Seizure Disorders (Epilepsy)  A seizure is an abnormal, unregulated

electrical discharge that occurs within the

 A seizure is a sudden, uncontrolled electrical brain’s cortical gray matter and transiently
disturbance in the brain. It can cause changes interrupts normal brain function; a seizure

typically causes altered awareness,

in behavior, movements or feelings, and in
abnormal sensations, focal involuntary
levels of consciousness.
movements, or convulsions (widespread
violent involuntary contraction of
 Epilepsy is defined as a brain disorder
voluntary muscles).
characterized by an enduring
predisposition to generate epileptic
seizures and by the neurobiological, Classification

cognitive, psychological, and social

Seizures are classified as generalized or partial.
consequences of this condition.
 One of the earliest descriptions of a
1. Generalized seizures. In generalized
secondary generalized tonic-clonic seizure
seizures, the aberrant electrical discharge
was recorded over 3000 years ago in
diffusely involves the entire cortex of both
Mesopotamia; the seizure was attributed
hemispheres from the onset, and
to the god of the moon.
consciousness is usually lost; generalized
 Hippocrates wrote the first book about
seizures result most often from metabolic
epilepsy almost 2500 years ago; he
disorders and sometimes from genetic
rejected ideas regarding the divine
disorders.
etiology of epilepsy and concluded that
the cause was excessive phlegm leading to
abnormal brain consistency.
 2. Partial seizures. In partial seizures, the these 2 types of seizure and are therefore
excess neuronal discharge occurs in one discussed separately.
cerebral cortex, and most often results

from structural abnormalities; revised

terminology for partial seizures has been Statistics and Incidences
proposed; in this system, partial seizures
 Incidences of seizure disorders in the United
are called focal seizures.
States and worldwide occurs as follows:

Pathophysiology
 Hauser and collaborators demonstrated

 Seizures are paroxysmal manifestations of the that the annual incidence of recurrent

electrical properties of the cerebral cortex. nonfebrile seizures in Olmsted County,

Minnesota, was about 100 cases per

 A seizure results when a sudden imbalance 100,000 persons aged 0–1 year, 40 per

occurs between the excitatory and 100,000 persons aged 39–40 years, and

inhibitory forces within the network of 140 per 100,000 persons aged 79–80 years.

cortical neurons in favor of a sudden-onset  By the age of 75 years, the cumulative

net excitation. incidence of epilepsy is 3400 per 100,000

 The brain is involved in nearly every bodily men (3.4%) and 2800 per 100,000 women

function, including the higher cortical (2.8%).

functions; if the affected cortical network  Studies in several developed countries

is in the visual cortex, the clinical have shown incidences and prevalence of

manifestations are visual phenomena. seizures similar to those in the United

 The pathophysiology of focal-onset States.

seizures differs from the mechanisms

underlying generalized-onset seizures. Causes
 Overall, cellular excitability is increased,
 In a substantial number of cases, the cause of
but the mechanisms of synchronization
epilepsy remains unknown.
appear to substantially differ between
1. Genetic syndromes. A number of genetic Phases
syndromes are known to causes seizures;
however, a number of more common  The phases of seizure activity are prodromal,

syndromes should be considered in the aural, ictal, and postictal.

patient who presents with seizures and

1. The prodromal phase involves mood or
other findings.
behavior changes that may precede a
2. Chromosomal 22q deletion or duplication
seizure by hours or days.
syndromes. Chromosomal 22q deletion
2. The aura is a premonition of impending
syndrome is a spectrum of findings caused
seizure activity and may be visual, auditory,
by a deletion on chromosome 22q11.2;
or gustatory.
seizures occur in 7% of patients with
3. The ictal stage is characterized by seizure
chromosomal 22q deletion syndrome.
activity, usually musculoskeletal.
3. Metabolic disorders. Many different
4. The postictal stage is a period of
metabolic disorders can cause seizures,
confusion/somnolence/irritability that
some as a result of a metabolic
occurs after the seizure.
disturbance such as hypoglycemia or
acidosis and some as a primary
manifestation of the seizure disorder. Clinical Manifestations

4. Mitochondrial diseases. Mitochondrial
 The clinical diagnosis of seizures is based on
disorders are underdiagnosed but often
the history obtained from the patient and,
involve seizures and other neurologic
most importantly, the observers.
manifestations; mitochondrial
encephalomyopathy, lactic acidosis, and
 Aura. An aura (unusual sensations)
stroke like episodes (MELAS) syndrome is
precedes seizures in about 20% of people
a mitochondrial disorder that is associated
who have a seizure disorder.
with seizures; often, seizures are the
 Short duration. Almost all seizures are
presenting manifestation.
relatively brief, lasting from a few seconds
5. Seizure disorders caused by single -gene
to a few minutes; most seizures last 1 to 2
mutations. Autosomal dominant nocturnal
minutes.
frontal lobe epilepsy is caused by
 Postictal state. When a seizure stops,
mutations in the CHRNA4, CHRNB2, or
people may have a headache, sore
CHRNA2 genes; it is characterized by
muscles, unusual sensations, confusion,
nocturnal motor seizures.
and profound fatigue; these after-effects
6. Idiopathic or unknown origin.
are called the postictal state.
  Todd paralysis. In some people, one side of  Neuroimaging studies. A neuroimaging
the body is weak, and the weakness lasts study, such as brain magnetic resonance
longer than the seizure (a disorder called imaging (MRI) or head computed
Todd paralysis). tomography (CT) scanning, may show
 Visual hallucinations. Visual hallucinations structural abnormalities that could be the
(seeing unformed images) occur if the cause of a seizure.
occipital lobe is affected.  Electroencephalography. Interictal
 Convulsions. A convulsion (jerking and epileptiform discharges or focal
spasms of muscles throughout the body) abnormalities on electroencephalography
occur if large areas on both sides of the (EEG) strengthen the diagnosis of epileptic
brain are affected. seizures and provide some help in
determining the prognosis.

Assessment and Diagnostic Findings  Video- EEG. Video-EEG monitoring is the

criterion standard for classifying the type
 Epileptic seizures have many causes, and of seizure or syndrome or for diagnosing
some epileptic syndromes have specific pseudoseizures; that is, for establishing a
histopathologic abnormalities. definitive diagnosis of spells with
impairment of consciousness.
 Prolactin study. The American Academy of
 Lumbar puncture. Detects
Neurology (AAN) recommends serum
abnormal cerebrospinal fluid (CSF)
prolactin assays, measured in the
pressure, signs of infections
appropriate clinical setting at 10-20
or bleeding (i.e., subarachnoid, subdural
minutes after a suspected event as a useful
hemorrhage) as a cause of seizure activity
adjunct for differentiating generalized
(rarely done).
tonic-clonic or complex partial seizure
from psychogenic nonepileptic seizure in
Medical Management
adults and older children.
 Serum studies of anticonvulsant  The goal of treatment in patients with
agents. Judicious testing of serum levels epileptic seizures is to achieve a seizure-free
of antiepileptic drugs (AEDs) may help to status without adverse effects.
improve the care for patients with seizures
and epilepsy; however, note that many  Monotherapy. Monotherapy is desirable
new AEDs do not have readily obtainable because it decreases the likelihood of
or established levels. adverse effects and avoids drug
interactions; also, monotherapy may be
 less expensive than polytherapy, as many protein, calories, and fluids; in small
of the older anticonvulsant agents have studies of children with intractable
hepatic enzyme-inducing properties that epilepsy, seizure reductions of more than
decrease the serum level of the 50% have been seen within 3 months in
concomitant drug, thereby increasing the some children placed on this diet,
required dose of the concomitant drug. particularly with carbohydrate limits of 10 g
 Anticonvulsant therapy. The mainstay of per day.
seizure treatment is  Vagal nerve stimulation. VNS is a palliative
anticonvulsant medication; the drug of technique that involves surgical
choice depends on an accurate diagnosis implantation of a stimulating device; VNS is
of the epileptic syndrome, as a response to FDA approved to treat medically refractory
specific anticonvulsants varies among focal-onset epilepsy in patients older than
different syndromes. 12 years; some studies demonstrate its
 Discontinuing anticonvulsant agents. After a efficacy in focal-onset seizures and a small
person has been seizure free for typically 2- number of patients with primary
5 years, the physician may consider generalized epilepsy.
discontinuing that patient’s medication;  Implantable neurostimulator. The
many patients outgrow many epileptic NeuroPace RNS System, a device that is
syndromes in childhood and do not need implanted into the cranium, senses, and
to take anticonvulsants. records electrocorticographic patterns and
 Ketogenic diet. The ketogenic diet, which delivers short trains of current pulses to
relies heavily on the use of fat, such as interrupt ictal discharges in the brain.
hydrogenated vegetable oil shortening  Lobectomy. In a randomized, controlled
(e.g., Crisco), has a role in the treatment of trial of surgery in 80 patients with
children with severe epilepsy; although temporal lobe epilepsy, 58% of patients in
this diet is unquestionably effective in the group randomized to anterior
some refractory cases of seizure, a temporal lobe resective surgery were free
ketogenic diet is difficult to maintain; less from seizures impairing awareness at 1
than 10% of patients continue the diet after year, as compared with 8% in the group
a year. that received anticonvulsant treatment.
 Atkins diet. Preliminary data have been  Lesionectomy. In a study presented at the
published about improvement of seizure 66th Annual Meeting of the American
frequency following a modified Atkins Epilepsy Society, investigators suggested
(low-carbohydrate) diet that mimics the that, in select pediatric patients, smaller
ketogenic diet but does not restrict lesionectomy resections in the surgical
 treatment of seizures may be as effective and electrical seizure activity;
as larger resections, and they may spare anticonvulsants are normally reserved for
children the functional and developmental patients who are at increased risk for
deficits associated with the larger recurrent seizures.
resections.  Anticonvulsants, barbiturates. Like
 Activity modification and restrictions. The benzodiazepines, barbiturates bind to the
major problem for patients with seizures is gamma-aminobutyric acid (GABA)
the unpredictability of the next seizure; receptor, enhancing the actions of GABA
clinicians should discuss the following by extending GABA-mediated chloride
types of seizure precautions with patients channel openings and allowing neuronal
who have epileptic seizures or other spells hyperpolarization.
of sudden-onset seizures: driving,  Anticonvulsants, benzodiazepines. These
ascending heights, working with fire or agents bind to the gamma-aminobutyric
cooking, using power tools and other acid (GABA) receptor, thereby enhancing
dangerous equipment, taking the actions of GABA.
unsupervised baths, and swimming.  Anticonvulsants, succinimide. These agents
 Long-term monitoring. In 2018, the FDA reduce current in T-type calcium channels.
cleared for marketing the first smartwatch  Anticonvulsants, neuronal potassium channel
for seizure tracking and epilepsy opener. Stabilizes neuronal KCNQ (Kv7)
management; the Embrace smart watch channels in the open position, increasing
identifies convulsive seizures and sends an the stabilizing membrane current and
alert via text and phone message to preventing bursts of action potentials
caregivers; the watch also records sleep, during the sustained depolarizations
rest, and physical activity data; the device associated with seizures.
was tested in a study of 135 epileptic  Anticonvulsants, hydantoins. These agents
patients and found the watch’s algorithm stabilize sodium channels and prevent the
detected 100% of patient seizures. return of the channels to the active state.

Pharmacologic Management Nursing Management

 The number of anticonvulsants has increased, Nursing care for a child with seizure disorder include
offering many more medication choices the following:
for physicians and their patients.

1. History. The diagnosis of epileptic seizures

 Anticonvulsants. These agents prevent is made by analyzing the patient’s detailed
seizure recurrence and terminate clinical
 clinical history and by performing ancillary Nursing Care Planning and Goals
tests for confirmation; someone who has
The major nursing goals for a child with seizure
observed the patient’s repeated events is
disorder are:
usually the best person to provide an
accurate history; however, the patient also
 The patient or caregiver will verbalize
provides invaluable details about auras,
understanding of factors that contribute
preservation of consciousness, and
to the possibility of trauma and or
postictal states.
suffocation and take steps to correct the
2. Physical exam. A physical examination
situation.
helps in the diagnosis of specific epileptic
 The patient or caregiver will identify
syndromes that cause abnormal findings,
actions or measures to take when seizure
such as dermatologic abnormalities (e.g.,
activity occurs.
neurocutaneous syndromes such as
 The patient or caregiver will identify and
Sturge-Weber, tuberous sclerosis, and
correct potential risk factors in the
others); also, patients who for years have
environment.
had intractable generalized tonic-clonic
 The patient or caregiver will demonstrate
seizures are likely to have suffered injuries
behaviors, lifestyle changes to reduce risk
requiring stitches.
factors and protect self from injury.
 The patient or caregiver will modify the
Nursing Diagnosis
environment as indicated to enhance
Based on the assessment data, the major nursing safety.
diagnoses are:  The patient or caregiver will maintain
treatment regimen to control or eliminate
 Risk for trauma or suffocation related to seizure activity
loss of large or small muscle coordination.  The patient or caregiver will recognize the
 Risk for ineffective airway clearance related need for assistance to prevent accidents or
to neuromuscular impairment. injuries.
 Situational low self-esteem related to  The patient will maintain effective
stigma associated with the condition. respiratory pattern with airway patent
 Deficient knowledge related to information or aspiration prevented.
misinterpretation.  The patient or caregiver will demonstrate
 Risk for injury related to weakness, behaviors to restore positive self-esteem.
balancing difficulties, cognitive limitations  The patient or caregiver will participate in
or altered consciousness. treatment regimen or activities to correct
factors that precipitated a crisis.
  The patient or caregiver will verbalize activities, providing supervision and
understanding of the disorder and various monitoring when indicated; know the
stimuli that may increase potentiate attitudes or capabilities of SO; help an
seizure activity. individual realize that his or her feelings
are normal; however, guilt and blame are
Nursing Interventions not helpful.
4. Enforce education about the disease. Review
Nursing interventions for a child with seizure disorder
pathology and prognosis of condition and
include the following:
lifelong need for treatments as indicated;
discuss patient’s particular trigger factors
1. Prevent trauma/injury. Teach SO to
(flashing lights, hyperventilation, loud
determine and familiarize warning signs
noises, video games, TV viewing); know
and how to care for patient during and
and instill the importance of good oral
after seizure attack; avoid using
hygiene and regular dental care; review
thermometers that can cause breakage;
medication regimen, necessity of taking
use tympanic thermometer when
drugs as ordered, and not discontinuing
necessary to take temperature; uphold
therapy without physician supervision;
strict bedrest if prodromal signs or aura
include directions for missed dose.
experienced; turn head to side and suction
airway as indicated; support head, place on
Evaluation
soft area, or assist to floor if out of bed; do
not attempt to restrain; monitor and Goals are met as evidenced by:
document AED drug levels, corresponding
side effects, and frequency of seizure  The patient or caregiver verbalized
activity. understanding of factors that contribute
2. Promote airway clearance. Maintain in lying to the possibility of trauma and or
position, flat surface; turn head to side suffocation and take steps to correct the
during seizure activity; loosen clothing situation.
from neck or chest and abdominal areas;  The patient or caregiver identified actions
suction as needed; supervise supplemental or measures to take when seizure activity
oxygen or bag ventilation as needed occurs.
postictally.  The patient or caregiver identified and
3. Improve self-esteem. Determine individual corrected potential risk factors in the
situation related to low self-esteem in the environment.
present circumstances; refrain from over
protecting the patient; encourage
  The patient or caregiver demonstrated  Responses to interventions, teaching, and
behaviors, lifestyle changes to reduce risk actions performed.
factors and protect self from injury.
 The patient or caregiver modified
environment as indicated to enhance
safety.
 The patient or caregiver-maintained
treatment regimen to control or eliminate
seizure activity
 The patient or caregiver recognized the
need for assistance to prevent accidents or
injuries.
 The patient maintained effective
respiratory pattern with airway patent
or aspiration prevented.
 The patient or caregiver demonstrated
behaviors to restore positive self-esteem.
 The patient or caregiver participated in
treatment regimen or activities to correct
factors that precipitated a crisis.
 The patient or caregiver verbalized
understanding of the disorder and various
stimuli that may increase potentiate
seizure activity.

Documentation Guidelines

 Individual findings, including factors

affecting, interactions, nature of social
exchanges, specifics of individual behavior.
 Cultural and religious beliefs, and
expectations.
 Plan of care.
 Teaching plan.