EPILEPSY

EPILEPSY

 

            Epilepsy (also called seizures) is a recurrent paroxysmal disorder of cerebral function characterized by sudden, brief attacks of altered consciousness, motor activity, sensory phenomena, or inappropriate behavior. Convulsive seizures, the most common form of attacks, begin with loss of consciousness and motor control, and tonic or clonic jerking of all extremities, but any recurrent seizure pattern may be termed epilepsy.

            Epileptic seizures are best classified by their pattern of onset, since this often gives clues to the affected site in the brain and may even reflect a specific cause. Seizures may be generalized, affecting both consciousness and motor function from the outset, as in some grand mal seizures, petit mal, and some of the akinetic seizures of children. Generalized seizures will be the focus of this paper. Another type of seizure is partial seizure wherein the source of the seizure within the brain is localized. Focal seizures begin with a specific sensory, motor, or psychic aberration that reflects the affected part of the cerebral hemisphere where the seizure originates. Focal manifestations that immediately precede generalized convulsions are called the aura, and likewise reflect where the seizure begins. Sometimes a focal lesion of the hemispheres will activate deeper parts of the brain so rapidly that it produces a generalized grand mal seizure before any focal sign appears (2006).

The table below gives some of the characteristic manifestations and their sites of origin.

Focal Manifestation

Site of Dysfunction

Localize4d twitching of muscles (Jacksonian seizure)

Frontal lobe (motor cortex)

Localized numbness or tingling

Parietal lobe (sensory cortex)

Chewing movements or smacking of lips

Anterior temporal lobe

Olfactory hallucinations

Posterior temporal lobe

Visual hallucinations (formed images)

Temporal lobe

Visual hallucinations (flashes of light)

Occipital lobe

Complex automatic behaviorisms

Temporal lobe

 

Etiology

            Epilepsy is classed etiologically as symptomatic or idiopathic; symptomatic implying that a probable cause has been identified which at times permits a specific course of therapy. No obvious cause can be found in a larger percentage of adults and a smaller percentage of children under age 3 (2006).

 

Assessment observations specific to chosen condition

            Epilepsy is characterized by uncontrolled excessive activity of either part or all part of the central nervous system. A seizure involves a hyperexcitation of the neurons in the brain leading to a sudden, violent, involuntary series of contractions of a group if muscles. A person who is predisposed to epilepsy has attacks when the basal level of excitability of the nervous system rises above a certain critical threshold ( 2000). The patient often loses consciousness. However, it must be noted that the symptoms and signs that a nurse can see upon assessment depends on what kind of epilepsy the patient has,

            Grand mal seizures occasionally begin with a sinking or rising sensation in the epigastrium (aura) followed by an outcry; the seizure continues with loss of consciousness; falling; and tonic, then clonic contractions of the muscles of the extremities, trunk, and head ( 2000). Urinary and fecal incontinence may be present upon assessment of the patient. The attack may be preceded by a prodromal mood change, and may be followed by a postictal stage, with deep sleep, headache, muscle soreness or, at times, focal motor or sensory phenomena. The attacks may occur at any age.

            Petit mal attacks are generalized seizures manifested by a 10- to 30-second loss of consciousness, with eye or muscle flutterings, and with or without loss of muscle tone. The patient suddenly stops any activity in which he is engaged and resumes it after the attack. Petit mal seizures are genetically determined and occur predominantly in children; they never begin after the age of 20. The attacks are likely to occur several or many times a day, often when the patient is sitting quietly. They are not frequent during exercise. Petit mal attacks rarely indicate gross brain damage, and many patient are highly intelligent (2006).

            During a seizure a patient’s jaw muscles can become tense. It has been found that significant injury to the patient’s oral cavity is rare, even during the most violent seizures. Injury may instead occur from a caregiver forcing an object into the patient’s mouth and from the teeth hitting down on a hard object.

Assessment for a patient’s need for seizure precautions cannot be delegated. If a seizure occurs, the nurse must constantly assess the patient’s airway patency, adequacy of breathing, and circulatory status. Clinical judgments must be made quickly.

 

Nursing care required

            The nurse must first assess seizure history, noting frequency of seizures, presence of aura, and sequence of events, if known. Medical and surgical conditions that may lead to seizures or exacerbate existing seizure conditions must be assessed. This will enable the nurse to anticipate onset of seizure activity. Seizure medications must be taken as prescribed and not stopped suddenly, because this may precipitate seizure activity (2004).

            The nurse should then inspect the patient’s environment for potential safety hazards if risk for seizure exists. This would prevent the patient from sustaining injury by striking head or body on furniture or equipment ( 2004).

            When the seizure begins, the nurse should position the patient safely. If the patient is standing or sitting, the patient should be guided to the floor and the head protected by cradling it in the nurses’ lap or by placing a pillow under the head of the patient. Surrounding areas of furniture should be cleared. If the patient is in the bed at the time of the seizure, side rails of the bed should be raised, padding should be added, and bed should be placed in a low position ( 2004). The rationale for all these actions is to protect the patient from traumatic injury, especially head injury.

 

Pharmacologic agents used and their rationale

            No single drug controls all types of seizures, so that patients may require several drugs. Also, since dosage requirements vary, one begins with a small dose, increasing it gradually until seizures are controlled or until seizures are controlled or until untoward side effects appear. Blood levels can be determined for most anticonvulsants and often help in managing a difficult case. Medication should be continued for at least 5 seizure-free years.

            For grand mal seizures, phenytoin and phenobarbital are most effective. Phenobarbital alone can be given once a day at bedtime when seizures are not frequently occurring. Phenytoin, on the other hand, is the drug of choice for frequent seizures. The drugs used for grand mal also control epileptic equivalents and psychomotor seizures ( 2006). In the latter, larger doses may be necessary.

            Phenobarbital frequently causes incapacitating drowsiness and, in very few cases, an allergic reaction or rash. In high doses, phenytoin may also cause restlessness, nervousness, nystagmus, nausea, vomiting, unsteady gait, dermatitis, hypertrophy of the gums, and confusion. Adenopathy is a rare complication (2005).

            When an overdose reaction occurs, one reduces the amount of the drug until the intoxication subsides. When more serious toxicity appears, the suspect drug should be discontinued and a new anticonvulsant should be promptly substituted (2006).

 

Nursing interventions with rationales to prevent complications

General Principles: In idiopathic epilepsy, treatment is primarily control of seizures. In symptomatic epilepsy, the associated disease must be treated as well; continued anticonvulsant treatment is usually needed after surgical removal of cerebral lesions.

A normal life should be encouraged. Moderate exercise is recommended; such sports as swimming and horseback riding are permitted with proper safeguards. Movies, dancing, and other social activities should be encouraged. Automobile driving is usually permitted after seizures have stopped for one year. Alcoholic beverages are contraindicated.

Members of the family must be taught a common sense attitude toward the patient’s illness. Instead of overprotection and oversolicitude, sympathetic support should be directed against feelings of inferiority, self-consciousness, and other emotional handicaps, and emphasis should be placed on preventing invalidism. Vocational rehabilitation may help. Institutional care is advisable only for patients with severe mental retardation or with attacks that are frequent, violent, and not controlled by medication.

Management of a Convulsion: Whatever its etiology, management is limited to preventing injury. A firm but reasonably soft object should be inserted between the teeth, but attempts to protect the tongue should not be too vigorous or teeth may be damaged. Clothing about the neck should be loosened, and a pillow may be placed under the head. A responsible fellow may be trained to give emergency aid if the patient concurs.

Elimination of Causative or Precipitating Factors: Physical disorders should be corrected. Organic lesions of the brain, such as tumors and abscesses, should be removed surgically. Cortical scars from trauma, vascular lesions, or birth injuries can sometimes be excised when focal attacks resist medical therapy. After surgical removal of organic lesions, continued medical treatment is usually necessary.

 

Patient education

            There has been increasing recognition that epilepsy is not simply a medical problem, it is a problem that affects the psychosocial needs of the individual. Thus this precipitates the need to focus on this need in terms of preventive care. The emotional effects of epilepsy take a toll on relationships and psychological well-being of the patient who will then require sympathetic understanding and practical support, which the nurse can often provide. Additionally, the nurse can educate the family of the patient about this. In acknowledging fears and allaying uncertainties, the nurse can articulate the individual’s concerns, correct misconceptions, assist in social and emotional adjustment, and help the individual come to terms with his or her condition.

In all these, it must be noted that the provision of information from the nurse to the patient is not a one-way, process. Patient education should be an activity wherein there is collaboration between the nurse or other health care professionals and the patient. People with epilepsy value the opportunity and time to ask questions, raise issues of concern, which, due to pressure of limited time within a consultation, many doctors find difficult to cover. The consultation with a nurse may also be at a time and in a place when the individual is less distressed by the diagnosis and more able to ask for and use the information given. The role of the nurse is to inform, advise, and help the individual rather than just manage the condition. For example, referral to the social worker for assistance in social benefits claims is often appreciated ( 2000).

            The nurse in patient educations should promote the provision of information with literature and leaflets about epilepsy, first aid instruction demonstration, and if possible, an epilepsy video. In some countries, these are available from voluntary and government organizations. Referral and encouragement for the patient to join a support group is helpful, because people with epilepsy may gain peer support, information, free literature searches, and practical help. It has been found out that independently of education, self-help group membership is associated with a greater knowledge of epilepsy.

 

Discharge plan

            As the key worker, upon discharge, the nurse facilitates a close liaison with other professionals and coordinates the multidisciplinary service needed for people with epilepsy. Coordination may be needed between hospital neurologists and family doctors at the primary-secondary interface and among patients and community social workers, midwives, psychologists, counselors, pharmacists, dentists, employment advisers, government and voluntary agencies, and informal caregivers. This is to ensure that upon discharge the patient with epilepsy knows other ways and means by which he or she can look for help. If the nurse provides accelerated access to medical care when epilepsy control deteriorates, this may help to reduce the unnecessary use of emergency services and hospital admissions for people with severe epilepsy (2000).

 

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