SEIZURES DISORDERS AND ITS NURSING MX.pptx

What is seizure, type, sign and symptoms and its management
Nursing management of seizures

1. SEIZURES DISORDERS AND ITS NURSING MANAGEMENT CHANDRAMUKHI KUMARI M.N. FINAL YEAR RAKCON

2. INTERNATIONAL EPILEPSY DAY : -8 FEBRUARY

3. INTRODUCTION Epilepsy accounts for 0.5% of the global burden of disease, a time-based measure that combines years of life lost due to premature mortality and time lived in less than full health Epilepsy has significant economic implications in terms of health-care needs, premature death and lost work productivity.

4. SEIZURES Seizures are episodes of abnormal motor, sensory and autonomic or psychic activity (or combination of these) that results from sudden excessive discharge from cerebral neurons Transient , uncontrolled electrical discharge of neurons in the brain that interrupts normal function. OR

5. CHARACTERISTIC OF SEIZURE The characteristic seizure is a manifestation of this excessive neuronal discharge. Associated loss of consciousness , excess movement or loss of muscle tone or movement , and disturbances of behavior, mood, sensation, and perception may also occur. The specific causes of seizures are varied and can be categorized as idiopathic ( genetic , developmental defects ) and acquired

6. Seizures may accompany a variety of disorders , or they may occur spontaneously without any apparent cause. Seizures resulting from systemic and metabolic disturbances are not considered epilepsy if the seizures cease when the underlying problem is corrected. Metabolic disturbances that causes include acidosis ,electrolyte imbalance , hypoglycemia, hypoxia alcohol and barbiturate withdrawal , dehydration and water intoxication. Extra cranial disorders that can cause seizures are heart, lung, liver, or kidney diseases; systemic lupus erythematous ; diabetes mellitus; hypertension and septicemia. CHARACTERISTIC OF SEIZURE

7. EPILEPSY It is a condition in which a person has spontaneous recurring seizures caused by a chronic underlying condition.

8. KEY FACTS ABOUT EPILEPSY Epilepsy is a chronic non-communicable disease of the brain that affects people of all ages. Around 50 million people worldwide have epilepsy, making it one of the most common neurological diseases globally. Nearly 80% of people with epilepsy live in low- and middle-income countries. It is estimated that up to 70% of people living with epilepsy could live seizure- free if properly diagnosed and treated. The risk of premature death in people with epilepsy is up to three times higher than for the general population. Three quarters of people with epilepsy living in low-income countries do not get the treatment they need. In many parts of the world, people with epilepsy and their families suffer from stigma and discrimination.

9. GLOBAL SCENARIO OF EPILEPSY At the global level, it is estimated that nearly 70 million people suffer from epilepsy and the prevalence of epilepsy across the globe is estimated to be 5-9 per 1,000 population. As per the GBD analysis for 2010, epilepsy accounted for 0.7% of the global burden or more than 17 million DALYs and nearly 90% of these were reported from low and middle-income countries (LMICs).

10. PREVALENCE AND INCIDENCE IN INDIA I n India; which contributes to nearly one-sixth of the global burden. This paper (first of the two part series) provides an in-depth understanding of the epidemiological aspects of epilepsy in India for developing effective public health prevention and control programs. The overall prevalence (3.0-11.9 per 1,000 population) and incidence (0.2-0.6 per 1,000 population per year) data from recent studies in India on general population are comparable to the rates of high-income countries (HICs) despite marked variations in population characteristics and study methodologies.

11. CAUSES Epilepsy occurs when permanent changes in the brain cause it to be too excitable or irritable As a result, the brain sends out abnormal signals. This leads to repeated unpredictable seizures. Idiopathic Acquired Hypoxemia ( including vascular insufficiency ) Fever(childhood) Head injury Stroke Central nervous system infections   Acquired Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal Cerebrovascular disorders Hypertension Allergies

12. PREVENTION OF SEIZURES AND ITS RELATED COMPLICATIONS An estimated 25% of epilepsy cases are preventable.   Preventing seizures and other problems must be part of seizure management. This means client should be working together with his/her health care team to control seizures as best as possible. Preventing head injury is the most effective way to prevent post-traumatic epilepsy. Adequate perinatal care can reduce new cases of epilepsy caused by birth injury.  

13. PREVENTION OF SEIZURES AND ITS RELATED COMPLICATIONS The use of drugs and other methods to lower the body temperature of a feverish child can reduce the chance of febrile seizures. The prevention of epilepsy associated with stroke is focused on cardiovascular risk factor reduction, e.g. measures to prevent or control high blood pressure, diabetes and obesity, and the avoidance of tobacco and excessive alcohol use.

14. Central nervous system infections are common causes of epilepsy in tropical areas, where many low- and middle-income countries are concentrated. Elimination of parasites in these environments and education on how to avoid infections can be effective ways to reduce epilepsy worldwide, for example those cases due to neurocysticercosis. Ways to prevent seizures and other problems must include taking seizure medicines regularly as problems taking medicines is one of the biggest risks for uncontrolled seizures. PREVENTION OF SEIZURES AND ITS RELATED COMPLICATIONS

15. People can also adjust their lifestyle and environment to reduce the chance of Seizures. Avoiding alcohol and other substances and managing stress may help seizure control and lessen the risk of mood disorders. Keeping good seizure control and avoiding side effects of medicines may help prevent or lessen cognitive problems, mood changes and falls. PREVENTION OF SEIZURES AND ITS RELATED COMPLICATIONS

16. Keeping a regular sleep schedule can help prevent seizures from poor sleep and help treat sleep disorders and stress. Choosing seizure medicines carefully can help lessen the risk of bone problems, (thinning of the bones or osteoporosis) or developing hormonal problems. These hormonal problems could affect having children or cause other health problems. Taking Vitamin D and exercising can help keep bones strong and hopefully decrease fracture Wearing protective helmets can lessen the chance of head injury.   PREVENTION OF SEIZURES AND ITS RELATED COMPLICATIONS

17. PATHOPHYSIOLOGY

18. CLASSIFICATION OF SEIZURE In 2017, the International League against Epilepsy (ILAE) developed a new classification system for seizures. After diagnosis of the seizure type, the next step is diagnosis of epilepsy type, including focal epilepsy, generalized epilepsy, combined generalized, and focal epilepsy, and also an unknown epilepsy group. The third level is that of epilepsy syndrome, where a specific syndromic diagnosis can be made. The new classification incorporates etiology along each stage, emphasizing the need to consider etiology at each step of diagnosis, as it often carries significant treatment implications.

19. ACCORDING TO ILAE CLASSIFICATION

20. Initial classification is by type of onset 1. GENERALIZED ONSET 2. FOCAL ONSET 3. UNKNOWN ONSET

21. 1) GENERALIZED-ONSET SEIZURES 1) GENERALIZED-ONSET SEIZURES In generalized-onset seizures, seizures originate in networks in both hemispheres. Awareness is usually impaired, and consciousness is usually lost. Generalized-onset seizures are classified as motor and non-motor (absence) seizures. (However, non-motor seizures may involve motor activity.)

22. A) Generalized-onset motor seizures A) Generalized-onset motor seizures may be further classified by type of seizure: • Tonic- clonic seizures (formerly, grand mal seizures) • Clonic seizures (sustained rhythmic jerking) • Tonic seizures (stiffening without rhythmic jerking) • Atonic seizures (loss of muscle tone) •Myoclonic seizures (rhythmic jerking not preceded by stiffening) •Myoclonic-tonic- clonic seizures (myoclonic jerking followed by tonic and clonic movements) •Myoclonic-atonic seizures (myoclonic jerking followed by atonia) •Epileptic spasms (formerly, infantile spasms)

23. B) Generalized-onset non-motor seizures B) Generalized-onset non-motor seizures may be further classified by type of seizure (defined by the earliest prominent feature): • Typical absence seizures • Atypical absence seizures ( eg , with less abrupt onset or termination or with abnormal changes in tone) • Myoclonic seizures • Eyelid myoclonia Generalized-onset seizures result most often from metabolic disorders and sometimes from genetic disorders.

24. 2) FOCAL-ONSET SEIZURES 2) FOCAL-ONSET SEIZURES Focal-onset seizures originate in networks in one hemisphere and may originate in subcortical structures. They may be discretely localized or more widely distributed. Focal-onset seizures may be classified by level of awareness: • Focal aware seizures (formerly, simple partial seizures) Focal impaired-awareness seizures (formerly, complex partial seizures) If awareness is impaired during any part of the seizure, the seizure is classified as a focal impaired-awareness seizure.

25. A) Focal-onset motor seizures • Automatisms (coordinated, purposeless, repetitive motor activity) • Atonic (focal loss of muscle tone) • Clonic (focal rhythmic jerking) • Epileptic spasms (focal flexion or extension of arms and flexion of trunk) A) Focal-onset motor seizures may be further classified by type of seizure: Hyperkinetic (causing pedaling or thrashing) • Myoclonic (irregular, brief focal jerking) • Tonic (sustained focal stiffening) • Awareness level is usually not specified for atonic seizures or epileptic spasms.

26. B) Focal-onset non-motor seizures may be further classified based on the earliest prominent feature: • Autonomic dysfunction (autonomic effects such as gastrointestinal (GI) sensations, a sense of heat or cold, flushing, sexual arousal, piloerection, and palpitations) • Behavior arrest (cessation of movement and unresponsiveness as the main feature of the entire seizure) • Cognitive dysfunction (impairment of language or other cognitive domains or positive features such as déjà vu, hallucinations, illusions, or perceptual distortions) • Emotional dysfunction (manifesting with emotional changes, such as anxiety, fear, joy, other emotions, or affective signs without subjective emotions) • Sensory dysfunction (causing somatosensory, olfactory, visual, auditory, gustatory, or vestibular sensations or a sense of heat or cold)

27. 3) UNKNOWN-ONSET SEIZURES Seizures are usually classified as unknown-onset seizures when information about onset is lacking. If clinicians acquire more information about the seizures, these seizures may be reclassified as focal-onset or generalized-onset. Seizures of unknown onset can be motor or non-motor.

28. Unknown-onset motor seizures may be further classified Tonic- C lonic Epileptic spasms Unknown-onset non-motor seizures may be further classified • Behavior arrest

29. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION PARTIAL SEIZURE GENERALIZED SEIZURE MIXED SIEZURE CONTINUOUS SEIZURES SIMPLE PARTIAL SEIZURE COMPLEX PARTIAL SEIZURE ABSENCE SEIZURES MYOCLONIC SEIZURE CLONIC SEIZURES TONIC–CLONIC SEIZURES ATONIC SEIZURES STATUS EPILEPTICUS EPILEPSIA PARTIALIS CONTINUA

30. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION 1. PARTIAL SEIZURE SIMPLE PARTIAL SEIZURE : affect only a small region of the brain, often the temporal lobes and/or hippocampi. People who have simple partial seizures retain consciousness. COMPLEX PARTIAL SEIZURE : may involve the unconscious repetition of simple actions, gestures or verbal utterances, or simply a blank stare and apparent unawareness of the occurrence of the seizure, followed by no memory of the seizure.  

31. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION GENERALIZED SEIZURE ABSENCE SEIZURES: – Involve an interruption to consciousness where the person experiencing the seizure seems to become vacant and unresponsive for a short period of time (usually up to 30 seconds). Slight muscle twitching may occur. MYOCLONIC SEIZURES: – Involve an extremely brief (< 0.1 second) muscle contraction and can result in jerky movements of muscles or muscle groups. CLONIC SEIZURES: – Are myoclonus that are regularly repeating at a rate typically of 2-3 per second. in some cases, the length varies.

32. TONIC–CLONIC SEIZURES: – Involve an initial contraction of the muscles (tonic phase) which may involve tongue biting, urinary incontinence and the absence of breathing. This is followed by rhythmic muscle contractions ( clonic phase). This type of seizure is usually what is referred to when the term 'epileptic fit' is used colloquially. ATONIC SEIZURES: – Involve the loss of muscle tone, causing the person to fall to the ground. These are sometimes called 'drop attacks' but should be distinguished from similar looking attacks that may occur in cataplexy. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION GENERALIZED SEIZURE

33. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION MIXED SIEZURE- Mixed seizure is defined as the existence of both generalized and partial seizures in the same patient.

34. STATUS EPILEPTICUS: – Refers to continuous seizure activity with no recovery between successive seizures. When the seizures are convulsive, it is a life-threatening condition and emergency medical assistance should be called immediately if this is suspected. A tonic- C lonic seizure lasting longer than 5 minutes (or two minutes longer than a given person's usual seizures) is usually considered grounds for calling the emergency services. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION CONTINUOUS SEIZURES-

35. CLASSIFICATION BASED ON CLINICAL AND EEG MANIFESTATION CONTINUOUS SEIZURES- EPILEPSIA PARTIALIS CONTINUA: – Is a rare type of focal motor seizure (hands and face) which recurs every few seconds or minutes for extended periods (days or years). It is usually due to strokes in adults and focal cortical inflammatory processes in children (Rasmussen's encephalitis), possibly caused by chronic viral infections or autoimmune processes.

36. SEVERAL PHASES OF SEIZURE The prodromal phase (with signs or activity which precede a seizure). The aural phase , with a sensory warning (aura is an unusual sensations of smell / taste/ butterflies in stomach / feeling of opposite or unfamiliar and intense feeling). The ictal phase (with full seizure). The postictal phase (period of recovery after seizure  

37. CLINICAL MANIFESTATION MOTOR MANIFESTATIONS SOMATO-SENSORY MANIFESTATIONS MOTOR MANIFESTATIONS : These arise from a focus in motor cortex. The resulting seizures occur in part of body innervated by motor neurons originating in the affected region of cortex. Because the hand and fingers have largest cortical representations , many focal motor seizures begin with convulsive movement in the upper extremity. Involuntary movements may spread centrally & involve the entire limb, including one side of face & lower extremity. This progression or spread is known as the ‘’ Jacksonian march’’. The client also may exhibit changes in posture or spoken utterances

38. MOTOR MANIFESTATIONS : These arise from a focus in motor cortex. The resulting seizures occur in part of body innervated by motor neurons originating in the affected region of cortex. Because the hand and fingers have largest cortical representations , many focal motor seizures begin with convulsive movement in the upper extremity. Involuntary movements may spread centrally & involve the entire limb, including one side of face & lower extremity. This progression or spread is known as the ‘’ Jacksonian march’’. The client also may exhibit changes in posture or spoken utterances

39. SOMATO-SENSORY MANIFESTATIONS If the epileptogenic focus is in the parietal region the client experiences sensory phenomena such as numbness & tingling in the affected area. If the focus is in the occipital region, the client may experience bright, flashing lights in the field of vision opposite the side of focus. Likewise the client can have changes in speech or taste with involvement of the posterior temporal area of dominant hemisphere.

40. SIGN AND SYMPTOMS ABSENCE SEIZURE staring The consumer suddenly stops what they is doing a few seconds of unresponsiveness (usually less than 10 seconds, but it can be up to 20 seconds) that can be confused with daydreaming No response when you touch the consumer The consumer is alert immediately after the seizure The consumer may have many seizures per day Less common features include: – repetitive blinking – eyes rolling up – head bobbing – automatisms such as licking, swallowing ,and hand movements – autonomic symptoms such as dilated pupils, flushing, pallor, rapid heartbeat, or salivation

41. MYOCLONIC SEIZURE One or many brief jerks, which may involve the whole body or a single arm or leg In juvenile myoclonic epilepsy, these jerks often occur upon waking The consumer remains conscious ATONIC SEIZURE Sudden loss of muscle tone The consumer goes limp and falls straight to the ground The consumer remains conscious or has a brief loss of consciousness Eyelids droop, head nods jerking The seizure usually lasts less than 15 seconds, although some may last several minutes The consumer quickly becomes conscious and alert again after the seizure SIGN AND SYMPTOMS

42. SIGN AND SYMPTOMS TONIC-CLONIC SEIZURE The consumer cries out or groans loudly The consumer loses consciousness and falls down In the tonic phase, the consumer is rigid, their teeth clench, their lips may turn blue because blood is being sent to protect their internal organs, and saliva or foam may drip from their mouth; they may appear to stop breathing because their muscles, including their breathing muscles, are stiff Heart rate and blood pressure rise Sweating

43. Tremor In the C lonic phase, the consumer resumes shallow breathing; their arms and legs jerk quickly and rhythmically; their pupils contract and dilate At the end of the clonic phase, the consumer relaxes and may lose control of their bowel or bladder. Following the seizure, the consumer regains consciousness slowly and may appear drowsy, confused, anxious, or depressed   SIGN AND SYMPTOMS TONIC-CLONIC SEIZURE

44. SIGN AND SYMPTOMS MOTOR SEIZURE Brief muscle contractions (twitching, jerking, or stiffening), often beginning in the face, finger, or toe on one side of the body Twitching or jerking spreads to other parts of the body on the same side near the initial site Other motor seizures may involve movement of the eye and head The seizure begins the same way each time The consumer remains conscious

45. Seeing something that is not there, such as shapes or flashing lights, or seeing something as larger or smaller than usual Hearing or smelling something that is not there Feeling of pins and needles or numbness in part of the body The consumer remains conscious   SENSORY SEIZURES SIGN AND SYMPTOMS

46. SIGN AND SYMPTOMS AUTONOMIC SEIZURE Changes in heart rate Changes in breathing Sweating Goose bumps Flushing or pallor The consumer remains conscious Strange or unpleasant sensation in the stomach, chest, or head

47. SIGN AND SYMPTOMS PSYCHIC SEIZURE Problems with memory Parbled speech Problems with memory Garbled speech Sudden emotions for no apparent reason, such as fear, depression, rage, or happiness Feeling as though they are outside their own body Feelings of déjà vu, or knowledge of the future  

48. SIGN AND SYMPTOMS COMPLEX PARTIAL SEIZURE Warning sign such as a feeling of fear or nausea • Loss of awareness • Confusion after the seizure • Loss of memory about events just before or after the seizure • Loss of awareness • Blank stare

49. Walking or running • Screaming, yelling, or thrashing, either from sleep or while awake • Automatisms such as mouth movements, picking at air or clothing, repeating words or phrases • Confusion after the seizure • Loss of memory about events just before or after the seizure COMPLEX PARTIAL SEIZURE SIGN AND SYMPTOMS

50. COMPLICATIONS OF SEIZURES Fracture of bone. Impair intelligence. Unable to get job, driver’s license, life insurance. Socially stigmated . Reduced quality of life. A complication called ‘’sudden unexpected death in epilepsy’’.  

51. OTHER PROBLEMS FACED BY PERSON WITH EPILEPSY Cognitive problems (for example problems with thinking, remembering, problem solving, paying attention) Mood disorders or problems with depression and anxiety

52. A complete seizure profile and history taking, Physical examination including neurologic examination & description of seizure activity. Birth and development history Significant illnesses and injuries Family history Febrile seizures Comprehensive neurologic assessment History and physical examination History and physical examination

53. DIAGNOSTIC EVALUATION Seizure history Precipitating factors Antecedents events Seizures description ( including onset , duration , frequency, postictal state) Seizures description ( including onset , duration , frequency, postictal state)

54. DIAGNOSTIC EVALUATION Major diagnostic tool i.e., EEG (electroencephalogram). This test assists in: – Locating the focus of abnormal electrical discharges, if present. – Establishing a diagnosis of epilepsy. – Identifying the specific type of seizures. •ECG. •CT scan & MRI, MRA (Magnetic resonance angiography) , MRS(Magnetic resonance spectroscopy ) are used to rule out brain lesions that can trigger seizures.

55. DIAGNOSTIC EVALUATION •PET (positron emission tomography) & SPECT (single photon emission computed tomography) may be helpful to measure cerebral blood in clients undergoing surgery for epilepsy. • Lab studies may rule out other causes for the seizures: RBS, CBC, KFT, LFT, Lumbar puncture, CSF analysis, urinalysis etc.

56. COLLABORATIVE THERAPY Antiseizure drugs Surgery Vagal nerve stimulation Psychosocial counselling Coordination problems Side effects of medicine Thinning of the bones Reproductive or hormonal problems Dying from complications of seizures or injuries.

57. MANAGEMENT MEDICAL MANAGEMENT • Goals of management of clients with seizures and epilepsy are – To prevent injury during seizures, – To eliminate factors that precipitate seizure, and – To control seizures to allow a desired lifestyle.

58. MEDICAL MANAGEMENT During the seizures the major goals are To maintain the airway. – To prevent injury to client. – To observe the seizure activity. – To administer appropriate anticonvulsant drugs. • In a hospital setting, suction equipment should be readily available. • The person experiencing a seizure usually requires protection from the environment. • Objects should be moved out of the way so that the client does not strike his/her head or extremities.

59. MEDICAL MANAGEMENT Any tight clothing around the person’s neck is loosened. • Put a pillow or folded blanket under the affected person’s head, but not flex the neck sharply or close the airway. • Turning the client to his/her side displaces the tongue and usually opens the airway once the tonic phase has ceased. •Do not attempt to open the airway with your fingers. •A jaw thrust maneuver (head tilt - chin lift) will open the airway without the potential to harm the client or the caregiver. •The factors that precipitate seizure should be eliminated, if possible. •Eating a balanced diet, restricting excessive caffeine and alcohol intake, sleeping well, avoiding seizure triggers (means initiations) (ex- flashing lights), and minimizing emotional stress may be helpful in preventing seizures. During the seizures the major goals are

60. Observer’s descriptions of a seizure can be helpful in making a diagnosis. • Instruct the family & unlicensed assistive personnel to make the following observations: – How long did the seizure last? – Where in the body did the seizures begin and how did it progress? – Did the client’s eyes or head deviate? – Were the respirations labored or frothy? – Was the client incontinent? – Did the client lose consciousness? – What were the types of movements and what body parts moved? During the seizures the major goals are MEDICAL MANAGEMENT

61. Monotherapy Monotherapy is desirable because it decreases the likelihood of adverse effects and avoids drug interactions; also, monotherapy may be less expensive than polytherapy, as many of the older anticonvulsant agents have hepatic enzyme-inducing properties that decrease the serum level of the concomitant drug, thereby increasing the required dose of the concomitant drug.

62. Anticonvulsant therapy The mainstay of seizure treatment is Anticonvulsant medication ; the drug of choice depends on an accurate diagnosis of the epileptic syndrome, as a response to specific anticonvulsants varies among different syndromes.

63. Discontinuing anticonvulsant agents After a person has been seizure free for typically 2-5 years, the physician may consider discontinuing that patient’s medication; many patients outgrow many epileptic syndromes in childhood and do not need to take anticonvulsants.

64. Ketogenic diet The ketogenic diet, which relies heavily on the use of fat, such as hydrogenated vegetable oil shortening (e.g., Crisco), has a role in the treatment of children with severe epilepsy; although this diet is unquestionably effective in some refractory cases of seizure, a ketogenic diet is difficult to maintain; less than 10% of patients continue the diet after a year.

65. Atkins diet. Preliminary data have been published about improvement of seizure frequency following a modified Atkins (low-carbohydrate) diet that mimics the ketogenic diet but does not restrict protein, calories, and fluids; in small studies of children with intractable epilepsy, seizure reductions of more than 50% have been seen within 3 months in some children placed on this diet, particularly with carbohydrate limits of 10 g per day.

66. Activity modification and restrictions The major problem for patients with seizures is the unpredictability of the next seizure; clinicians should discuss the following types of seizure precautions with patients who have epileptic seizures or other spells of sudden- onset seizures: driving, ascending heights, working with fire or cooking, using power tools and other dangerous equipment, taking unsupervised baths, and swimming.

67. Long-term monitoring In 2018, the FDA cleared for marketing the first smart watch for seizure tracking and epilepsy management; the Embrace smart watch identifies convulsive seizures and sends an alert via text and phone message to caregivers; the watch also records sleep, rest, and physical activity data; the device was tested in a study of 135 epileptic patients and found the watch’s algorithm detected 100% of patient seizures.  

68. SURGICAL MANAGEMENT Vagal nerve stimulation VNS is a palliative technique that involves surgical implantation of a stimulating device; VNS is FDA approved to treat medically refractory focal-onset epilepsy in patients older than 12 years; some studies demonstrate its efficacy in focal-onset seizures and a small number of patients with primary generalized epilepsy.

69. Implantable neurostimulator The NeuroPace RNS System , a device that is implanted into the cranium, senses, and records electrocorticographic patterns and delivers short trains of current pulses to interrupt ictal discharges in the brain. Lobectomy. In a randomized, controlled trial of surgery in 80 patients with temporal lobe epilepsy, 58% of patients in the group randomized to anterior temporal lobe resective SURGICAL MANAGEMENT

70. Lobectomy In a randomized, controlled trial of surgery in 80 patients with temporal lobe epilepsy, 58% of patients in the group randomized to anterior temporal lobe resective surgery were free from seizures impairing awareness at 1 year, as compared with 8% in the group that received anticonvulsant treatment. SURGICAL MANAGEMENT

71. SURGICAL MANAGEMENT Lesionectomy In a study presented at the 66th Annual Meeting of the American Epilepsy Society, investigators suggested that, in select pediatric patients, smaller lesionectomy resections in the surgical treatment of seizures may be as effective as larger resections, and they may spare children the functional and developmental deficits associated with the larger resections.  

72. PHARMACOLOGICAL MANAGEMENT Anticonvulsants, other. These agents prevent seizure recurrence and terminate clinical and electrical seizure activity; anticonvulsants are normally reserved for patients who are at increased risk for recurrent seizures. Anticonvulsants, barbiturates. Like benzodiazepines, barbiturates bind to the gamma- amino butyric acid (GABA) receptor, enhancing the actions of GABA by extending GABA-mediated chloride channel openings and allowing neuronal hyperpolarization. Anticonvulsants, benzodiazepines. These agents bind to the gamma-amino butyric acid (GABA) receptor, thereby enhancing the actions of GABA.

73. Anticonvulsants, succinimide. These agents reduce current in T-type calcium channels. Anticonvulsants, neuronal potassium channel opener. Stabilizes neuronal KCNQ (Kv7) channels in the open position, increasing the stabilizing membrane current and preventing bursts of action potentials during the sustained depolarization associated with seizures. Anticonvulsants, hydrations. These agents stabilize sodium channels and prevent the return of the channels to the active state. PHARMACOLOGICAL MANAGEMENT

74.   MEDICATIONS ARE USED TO CONTROL SEIZURES Currently available anti-epileptic drugs appear to act primarily by blocking the initiation or spread of seizures. Ex. Phenytoin, Fosphenytoin sodium, Carbamazepine, Valproic acid, Lamotrigine. (These inhibit sodium-dependent action potentials, blocking the burst and firing of neurons).

75. NURSING MANAGEMENT ASSESSMENT A major responsibility of the nurse is to observe and record the sequence of signs. The nature of the seizure usually indicates the type of treatment that is required (AANN, 2007) Description of circumstances before the seizure (visual, auditory, or olfactory stimuli, tactile stimuli, emotional or psychological disturbances sleep, hyperventilation). The occurrence of an aura. The first thing the patient does in the seizure where the movements or the stiffness begins, the position of the head at the beginning of the seizure. The type of movements in the part of the body involved. The areas of the body involved. The size of both pupils and whether the eyes are open.

76. Whether the eyes or head turned to one side. The presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing. Incontinence of urine or stool. Duration of each phase of the seizure. Unconsciousness if present and its duration. Any obvious paralysis or weakness of arms or legs after seizure. Inability to speak after the seizure. Whether or not the patient the patient sleeps afterward. Cognitive statues (Confused or not confused) after the seizure.   NURSING MANAGEMENT ASSESSMENT

77. NURSING ASSESSMENT ASSESSMENT Epilepsy and Seizure Disorders Subjective Data Important Health Information Past health history : - Previous seizures, birth defects or injuries, anoxia episodes CNS trauma, tumors, or infections. Stroke, metabolic disorders , alcoholism, exposure to metals and carbon monoxide, hepatic or renal failure, fever, pregnancy, systemic lupus Medications: Adherence to antiseizure medication regimen Barbiturate or alcohol withdrawal Use and overdose of cocaine, amphetamines, lidocaine, theophylline, penicillin lithium phenothiazine’s, tricyclic antidepressants, benzodiazepines

78. Functional Health Patterns:- Health perception-health management Positive family history, Cognitive-perceptual Headaches, aura, mood or behavioral changes before seizure. Mentation changes Abdominal pain, muscle pain (postictal) Self-perception-sell-concept Anxiety, depression Loss of self-esteem social isolation Sexuality reproductive Decreased sexual drive, erectile dysfunction Increased sexual drive (postictal) NURSING ASSESSMENT

79. NURSING ASSESSMENT Objective Data General Precipitating factors , including severe metabolic acidosis or alkalosis. hyperkalemia, hypoglycemia, dehydration, or water intoxication Integumentary Bitten tongue, soft tissue damage, cyanosis, diaphoresis (postictal) Respiratory Abnormal respiratory rate, rhythm, or depth Apnea (ictal). Absent or abnormal breath sounds, possible airway occlusion

80. Cardiovascular Hypertension, tachycardia or bradycardia (ictal) Gastrointestinal Bowel incontinence, excessive salivation Urinary Incontinence Objective Data

81. Objective Data Neurologic Generalized Tonic Clonic : - Loss of consciousness, muscle tightening, thon jerking Dilated pupils Hyperventilation, then apnea Postictal somnolence Absence: Altered consciousness (5-30 sec), minor facial motor activity Focal Simple : - Aura Focal sensory, motor cognitive, or emotional phenomena focal motor Unilateral marching motor seizure (jacksonian) Complex Altered consciousness with inappropriate behaviors, automatisms amnesia of event Musculoskeletal Weakness, paralysis, ataxia (postictal)

82. NURSING DIAGNOSIS Risk for trauma/ injury related to loss of large or small muscle co-ordination as evidenced by abnormal body spasm. Risk for ineffective airway clearance related to tracheo -bronchial obstruction as evidenced by oral secretions. Low self - esteem or situational low self -esteem related to stigma associated with condition as evidenced by verbalization about changed lifestyle.

83. Ineffective self - health management related to drug therapy and lifestyle adjustment Knowledge deficient / deficit related to lack of exposure and unfamiliarity with resources as evidenced by questions & statement of concerns. Risk for Ineffective therapeutic regimen management. Fear related to the possibility of seizures. NURSING DIAGNOSIS

84. GOALS: Seizures activity control. Complications or injury prevented. Improving coping mechanism Disease process or prognosis, therapeutic regimen, and limitations understood. Plan in place to meet needs after discharge. Reducing fear of seizures

85. INTERVENTIONS Nurse has to set the action priorities: Maintain airway or respiratory function. Prevent or control seizure activity. Protect patient from injury. Promote positive self-esteem. Provide information about disease process, prognosis, and treatment needs.  

86. Prevent trauma/injury Teach SO to determine and familiarize warning signs and how to care for patient during and after seizure attack; avoid using thermometers that can cause breakage; use tympanic thermometer when necessary to take temperature; uphold strict bed rest if prodromal signs or aura experienced; turn head to side and suction airway as indicated; support head, place on soft area, or assist to floor if out of bed; do not attempt to restrain; monitor and document AED drug levels, corresponding side effects, and frequency of seizure activity.

87. Improve self-esteem Determine individual situation related to low self-esteem in the present circumstances; refrain from over protecting the patient; encourage activities, providing supervision and monitoring when indicated; know the attitudes or capabilities of SO; help an individual realize that his or her feelings are normal; however, guilt and blame are not helpful.

88. Promote airway clearance Maintain in lying position, flat surface; turn head to side during seizure activity; loosen clothing from neck or chest and abdominal areas; suction as needed; supervise supplemental oxygen or bag ventilation as needed postictally.

89. Enforce education about the disease Review pathology and prognosis of condition and lifelong need for treatments as indicated; discuss patient’s particular trigger factors (flashing lights, hyperventilation, loud noises, video games, TV viewing); know and instill the importance of good oral hygiene and regular dental care; review medication regimen, necessity of taking drugs as ordered, and not discontinuing therapy without physician supervision; include directions for missed dose.

90. Reducing fear of seizures with proper education and adherence to medication will help to reduce the fear in the client as well as family members.

91. CARE DURING SEIZURE Provide privacy and protect the patient from curious on lookers. Ease the patient to the floor if possible. Protect the head with a pad to prevent injury from striking a hard surface. Loosen constrictive clothing. Push aside any furniture if present. If the patient is in bed, remove pillows and raise side rails.

92. CARE DURING SEIZURE IF an aura precedes the seizure, insert an oral air way to reduce the possibility of the patient's biting the tongue or cheek. Do not attempt to try open jaws that are clenched in a spasm or to insert anything. No attempt should be made to restrain the patient during the seizure, because muscular contractions are story and restrain can produce injury. If possible, place the patient on one side with head flexed forward which allows the tongue to fall forward and facilitates drainage of saliva and mucous. If suction is available use it if necessary to clear secretions.

93. NURSING CARE AFTER THE SEIZURE Keep the patient on one side to prevent aspiration. Make sure the airway is patent. There is usually a period of confusion after a grand mal seizure. The patient on awaking should be reoriented to the environment. If the patient becomes agitated after a seizure (postictal use persuasion and gentle restrain to assist him or her to stay calm.)

94. PATIENT AND CAREGIVER TEACHING GUIDE SEIZURES DISORDERS AND EPILEPSY Include the following in the teaching plan for the patient with a seizure disorder Take drugs as prescribed . Report any and all side effects of drugs to the health care provider. When necessary, blood is drawn to ensure that therapeutic levels are maintained. Use no drug technique , such as relaxation therapy and biofeedback training , to potentially reduce the number of seizures. Be aware of availability of the resources in the community Wear a medical alert bracelet or necklace , and carry an identification card. Avoid excessive alcohol intake, fatigue and loss of sleep. Eat regular meals and snacks in between if feeling shaky , faint or hungry.

95. CAREGIVERS SHOULD RECEIVE THE FOLLOWING INFORMATION For first aid treatment of tonic clonic seizures, it is not necessary to, call an ambulance or send the patient to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows or extensive injury has occurred. During an acute seizure, it is important to protect the patient from injury, this may involve supporting and protecting the head, turning the patient to the side, loosing the constructive clothing, and easing the patient to the floor, if seated.

96. SOME GENERAL GUIDELINES FOR RESPONDING TO SEIZURES INCLUDE FOR CONVULSIVE TYPE SEIZURES Stay calm and time the seizure. If the person is having a convulsive type seizure, loosen any tight clothing and remove eyeglasses if they wear them. Clear the area of any potential hazards that could cause an injury to the consumer such as hard, sharp, or hot objects, but do not interfere with their movements If you can do so safely, turn the person’s body to the side to permit the draining of fluids. Something soft should be placed under the head. Stay with the person. Continue to monitor the person after the seizure. If the person is tired, assist him/her to a quiet comfortable place and allow time to rest.

97. FOR NON‐CONVULSIVE TYPE SEIZURES SOME GENERAL GUIDELINES FOR RESPONDING TO SEIZURES INCLUDE FOR NON‐CONVULSIVE TYPE SEIZURES (seizures that may involve the person’s senses or behavior, but that do not involve convulsions.) Time the seizure. Be available if they need assistance.

98. WHAT NOT TO DO DURING A SEIZURE Do NOT attempt to stop the seizure! Do NOT restrain the person or try to hold them down in any way! Do NOT force anything between their teeth or put anything in their mouth! Do NOT give the person anything to eat or drink until s/he has fully recovered consciousness

99. CONCLUSION AND SUMMARY A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behaviour, movements or feelings, and in levels of consciousness. There are many do’s and donot does so each and individual in the society has to be aware about this about the hospital setting only. Regarding the myths and facts we have to give proper education to avoid many complication and better prevention and outcome.

100. Human rights People with epilepsy can experience reduced access to educational opportunities, a withholding of the opportunity to obtain a driving license, barriers to enter particular occupations, and reduced access to health and life insurance. In many countries legislation reflects centuries of misunderstanding about epilepsy. For example: Legislation based on internationally-accepted human rights standards can prevent discrimination and rights violations, improve access to health-care services, and raise the quality of life for people with epilepsy.

101. RESEARCH INPUTS A structured, nurse-led intervention program improves quality of life in patients with epilepsy: A randomized, controlled trial GretheHelde , GunnarBovim , GeirBråthen , EylertBrodtkorb Available online 8 August 2005 Department of Neuroscience, Faculty of Medicine, NTNU, N-7006 Trondheim, Norway We tested the hypothesis that structured epilepsy nursing improves quality of life (QOL). One hundred fourteen adult patients with uncontrolled epilepsy were randomly assigned to either an intervention group or a control group. The intervention group was offered an interactive, 1-day group education program followed by extended nurse follow-up and counseling.  

102. RESEARCH INPUTS METHODS Participants from a tertiary epilepsy center were randomized to a KD group (intervention) or a care-as-usual (CAU) group (control). Follow- up assessments on cognition and behavior were performed approximately 4 months after initiation of the KD with a combination of parent report questionnaires and individually administered psychological tests for the children. RESULTS A total of 50 patients were enrolled in this study, 28 patients from the KD group and 22 patients from the CAU group. The KD group showed lower levels of anxious and mood- disturbed behavior and was rated as more productive. Cognitive test results showed an improvement of activation in the KD group.

103. REFERANCES Brunner and Siddhartha’s, Textbook of Medical Surgical Nursing second south east, Volume- 2,10th edition. New Delhi, Lippincott publications, 2010. Black M J, Hawks H J. Medical surgical nursing: clinical management for positive outcomes. 8th edition 2.New Delhi: Elsevier publishers; 2009 Lewis, Bucher , Chintamani , Lewis’s medical-surgical nursing, Third south Asia edition, vol.2 page no1331-38 https:// www.researchgate.net/publication/282361750_Epilepsy_in_India_I_Epidemiolog y_and_public_health https:// www.epilepsy.com/learn/managing-your-epilepsy/understanding-seizures-and- emergencies/importance-preventing-seizures