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83 Cards in this Set
- Front
- Back
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During which phase does a person known for seizure experience the epileptic cry, is conscious or unconscious and falls
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Ictal
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What type of seizure does this patient have when they epxerience sudden collapse and falls, loss of muscle tone, drop attacks, and regain consciousness in 10 to 60 seconds
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Gerneralized: Atonic
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A patient is experiencing a seizure during your shift what would not be an appropriate intervention
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Hold them firmly so they do not hurt themselves
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What would be appropriate nursing interventions for pt experiencing a seizure
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Turn client to side of bed
Maintain airway Loosen client's clothing |
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When discharging a patient who experiences seizures what should you inform them about their new dilantin medication
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Make surethey maintain good oral care because medication can cause gingival hyperplasia
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What would be a priority nursing diagnosis for a patient who experiences seizures
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Risk for injury related to seizure disorder
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You are caring for a client who has had a recent onset of seizures. The client asks "what type of tests will they do to figure out why I am having seizures all of a sudden?" As the nurse, your explanation should incllude
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Basic Metaboli Panel
Neurological Assessments EEG |
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Nursing interventions when caring for a client with an onset of seizures should include
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Making sure there is suction equipment available in the patient's room
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What are potential risk factors for developing a seizure disorder
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Aging
ETOH History of dementia |
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As a nurse, you know that seizure activity most often occurs
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during sleep
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A example of someone who is at greatest risk for onset of seizures
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An elderly woman who has suffered a stroke
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A person taking AED demonstrates understanding of medications if they respond to patient teaching with
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I should be weaned off gradually
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A pt is presented to you in the ED, his symptoms started with a blank stare, followed by chewing or smaking of mouth, then followed by random activity. You as the nuse would recognize this type of seizure as
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Complex partial
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A pt in your care has seizure activity, what would be aprimary intervention
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Have suction readily available to maintain airway clearance
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A NI that is not part of post-ictal care
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Protecting from injury
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Post-ictal NI of pt
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Allow client to rest
Document seizure Keep client on their side |
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A pt's EEG reveals that neural discharges are involving both hemispheres. This would be known as
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A generalized seizure
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Status epilepticus occurs
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For at least 5 minutes and the patient may not recover fully from one seizure before having another
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Teh nurse should advise a patient who is scheduled to have an EEG to avoid
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Caffeine
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How should tegretol be given
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by mouth
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Klonopin (Clonazepam) would be contraindicated in what type of patient
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67 year old female with respiratory dysfunction
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What inreased risks to women with epilepsy have
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Fetal malformations due to multiple antiseizure meds
Decreased contraceptive effectiveness due to antiseizure meds Increased bone loss Increased seizure activity during menses |
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What is priority one NI for a seizure patient
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Prevention of injury
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During the seizure the nurse needs to document
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occurances before the seizure
type of movements involved and with what part of the body Size of pupils Duration of each phase of the seizure |
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Primary epilepsy
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Not associated with an identifiable brain lesion, probably inherited condition, usually starts in childhood
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Secondary epilepsy
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Related to underlying brain disease or lesion
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Epilepsy
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recurrent sterotypical seizures. A recurrent seizure disorder. One seizure does not equal epilepsy
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Seizure
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Suddent, involuntary motion, change in behavior, muscle control, consciousness. Accompanied by abnormal electrical discharge from the brain
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Phases of seizures
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Pre-ictal (pre-seizure)
Ictal (seizure) Post-Ictal (post seizure) |
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Pre-Ictal Phase
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1/2 of all seizures have an aura or sensation before seizure
An aura is a sensation such as numbness, flashing lights, dizziness, odors, or spots Sign of warning that seizure is going to occur |
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Ictal Phase
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may have epileptic cry (cat)
may have loss of consciousness and fall may be unconscious, or awake but unaware |
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Post-ictal Phase
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May or may not remember seizure
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Types of seizures
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Generalized or global - involves neural discharge in both brain hemispheres, always loss of consciousness, abrupt onset
Partial or focal - does not affect consciousness, usuallya ffects one hemisphere, can be interrupted |
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Types of Generalized Seizures
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Tonic-Clonic (Grand Mal)
Absence Seizures (petite mal) Myoclonic Atonic |
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Tonic-Clonic (Grand Mal)
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Lasts about 2 minutes
Cry, fall, LOC, stifffening, contractions, shallow greathing, cyanosis, incontinence, tongue biting Post-ictal state Confusion, fatigue, dorwsiness & exhaustion after seizure is over |
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Absence seizures (petite mal)
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staring, rapid eye blinking or mouth chewing, less than 1 minute, unaware, no post-ictal state, may or may not remember seizure, may occur frequently through the day
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Myoclonic
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sudden brief massive muscle jerks (few seconds), may spill what they are holding or cause client to fall, no post-ictal state
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Atonic (drop attacks)
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Sudden collapse & fall, brief loss of muscle tone, no post-ictal state, 10-50 seconds
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Partial Seizures
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Simple Partial (focal)
Complex Partial (involuntary) |
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Simple Partial
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Jerking of one area of the body
Starts in one part of body and may move to adjacent areas Focal twitching of extremity or face, speach arrest, special visual sensations, feeling of foom Have less motor, sensory, & consciousness involvement due to smaller area of the brain involved |
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Complex Partial
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Start with blank stare, followed by chewing, followed by random activity. Consciousness impaired and unaware of surroundigns, dazed , unresponsive, may run and appear afraid, automatic behavior (lip smacking, chewing, rubbing, or picking at clothes) which are involuntary, lasts a few minutes, post-ictal period of confusion, may spread to larger area of the brain and become generalized.
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Status epilepticus
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Episode of seizure activity taht lasts at least 5 minutes, or repeated seizures without full recovery between seizures.
Can cause increase in metabolic activity such that the bond cannot keep up with the O2 and nutrition demands leading to cellular exhaustion and death if not effectively treated. |
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Emergency Criteria
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Head trauma
1st seizure diabetes pregnant occurs in water prolonged (>5 min) Repeated seizures No med id |
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DX a seizure
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monitor brain waves while seizure is occuring. Many DX are basedon description of s/s, PE, and other tests
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Tests for Seizures
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PE and MRI
Blood test for metabolic abnormalities Neurologic assessment Memory, language, perception, thinging and emotional functioning |
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EEG
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records electrical activity of the brain and is the best way to DX, but is often noraml between seizures
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Prep for EEG
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Mean before test because low gblood sugar can alter brain pattern waves
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MRI
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identifies abnormalities in teh brain structure
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CT
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Checks for tumors, strokes and otehr abnormalities
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NI pre-ictal
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type of aura
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NI Ictal Phase
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Assessment - movement of head, eyes, muscle rigidity will give clues about location of the trigger focus int eh brain
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Seizure Assessment
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Progession and duration of the seizure, respiratory status, loss of consciousness, pupil size, incontiennce
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NI for seizures
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protect from injury
nothing into mouth Turn pt on side loosen clothing maintain airway and suction may be needed no not retrain client, guide movements if necessary no oral thermometers |
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NI of Post-ictal Phase
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Assess breathing pattern for rate, rhythm, and depth.
Establish the airway is priority intervention |
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NI Post-Ictal phase
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Re-orient client X3 level of sleeplessness, make pt comfortable, VS, neurologic chekc, keep on side, allow to rest, document seizure
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NDX
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Risk for injury related to seizure disorder
Fluid volume deficit r/t mental status and sudden loss |
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NI for risk of injury
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Seizure precautions (pad side rails, keep rails up and bed in low position), monitor frequently, rapid access to O2, suction, emergency equipment, administer AED as ordered, monitor pt response, insert NC as ordered
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NI for Fluid volume
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NPO until fully awake, IV as ordered, VS, monitor I/O
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Antiepileptic Drugs (AED)
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Goal is to control seizures without impairing normal function, often use e2 or more durgs in combination, selective depression of hyperactive areas of the brain
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How to test AED levels
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Blood test, drug serum levels
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Should AED be stopped suddenly
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No, wean gradually so that life threatening status epilepticus is avoided
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Hazardous activity for pts that taking AED's
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driving, other activities that require mental alertness
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Adverse SE that may require an adjustment in med dosage
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Serum blood levels not routinely done
Somnolence, fatigue, ataxia, dizziness, confusion, diplopa |
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Topamax
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Partial seizures, toxic effect nephrolithiasis. Drink 6-8 water to flush kidney
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Neurontin
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Partial seizure. Don't take with antacid, decreases absorption, routine blood levels not done.
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Lamictal
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Partial seizures
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Ativan
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Partial seizures, respiratory depression
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Phenobarbital
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Partial, clonic-tonic, status epilepticus
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Dilantin
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Partial, clonic-tonic, status epilepticus
Good oral care important |
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Klonopin
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Absence, myoclonig, atonic
high degree of toxicity, caution with respiratory disease |
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Valium
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Status epilepticus
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Depakote
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All types, contra in pg, thrombocytopenia, liver disease
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Zarontin
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All types, drug of choice for absence seizures
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Tegretol
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Partial, clonic-tonic, status epilepticus, SE leukopenia, diplopia
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Treatment available
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Seizure precautions
Surgery Vagus nerve stimulation Ketogenic diet Activity Client education |
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General Seizure Precuations
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Oxygen, suction equipment, airway, IV access, padded side rails, lossen clothes, no pillows, no restraint, no padded tongue blade, occur most ofent during sleep or shortly after awakening
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Surgical option
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Lobectomy - removal of one lobe of the brain
Hemishpherectomy - removal of 1/2 the brain hemisphere Corpus Callostomy - cutting the nerve fibers between the brain hemispheres |
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Vagus Nerve Stimulation
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Not a surgical candidate, unacceptable sE from meds, pacemake-like device, vagus nerve stimulated, use magnet to manually turn stimulator on or off
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Ketogenic Diet
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Children, high fat/low protein diet/low carbs
keep pt in a state of ketosis Controls seizures |
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Activity
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Avoid hazardous activity until meds are stabilized, maintain normal activity aafter stabilized, can perform personal care and wear own clothes, OOB
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Client education
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Diet, no ETOH, check OTC drugs, med alter braclet, regular sleep, low stress, good oral care and dental visits, control fevers, avoid bright flashing lights, swim with buddy, avoid noisy environments
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Speical population - Women
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contraceptives may be decreased because of AED, seizure pattern often changes when pg, may have first seizure during peri-menopausal time, considered high risk pg, may have birth defects with AED use
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Special population - Elderly
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High incidence fo new onset seizures > 65, risk factors include: stroke, head trauma, dementia, infection, ETOH, aging
Stroke is greatest risk |
