the time the seizure began and its duration.
- Protect the patient from injury: Guide the patient to the floor if standing or sitting.
- Loosen restrictive clothing, especially around the neck.
- Clear the surrounding area of hazards.
- Do not restrain the patient.
- Never insert anything into the patient’s mouth. This can cause injury to teeth or airway obstruction.
- Monitor airway and breathing.
- Once the seizure subsides, place the patient in the recovery position (on their side) to maintain airway patency and prevent aspiration.
- Assess for injuries that may have occurred during the seizure.
2. Stabilize patient condition post-seizure. Provide supportive care focusing on airway, breathing, and circulation. Administer benzodiazepines (lorazepam, midazolam, diazepam) as ordered for prolonged or cluster seizures or status epilepticus. For generalized convulsive status epilepticus, anticipate and initiate advanced airway management.
3. Implement seizure precautions. For hospitalized patients at risk, institute standard seizure precautions:
- Padded side rails on the bed.
- Bed in the lowest position.
- Suction equipment readily available at the bedside.
- Oxygen and resuscitation equipment nearby.
- Remove potentially hazardous furniture from the bedside area.
4. Manage alcohol withdrawal effectively. For patients experiencing alcohol withdrawal seizures, close monitoring for seizure recurrence is essential. Administer lorazepam or other benzodiazepines as per protocol to prevent further seizures.
5. Administer antiseizure medications as prescribed. Pharmacotherapy is the cornerstone of epilepsy management. A combination of antiseizure medications may be more effective than monotherapy in some cases. Common 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 (SV2A) binders: Levetiracetam, Brivaracetam
- Multiple mechanisms: Gabapentin, Pregabalin
6. Ensure access to rescue medications. Prescribe and educate patients and caregivers on rescue medications for breakthrough seizures or seizure clusters. Benzodiazepines (diazepam rectal gel, midazolam nasal spray or buccal film) are commonly used for rapid seizure termination outside of the hospital setting.
7. Educate on neuromodulation devices. For patients with medication-resistant epilepsy, discuss neuromodulation therapies:
- Deep brain stimulation (DBS): Implants electrodes in specific brain areas to regulate neuronal activity.
- Responsive neurostimulation (RNS): Detects abnormal brain activity and delivers targeted electrical stimulation to stop seizures.
- Vagus nerve stimulation (VNS): Stimulates the vagus nerve in the neck to modulate brain activity and reduce seizure frequency.
8. Discuss surgical options. Epilepsy surgery may be considered when seizures are refractory to medications. Surgical options include:
- Resective surgery: Removal of the seizure onset zone in the brain.
- Disconnective surgery: Interrupts seizure pathways in the brain to prevent spread.
9. Recommend dietary modifications. In conjunction with medication, dietary therapies can be beneficial, particularly for children with epilepsy:
- Ketogenic diet: High-fat, very low-carbohydrate diet that shifts the body’s metabolism to using fat for energy, producing ketones which can have antiseizure effects.
- Modified Atkins diet: Less restrictive than ketogenic diet, allows more protein and carbohydrates but still emphasizes fat intake.
10. Provide comprehensive safety education. Educate patients and families about seizure safety precautions:
- Wear a medical alert bracelet indicating epilepsy.
- Use helmets during activities like cycling to prevent head injury.
- Avoid unsupervised swimming or bathing.
- Exercise caution around heat and open flames.
For patients with uncontrolled seizures, advise additional precautions:
- Avoid climbing stairs alone.
- Do not work at unprotected heights.
- Avoid operating power tools or heavy machinery.
- Refrain from high-risk activities like rock climbing or scuba diving.
- Driving restrictions: Inform patients about state-specific driving laws related to seizures, which often require a seizure-free period (e.g., 3-12 months) to maintain a driver’s license.
11. Develop a seizure action plan. Collaborate with patients and families to create a written seizure action plan. This plan should include:
- Patient demographics and medical history.
- List of current medications, including dosages and timing.
- Emergency contact information for healthcare providers and family.
- Detailed seizure description and usual seizure pattern.
- Step-by-step instructions for seizure first aid.
- When to call emergency services.
- School or workplace accommodations, if needed.
12. Address complementary and alternative therapies. Discuss complementary therapies that patients may be considering, such as herbal remedies, acupuncture, massage, or meditation. Review potential benefits and risks and emphasize that these should not replace conventional medical treatment without physician consultation.
13. Consider referral to an epilepsy center. For patients with complex or uncontrolled epilepsy, referral to a specialized epilepsy center is recommended. Epilepsy centers offer comprehensive diagnostic services, including video-EEG monitoring, and multidisciplinary expertise to optimize treatment plans.
Nursing Care Plans for Risk for Seizures
Nursing care plans are essential tools for organizing and prioritizing nursing care for patients at risk for seizures. They guide assessments and interventions to achieve both short-term and long-term goals. Here are examples of nursing diagnoses relevant to patients at risk for seizures, with associated care plan components:
Risk for Injury
Nursing Diagnosis: Risk for Injury related to loss of muscle control, falls, loss of consciousness, altered sensations, convulsions, and impaired swallowing/airway clearance.
Expected Outcomes:
- Patient will remain free from injury during and following a seizure event.
- Patient and caregivers will verbalize and implement strategies to minimize seizure-related injury risk.
- Patient will maintain a safe environment to prevent seizure-related injuries.
Assessment:
- Identify individual seizure patterns and triggers: Determine if there are predictable patterns or triggers that precede seizures to help anticipate and prepare for events.
- Assess environmental safety: Evaluate the home and hospital environment for potential hazards that could cause injury during a seizure (e.g., sharp objects, unsecured furniture).
- Evaluate patient’s awareness of safety precautions: Assess the patient’s and caregiver’s understanding of seizure safety measures.
- Determine availability of support systems: Assess if the patient lives alone or has reliable caregivers who can provide assistance during and after seizures.
Interventions:
- Ensure airway protection during seizures: Position the patient on their side, loosen restrictive clothing, and have suction available.
- Create a safe environment: Pad bed rails, keep bed in the lowest position, remove hazards from the patient’s vicinity.
- Educate patient and caregivers on seizure first aid: Provide clear instructions on how to protect the patient during a seizure, including positioning, not restraining, and not inserting anything into the mouth.
- Advise on activity modifications: Discuss precautions related to activities that could be dangerous if a seizure occurs (swimming, driving, heights, machinery).
- Promote use of medical alert identification: Encourage the patient to wear a medical alert bracelet or necklace to ensure rapid identification in emergencies.
Risk for Aspiration
Nursing Diagnosis: Risk for Aspiration related to ineffective airway clearance, airway obstruction, loss of gag reflex, neuromuscular impairment, and decreased level of consciousness during and after seizures.
Expected Outcomes:
- Patient will maintain a patent airway during and after seizures.
- Patient will exhibit clear lung sounds bilaterally.
- Patient will remain free from aspiration pneumonia or other aspiration-related complications.
Assessment:
- Monitor for secretions, blood, or vomitus during seizures: Assess for increased risk of aspiration due to oral secretions or emesis.
- Assess oxygen saturation: Monitor oxygen saturation levels, especially postictally, as desaturation may indicate aspiration.
- Identify high-risk patients: Recognize patients with factors that increase aspiration risk (infants, elderly, impaired gag reflex, dysphagia).
Interventions:
- Position patient appropriately: Place the patient in a lateral or recovery position during and after seizures to facilitate drainage of secretions.
- Avoid oral intake during seizure and postictal phase: Keep the patient NPO until fully alert and with a restored gag reflex.
- Provide suctioning as needed: Suction oral secretions when safe and effective to clear the airway.
- Educate caregivers on aspiration precautions: Instruct caregivers on proper positioning and suctioning techniques, and when to seek emergency help.
Ineffective Airway Clearance
Nursing Diagnosis: Ineffective Airway Clearance related to retained secretions, airway obstruction (tongue, laryngospasm), neuromuscular impairment, and respiratory depression associated with seizure activity.
Expected Outcomes:
- Patient will maintain a patent airway throughout seizure episodes.
- Patient will demonstrate effective cough and clear breath sounds.
- Patient’s respiratory rate and oxygen saturation will remain within acceptable limits.
Assessment:
- Monitor respiratory status: Assess respiratory rate, rhythm, depth, and effort during and after seizures.
- Auscultate breath sounds: Assess for adventitious breath sounds (wheezing, rhonchi, crackles) indicating airway obstruction or secretions.
- Monitor oxygen saturation (SpO2): Continuously monitor SpO2 to detect hypoxia.
- Assess cough and swallow reflexes: Evaluate the patient’s ability to cough and swallow effectively, especially postictally.
Interventions:
- Administer supplemental oxygen: Provide oxygen as needed to maintain adequate SpO2 during and after seizures.
- Position patient for airway maintenance: Use the recovery position to promote drainage of secretions and prevent tongue obstruction.
- Loosen restrictive clothing: Ensure clothing is loose around the neck and chest to facilitate breathing.
- Suction airway as needed: Suction oral and nasal secretions to clear the airway, being careful not to insert anything into the mouth during active seizure.
By utilizing these nursing diagnoses and implementing targeted assessments and interventions, nurses can effectively manage patients at risk for seizures, minimize potential complications, and promote optimal patient safety and quality of life.
References
- Fisher, R. S., …, & Engel, J., Jr. (2017). ILAE official report: a revised classification of seizures and epilepsy. Epilepsia, 58(4), 531–542.
- National Institute of Neurological Disorders and Stroke (NINDS). (2023). Seizure and Epilepsy Information Page.
- Epilepsy Foundation. (n.d.). Seizure First Aid.
- World Health Organization. (2023). Epilepsy.
- American Epilepsy Society. (n.d.). About Epilepsy.
Alt text: A compassionate nurse explains seizure management strategies to a patient and their family, fostering understanding and confidence in managing seizure risks.
