Name: Mike Angelou O.

Fernandez BSN-IV
Clinical Instructor: Mrs. Maricar Mutia

SEIZURES
A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes
in your behavior, movements or feelings, and in levels of consciousness. If you have two or more
seizures or a tendency to have recurrent seizures, you have epilepsy. There are many types of
seizures, which range in severity. Seizure types vary by where and how they begin in the brain.
Most seizures last from 30 seconds to two minutes. A seizure that lasts longer than five minutes
is a medical emergency. Seizures are more common than you might think. Seizures can happen
after a stroke, a closed head injury, and an infection such as meningitis or another illness. Many
times, though, the cause of a seizure is unknown. Most seizure disorders can be controlled with
medication, but management of seizures can still have a significant impact on your daily life. The
good news is you can work with your health care professional to balance seizure control and
medication side effects.
Pathology of Seizures
Seizures are caused by paroxysmal discharges from groups of neurons, which arise as a
result of excessive excitation or loss of inhibition. The key unit of neurotransmission is the
synapse, and the fundamental components of synapses are ion channels. Thus, the cause of
seizures boils down to malfunction of ion channels. About one third of seizures are caused by
genetic abnormalities, mostly involving ion channels. A quarter or so are caused by structural
lesions. Patients with such lesions usually have additional neurological abnormalities. Some of
these lesions, such as brain tumors, traumatic brain injury, infections, and perinatal brain lesions,
are environmentally acquired. Others, including brain malformations, genetic tumor syndromes,
and metabolic disorders are genetic or have a strong genetic component. In about half of seizure
disorders, no genetic or structural abnormality is evident. Perhaps many of these cases are caused
by genetic or acquired channelopathies that are not yet recognized. In addition to genes and the
environment, brain (synapse) development has a strong influence on seizures. Synapses are in a
state of flux during childhood and adolescence; first they proliferate excessively and then they
are reduced to adult levels. The dynamic state of synapses explains why most seizures begin (and
often stop) for no apparent reason during childhood. Based on the pattern of the attack, seizures
are divided into generalized tonic-clonic (grand mal), partial or focal, and several special epileptic
syndromes.
 Structural lesions are frequently detected in focal seizures. The most common such lesions
are cerebral changes resulting from perinatal brain damage, malformations, cerebral infarcts,
trauma, brain tumors, and infections. These lesions involve the cerebral cortex and are
characterized by neuronal loss and gliosis. Residual neurons in epileptogenic foci, show loss of
dendritic spines, possibly due to loss of afferents. The sources of these afferents have been
presumably destroyed by tumors, trauma, stroke, or other lesion. Even minute lesions of the
cerebral cortex may destroy, out of proportion, small, inhibitory (GABAergic) interneurons, thus
reducing the inhibition that controls large pyramidal cells.
In most generalized seizures, no primary lesions are detected by imaging or
neuropathological examination. The most common seizures in children and adults are partial
complex seizures originating from the temporal lobe (temporal lobe epilepsy -TLE or
psychomotor epilepsy). These seizures begin with a visceral sensation or other aura (breeze) and
are followed by a state of impaired consciousness, automatic motor activities or convulsions. The
EEG localizes the epileptogenic focus in the medial portion of the temporal lobe. Because TLE
is refractory to drugs, it is often treated by resection of the temporal lobe including the
hippocampus and surrounding area and the amygdala. Examination of temporal lobectomy
specimens reveals pathology in most cases. The most common lesions are hippocampal sclerosis,
tumors (gangliogliomas, gliomas), cortical dysplasias and hamartomas, vascular malformations,
ischemic and traumatic lesions, and infectious-inflammatory lesions. In many cases, no pathology
is found.
Hippocampal sclerosis, left Normal hippocampus, right
Hippocampal sclerosis (HS) or Ammon's horn sclerosis consists of loss of neurons in the dentate
nucleus and the pyramidal layer of the hippocampus with variable gliosis. Four patterns of HS
are recognized, the most common one involving the CA4 (end folium) and CA1 (Sommer sector)
subfields of the pyramidal layer. These lesions cause shrinkage of the hippocampus that can be
detected by MRI. In addition to seizures, HS is seen in a significant proportion of patients with
Alzheimer's disease and other dementias. The pathogenesis of this lesion has been the subject of
a "chicken or the egg" argument for more than 100 years. Some authors propose that HS is the
cause of seizures and others that it is the result of seizures. Proponents of the former view argue
that the hippocampus is damaged early in life by birth injury, complicated febrile seizures, and
other events, and that this damage makes it prone to seizures. Unlike the neocortex, the
hippocampus continues to develop after birth and is more vulnerable to such insults. In some
cases of TLE, there is a history of febrile seizures and other insults but in most cases no such
history can be elicited. On the other hand, there is also strong support for the idea that HS is
secondary to seizures, particularly status epilepticus. Animal experiments and observations in
humans show that even a single seizure can cause neuronal damage and that this damage may
occur without convulsions, is cumulative, and correlates with the duration and severity of the
electrical abnormaliry. HS is also seen in patients who have seizures resulting from brain tumors,
cortical dysplasias, and other brain lesions. However, some patients with seizures and status
epilepticus have no HS. The presumed mechanism of damage in HS is discharge of glutamate
during the epileptic attack and the most frequent site of damage is the CA1 sector of the
hippocampus. This area is also especially vulnerable to hypoxia which also initiates an excitotoxic
cascade. This circular argument about HS underlines the rich connectivity and excitatory
neurotransmission of certain fields of the hippocampus. However, epileptic brain damage is not
limited to the hippocampus. Intractable epilepsy and status epilepticus cause also neuronal loss
in the cerebral cortex, thalamus, and cerebellum (Purkinje cells). In addition, patients with
epilepsy suffer brain damage from falls and have a high frequency of unexpected death.

Anatomy and Physiology Overview

Epilepsy is a neurological disease stemming from a deregulation of brain signaling. Nerve
cells within the brain, called neurons, commonly communicate with each other through cell
junctions called synapses. One nerve cell sends a chemical signal to a neighboring cell, which
then activates an electrical nerve impulse within the receiving neuron. Together, the series of
electrical impulses allows for proper brain functioning. Epilepsy develops when nerve cells lose
the ability to turn off electrical impulses, leading to over-stimulation of certain areas of the brain.
The disease can affect multiple centers of the brain and cause a range of symptoms.

Temporal Lobe
Some forms of epilepsy can affect the temporal lobes of the brain--regions that extend along
each side of the brain. Temporal lobes are the most common site of localized epileptic seizures,
although seizures beginning in the temporal lobes can extend to other parts of the brain. Temporal
lobe epilepsy can lead to a number of symptoms, including auras and hallucinations. Patient’s
experiencing temporal lobe seizures can hallucinate visions, sounds, tastes and smells for the
duration of the seizure, as well as feel an inability to explain their sensations afterwards. Left
untreated, temporal lobe seizures can lead to brain damage due to over-stimulation of brain cells.

Seizures types and signs/symptoms

Seizures are changes in the brain’s electrical activity. This change can cause dramatic,
noticeable symptoms or it may not cause any symptoms. The symptoms of a severe seizure
include violent shaking and a loss of control. However, mild seizures can also be a sign of a
significant medical problem, so recognizing them is important. Because some seizures can lead
to injury or be evidence of an underlying medical condition, it’s important to seek treatment if
you experience them.
Types of seizures include the following:
Non-epileptic seizures
Non-epileptic seizures result from an injury, such as a blow to the head, or an illness. When you
get treatment for the condition, the seizures go away.
Partial seizures
These seizures can occur if you have epilepsy, which is a condition that causes repeated seizures.
This type of seizure happens on only one side of the brain. As a result, one side of the body is
affected during a seizure. Other names for partial seizures include focal, Jacksonian, and temporal
lobe seizures.
Generalized seizures
These seizures occur on both sides of the brain and affect both sides of the body. Generalized
seizures include grand mal or tonic-clonic seizures, which can occur if you have epilepsy.
Petit mal seizures are another type of generalized seizure. They’re also known as absence
seizures. These seizures have few physical symptoms but may involve staring off into space for
several seconds. If you have an absence seizure, other people can’t get your attention during the
seizure.

Symptoms of a Seizure
You can experience both partial and generalized seizures at the same time, or one can
precede the other. The symptoms can last anywhere from a few seconds to 15 minutes per episode.
Sometimes, symptoms occur before the seizure takes place. These include:
 a sudden feeling of fear or anxiousness
 a feeling of being sick to your stomach
 dizziness
 a change in vision
 a jerky movement of the arms and legs that may cause you to drop things
 an out of body sensation
 a headache
Symptoms that indicate a seizure is in progress include:
 losing consciousness, which is followed by confusion
 having uncontrollable muscle spasms
  drooling or frothing at the mouth
 falling
 having a strange taste in your mouth
 clenching your teeth
 biting your tongue
 having sudden, rapid eye movements
 making unusual noises, such as grunting
 losing control of bladder or bowel function
 Having sudden mood changes.

Etiology/Causes seizures
Seizures can stem from a number of health conditions. Anything that affects the body also
may disturb the brain and lead to a seizure. Some examples include:

 alcohol withdrawal
 bites
 stings
 a brain infection, such as meningitis
 a brain injury during childbirth
 a brain defect present at birth
 choking
 drug abuse
 drug withdrawal
 an electrolyte imbalance
 electric shock
 epilepsy
 extremely high blood pressure
 a fever
 head trauma
 kidney or liver failure
 low blood glucose levels
 a stroke
Seizures can run in families. Tell your doctor if you or anyone in your family has a history of
seizures. In some instances, especially with young children, the cause of the seizure may be
unknown.
 Risk factors
Doctors don’t always know what causes epilepsy. Some things that may increase your risk for
epilepsy include the following:

 Genetics: People with a parent or sibling who has epilepsy are at an increased risk for
developing epilepsy.
 Head trauma: Serious head injuries can cause epilepsy, sometimes years after the injury.
 Infection: Infections such as meningitis, encephalitis, and AIDS can increase the risk of
epilepsy.
 Medical conditions: Other medical conditions can increase the risk of epilepsy, such as
Alzheimer’s disease, stroke, brain tumors, or problems with the blood vessels in the brain.
 Problems during pregnancy, birth, or early development: In some cases, infections during
pregnancy, problems during birth, congenital brain defects (problems with the brain that
are present at birth), or injury to an infant’s brain may cause epilepsy.

Complications
Complications of complex partial seizures are easily triggered by emotional stress. The limbic
structures (i.e., hypothalamus, hippocampus, amygdala) of the brain may be damaged by seizure
activity. The limbic system is concerned with emotion and motivation.
These patients may develop cognitive and behavioral difficulties, such as the following:
 Interictal personality: humorlessness, dependence, obsessions, anger, hypo- or
hypersexuality, emotionality
 Memory loss: short-term memory loss attributable to dysfunction in the hippocampus,
anomia (inability to recall words or names of objects)
 Poriomania: prolonged aimless wandering followed by amnesia
 Violent behavior: aggression and defensiveness when subjected to restraint during a seizure
Complications associated with tonic-clonic seizures may involve injury, such as the following:
 Aspiration (inhalation into the lungs) of secretions or vomited stomach contents
 Skull or vertebral fractures, shoulder dislocation
 Tongue, lip, or cheek injuries caused by biting
 Status epilepticus
Status epilepticus is a medical emergency in which seizures recur without the patient regaining
consciousness between events. This condition can develop in any type of seizure but is most
common in tonic-clonic seizures. Status epilepticus may cause brain damage or cognitive
dysfunction and may be fatal.
Subsequent seizures become briefer, more localized, and may be reduced to myoclonic activity.
Complications may include:
 Aspiration
 Cardiac arrhythmias
 Dehydration
 Fractures
 Myocardial infarction (heart attack)
 Oral and head trauma
 Pulmonary edema (fluid build-up in the lungs)
Sudden Unexplained Death in Epilepsy (SUDEP)
Sudden unexplained death in epilepsy (SUDEP) occurs in a small percentage of persons with
epilepsy. For reasons that are poorly understood, an otherwise healthy person with epilepsy can
die suddenly. While this also happens within the general population, persons with symptomatic
epilepsy have a much greater risk.
Autopsies have not uncovered a physical cause of SUDEP. It is possible that pulmonary edema
(fluid build-up in the lungs), suffocation, or cardiac arrhythmias (irregular heartbeat) may be
responsible. Some people appear to be at a higher risk than others, such as young adults with
generalized tonic-clonic seizures that are not fully controlled with medication and those who
abuse alcohol and illicit drugs. Patients using two or more anticonvulsants may be at increased
risk for SUDEP.

Pathophysiology
Seizure Pathophysiology: Mechanisms
What are the mechanisms involved with seizures? Think of a lightning storm on a warm, summer
evening. Sometimes you can look in the clouds and see random, rapid bursts of lightning shooting
throughout the sky. Neurons in the brain look this way during a seizure episode.
Neurons are nerve cells, which communicate through membrane potential. Positive and negative
ions in an appropriate balance inside and outside of a neuron determine if the neuron is at rest or
at work (i.e. sending messages). Ions are chemical messengers with positive or negative charges
that cause an electrical signal to be sent by the brain. A neuron is at a resting membrane potential
when the charge inside the cell is more negative than the outside. When a neuron is at work, its
action potential is engaged through the change in balance of positive and negative ions and an
electrochemical message is sent, which causes the body to voluntarily or involuntarily move, feel,
or behave. Thus, neurons are electrochemical messengers in the body.
During a seizure episode, the membrane potential of neurons is altered in a way that causes
neurons to be hypersensitive or overactive due to certain stimuli or triggering events. As we
discussed, the causes of seizures can be known or unknown. Environmental triggers can include
loud noises, strobe lights, and rhythmic music. Medical triggers include high fevers, infections,
tumors, hypoglycemia, poor nutrition (causing electrolyte imbalances), trauma, physical
exhaustion, menses, and toxic substances, such as medications, alcohol, and illicit drugs. Seizures
can even have psychosocial triggers, including emotional stress and shock.

Seizure Pathophysiology: Manifestations

By the way, did you know seizures are also called fits, spells, convulsions, tremors, and spasms?
These are great visual terms that somewhat help to describe what a seizure looks like, or its
manifestations. The appearance of a seizure can range from a brief staring spell to total body
convulsions and stiffening, or tonic-clonic movements. In fact, seizures are classified according
to the number and location of areas of the brain affected and the corresponding signs and
symptoms.

The two main categories of seizures are focal and generalized. Focal seizures, also known as
partial seizures, occur in one area of the brain causing neurons to misfire and have two
subcategories: simple and complex. Simple partial seizures do not involve a loss in level of
consciousness (LOC) but can cause sensory and emotional changes and possibly convulsive
jerking. Complex partial seizures cause LOC changes and repetitive movements.
 Diagnosis
 EEG, with or without video monitoring, locates epileptic focus, spread, intensity, and
duration, helps classify seizure type.
 CT scanning or MRI identifies lesion that may cause of seizure.
 Single photon emission CT scanning (SPECT) or positron emission tomography (PET)
identifies seizure foci.
 Neuropsychological studies evaluate for behavioral disturbances.
 Serum electrolytes, glucose, and toxicity screen determine the cause of first seizure.
 Lumbar puncture and blood cultures may be necessary if fever is present.
Treatment
Treatment for seizures often involves the use of anti-seizure medications. Several options exist
for anti-seizure medications. The goal is to find the medicine that works best for you and that
causes the fewest side effects. In some cases, your doctor might recommend more than one
medication.
Finding the right medication and dosage can be complex. Your doctor will consider your
condition, your frequency of seizures, your age and other factors when choosing which
medication to prescribe. Your doctor will also review any other medications you may be taking,
to ensure the anti-epileptic medications won't interact with them.

Nursing Management
Nursing Assessment
Collecting data about the seizure requires well-developed observational skills and an
understanding of what to look for and how to document observations. It may be helpful to
verbalize the observations as events occur. Verbal reinforcement provides for better recall. The
following are several points to consider when organizing information about a seizure:
 Was the seizure witnessed or not witnessed?
 Were there any warning signs or was there an aura?
 Where did the seizure begin and how did it proceed?
 What type of movement was noted and what parts of the body were involved?
 Were there any changes in the size of the pupils or was there conjugate gaze deviation?
 What was the duration of the entire attack and of each phase?
 Was the patient unconscious throughout the seizure?
 Was there urinary or bowel incontinence?
 Was there any weakness or paralysis of the extremities after the seizure?
  Were there any injuries noted?
 Did the patient sleep after the seizure? How long?

Nursing Diagnosis
1. Risk for Injury related to: uncontrolled seizure activity (balance disorder).
2. Ineffective airway clearance related to: blockage of the tongue, endotracheal, increased
secretion of saliva
3. Social isolation related to: low-self against the disease state, and the bad stigma against epilepsy
in the community.
4. Ineffective breathing pattern related to: dyspnea and apnea
5. Activity intolerance related to: decreased cardiac output, tachycardia
6. Impaired sensory perception related to: disturbances in nerve sensory organs of perception
7. Anxiety related to: lack of knowledge about the disease
8. Risk for Ineffective cerebral Tissue Perfusion related to: decreased oxygen supply to the brain.

Planning and Goals

 Provide privacy, and protect the patient from curious onlookers
 Ease the patient to floor, if possible.
 Protect the head with a pad to prevent injury.
 Loosen constrictive clothing.
 Push aside any furniture that may injure the patient during the seizure.
 Keep the patient on one side to prevent aspiration and make sure airway is patent.
 Reorient the patient to the environment on awakening.
 Document the events leading to and occurring during and after the seizure to prevent
complications

Nursing Interventions and Rationales

 Ensure safety and initiate seizure precautions for patients at-risk for seizures.
This includes having suction set up and working, having an ambu-bag in the room, padding side
rails, not restrain them or putting anything in their mouth if a seizure occurs, having all side rails
up, and so forth. Seizures frequently happen without warning, therefore we must ensure safety in
case it occurs. Once one begins, it’s too late to try to implement the safety precautions
 Maintain airway
During a seizure, the patient may not be able to maintain their own airway, or they may not be
able to handle their oral secretions and aspirate (this is why it is essential to have suction set up)
 Assess, monitor and document seizure activity
It is essential to know the precipitating factors, what actually happened during the seizure
(rhythmic twitching and specific location) and the specific timing (30 seconds vs. 2 minutes vs.
6 minutes) - you must be as specific as possible to enable the medical team to make appropriate
clinical decisions
 Administer antiepileptics (PRN and scheduled) medications per orders
Many patients with seizures, or who are at-risk will have schedule antiepileptic medications. They
must receive these promptly, as ordered. Also be aware of your PRN antiepileptics and when to
administer them (typically for seizures lasting longer than 2 minutes)
 Reevaluate any medications that may lower the seizure threshold (some antibiotics,
antidepressants, narcotics, and many more may do this)
We want to do all we can to prevent seizures from occurring, therefore the healthcare team must
evaluate meds that may increase the seizure risk and closely look at them to decide if the benefit
is worth the risk, or if an alternative is available that does not lower the seizure threshold
 Educate patient and family on hospital procedures, and when to notify staff
Some patients with a history of seizures can tell when one is coming on, which is helpful to
communicate to the nurse. Also, it’s helpful to let them know what you as the nurse will do
when/if a seizure occurs so that they are prepared mentally and emotionally, as it can be somewhat
scary for families to witness and patients to experience.

 Provide emotional support

Seizures are serious and upsetting to witness. The more empathy and support you can provide
patients and loved ones, the better.
 Evaluation
 Provided privacy
 Eased patient on the floor
 Protected the head
 Loosened constrictive clothing
 Maintained patent airway
 Assessed, monitored and document seizure activity
 Educated the family
 Provided emotional support

Prognosis
For patients with seizures, prognosis means the probability of further seizures after a single
unprovoked seizure or the likelihood of achieving seizure freedom or terminal remission after a
pattern of recurring seizures has been established. It is now accepted that up to 70% of people
with epilepsy will enter remission, usually in the early years of the condition. However, in
discussing the prognosis of epilepsy, various aspects need to be considered: the likelihood of
recurrence following a single seizure, the impact of early versus late treatment, the probability of
relapse after prolonged remission, the probability of seizure freedom following epilepsy surgery
or relapse following antiepileptic medication withdrawal.
Short- and medium-term prognosis
In a prospective study of children with newly diagnosed epilepsy followed up from the time
of diagnosis, 74% had achieved a period of remission (≥2 years’ seizure freedom), of whom 24%
had a further seizure. In those who had a relapse, approximately 50% occurred when an
antiepileptic drug (AED) was being withdrawn or had been stopped. In the NGPSE after nine
years, 86% had achieved a remission of three years and 68% a remission of five years. The
proportion in terminal remission by nine years was 68% for three years and 54% for five years10.
In a study of patients aged ≥17 with newly diagnosed epilepsy, at ten years’ follow-up the
cumulative remission rates were 68% (one year), 64% (three years) and 58% (five years).
Long-term prognosis
Few studies have looked at the long-term prognosis of people with epilepsy and most are
retrospective and in pediatric cohorts. In the Rochester study12, 65% had achieved a five-year
period of remission at ten-year follow-up and 76% at 20 years. At ten years after diagnosis 61%
were in terminal remission with 70% in terminal remission at 20 years. Of those in remission,
20% continued on AEDs while 50% had successfully discontinued medication and remained
seizure-free for ≥5 years. In a cohort of children with active epilepsy followed up for 12 years
64% were in terminal remission (defined as ≥3 years seizure free) after 12 years14. In a study of
children followed up for an average 37 years, 67% were in terminal remission, on or off
medication. Early remission, defined as remission occurring within the first year of treatment,
was achieved by 31%, and the remission continued to terminal remission in half of these.
Remission without relapse occurred in 50% with a mean delay of nine years. A total of 14%
entered remission but subsequently relapsed with further remission, indicating a relapse-remitting
pattern, while 19% continued with seizures from the onset17. Of children followed up for a
median of 40 years, 93% had one or more periods of remission (one year), emphasizing the overall
excellent prognosis of childhood epilepsy19. For those with chronic epilepsy, up to one-third will
have a relapsing remitting pattern with at least one period of significant seizure freedom
The overall prognosis for people with newly diagnosed epilepsy is good, with 60−70%
becoming seizure-free, many of whom doing so in the early course of the condition. The
probability of obtaining seizure freedom is particularly high in those with idiopathic generalized
epilepsy and normal neurological examination. For those who continue to have seizures despite
multiple appropriate AED treatments, in appropriate candidates epilepsy surgery is four times
more likely to render seizure freedom than continued medical treatment alone. Despite this,
medical changes will achieve a remission of 12 months in 4−5% a year of those with seemingly
intractable epilepsy.