Neurological Conditions: Seizures

Seizures occur when there is abnormal, excessive electrical activity in the brain. They can range from barely noticeable to severe convulsions. Nurses must know how to protect patients during seizures and recognize when seizures become medical emergencies.

Pathophysiology

Seizures result from:

• Sudden, abnormal electrical discharge in neurons
• May be localized (focal) or generalized throughout the brain
• Causes temporary changes in consciousness, movement, sensation, or behavior

Types of Seizures

Focal (Partial) Seizures - Start in one area:

Generalized Seizures - Both hemispheres from onset:

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Causes of Seizures

In Patients WITH Epilepsy:

• Medication non-compliance (most common)
• Sleep deprivation
• Illness, fever, infection
• Alcohol or drug use
• Missed meals (hypoglycemia)
• Stress
• Flashing lights (photosensitive epilepsy)

In Patients WITHOUT Epilepsy:

• Head trauma
• Stroke
• Brain tumor
• Metabolic disturbances (hypoglycemia, hyponatremia, hypoxia)
• Drug toxicity or withdrawal
• High fever (febrile seizures in children)
• Eclampsia (pregnancy)
• Alcohol withdrawal

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Phases of a Generalized Tonic-Clonic Seizure

1. Aura (Prodromal Phase)

• Warning sign before seizure
• Not all patients experience an aura
• May include visual, auditory, or olfactory sensations
• Allows patient to get to safety

2. Tonic Phase (10-20 seconds)

• Loss of consciousness
• Muscles stiffen
• May have a cry (air forced through vocal cords)
• Falls if standing
• May become cyanotic (not breathing)

3. Clonic Phase (30-60 seconds)

• Rhythmic muscle jerking
• May bite tongue
• Excessive salivation
• Loss of bladder/bowel control possible

4. Postictal Phase (Minutes to hours)

• Gradual return of consciousness
• Confusion, disorientation
• Fatigue, sleepiness
• Headache
• Muscle soreness
• No memory of seizure

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Nursing Care During a Seizure

The Priority is SAFETY

Do:

• Stay with the patient - Call for help but do not leave
• Time the seizure - Duration is critical information
• Protect from injury:
  • Lower to floor if standing
  • Move furniture and hard objects away
  • Place padding under head (pillow, folded blanket)
• Turn to side (recovery position) - Maintains airway, prevents aspiration
• Loosen restrictive clothing - Ties, collars, tight clothing
• Maintain airway - Suction secretions after seizure if needed

Do NOT:

• Do NOT restrain - Can cause injury during forceful movements
• Do NOT insert anything in mouth - No tongue blades, fingers, or airways
  • Cannot "swallow tongue"
  • Forcing mouth open can break teeth, injure jaw
• Do NOT give oral medications or fluids during seizure
• Do NOT leave patient unattended

Exam Tip: The most common incorrect answer choice is "insert a padded tongue blade." NEVER insert objects in the mouth during a seizure!

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Post-Seizure (Postictal) Care

After the seizure ends:

1. Maintain airway - Keep on side, suction if needed
2. Assess breathing - Apply oxygen if needed
3. Check for injuries - Tongue lacerations, head trauma, fractures
4. Provide orientation - Reorient patient gently; speak calmly
5. Allow rest - Patient will be exhausted
6. Document thoroughly:
   • Time seizure started and ended
   • Behavior before seizure (aura)
   • Body parts involved, progression
   • Loss of consciousness
   • Postictal state and duration

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Status Epilepticus

Definition: A seizure lasting longer than 5 minutes OR two or more seizures without regaining consciousness between them.

This is a MEDICAL EMERGENCY

Why It's Dangerous

• Prolonged seizure activity causes brain damage
• Hypoxia from impaired breathing
• Hyperthermia from muscle activity
• Metabolic acidosis
• Can be fatal

Treatment of Status Epilepticus

Priority Order:

1. Maintain airway - May need intubation
2. Oxygen - High flow
3. IV access - Establish immediately
4. Check blood glucose - Treat hypoglycemia with D50W
5. First-line medications:

1. Second-line if benzodiazepines fail:

   • Fosphenytoin or phenytoin IV
   • Levetiracetam (Keppra) IV
   • Valproate IV

2. Refractory status epilepticus:

   • Propofol, pentobarbital, or ketamine infusion
   • ICU admission required

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Seizure Precautions

For patients at risk for seizures:

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Antiepileptic Drugs (AEDs)

Common medications for seizure prevention:

Patient Education:

• Take medications as prescribed; do not skip doses
• Do not stop medications abruptly (can cause seizures)
• Avoid alcohol
• Get adequate sleep
• Know triggers and avoid them
• Wear medical identification

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Febrile Seizures in Children

• Occur with fever in children 6 months to 5 years
• Usually benign; most do not develop epilepsy
• Manage fever with acetaminophen or ibuprofen
• Tepid sponge bath (not ice water)
• Education for parents on seizure first aid

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Key Points for the NCLEX

• DO NOT restrain during seizure
• DO NOT insert anything in mouth
• Turn to side to protect airway
• Time the seizure - critical documentation
• Status epilepticus = seizure > 5 minutes = emergency
• Lorazepam IV is first-line for status epilepticus
• Seizure precautions: padded rails, suction, oxygen, bed low
• Postictal: patient is confused and exhausted; orient gently
• Phenytoin: watch for gingival hyperplasia, therapeutic level 10-20 mcg/mL