MENNONITECOLLEGEOFNURSINGat Illinois State University

NUR 317Nursing Care of Children

Seizure Disorder

Definitions-

a. convulsions - involuntary muscle contraction and relaxation

b. seizure- asudden attackresulting fromparoxysmal discharges in cortical neurons

c. epilepsy- having the tendency to experience seizures

I. Epilepsy

  1. Etiology
  2. idiopathic -having a genetic tendencythatinsomewayalterstheseizure threshold to influence neuronal discharge
  3. acquired-having a seizure as a resultofbrain injury during prenatal, perinatal, orpostnatal periods(trauma,hypoxia,infections,etc.)
  4. Pathophysiology
  5. Spontaneous electric discharges initiated by a group of hyperexcitable cells referredtoas“epilectic focus”thathave been stimulated bysome physiologic stimuli, activate normal cells spreading this excitation to the brainstem resulting in a generalized seizure.
  6. Symptoms
  7. A clear description of the phenomena is a valuable aid in localizing the area involved and frequently suggests the underlying pathology

(So watch all movements ofall extremities/eyemovements,timethem,
know events surrounding event ofseizure)

  1. Sensory-hallucinating phenomena -an“aura” warns persons ofanimpending attack and can also provide the most reliable clue to help localize the origin of the discharge. AURA ISNOT ALWAYS PRESENT.
  2. Aura: a sensation ofdizziness or an unusual feeling ofascending abdominal discomfort
  3. Motoreffects:
  4. eyemovement-provides cluestofocusofseizure. Discharges inthe cortexofone hemisphere tend tocause theeyes todeviate toopposite side. Bilateral discharges cause the eyes tomove upward orstraightahead.
  5. Muscle contraction -3types
  6. CLONIC -opposing muscles contractand relax, alternately producing rhythmicmovements
  7. TONIC-all muscles are maintained in acontraction foratime causing the person to become rigid
  8. Jacksonian-muscular twitching begin in one area and spreads toanother
  9. Sensorimotor: tingling, prickling, hallucinations orlightflashes,tastes,smells, orsounds. Sensations aredetermined bypartofbrain affectedD. Alterations ofconsciousness: maybeunaffected,lostcompletely, oraltered. Amnesia results when there is loss ofconsciousness.
  1. “Postictalstate”-period following seizure (sometimes drowsy, will sleep)usually

Lasts 5-30 minutesand is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine, and other disorienting symptoms

3. Classification ofEpilepsy (p.1466-1467- Hockenberry, 10thed)

a. Partial seizures -thehallmark ofthese seizures is the onset in a portion of one cerebral hemisphere

1. simple partial: no loss ofconsciousness, local area ofbrain

2. complex partial: may have loss ofconsciousness

b. Generalized seizures -clinical observationsindicate thatthe initial involvement is fromboth hemispheres

1. TONIC-CLONICseizure -“GRANDMAL”

Themostcommon and dramatic ofall seizures. Usually begins without aura; symmetricand generalized tonic contraction ofentire body musculature lasting 10-20 seconds, followed by violent jerking movements during clonic phase lasting 30 seconds. Postictal state-child isdrowsy

and may sleep for several hours. Upon awakening, child may have no recall ofseizure.

a. flexion

b. extension

c. tremorphase d. clonic phase

e. posticatal phase

2. ABSENCEseizures -“PETITMAL”

Characterized by a brief loss ofconsciousness with minimal or no alteration in muscle tone and may go unrecognized because the child’s behavior ischanged verylittle. Appears to“space out”.

Symptoms: minor movements aslip smacking, twitching ofeyelids or

face,orslighthandmovements. Maydrop object being held, but maintain postural control.

  1. STATUSEPILEPTICUS

Medical emergency: aseries ofseizures atintervals toobrief toallow the child to regain consciousness between attacks. Can lead toexhaustion, respiratory failure, and death.

3/17

4. Management --2goals 1. ascertain typeofseizure

2. attempttounderstand cause

A. Diagnosis

1. Thorough Hx and Assessment

-age ofonset

-typeofseizure &/orbehavior during attack

-timeattackoccurs

-precipitating factors;fever,injury,etc.

- duration and progressionofseizure and postictal state

-complete family hx and physical assessment

2. Laboratorytests

CBC -forinfection

glucose levels -forhypoglycemia

BUN,electrolytes,Calcium-formetabolic disturbances

CSF-forinfection ortrauma

3. Othertesting

Lumbar Puncture,skull X-ray,CTscan,echoencephalogram (EEG), brain scans

B. Therapeutic treatment-3goals

a. control orreduce frequency ofseizures

b. discover and correctcause

c. help child lead as normal a life as possible

  1. Drug therapy -anticonvulsantsreduce the responsiveness ofnormal neurons to the sudden, high frequencynerve impulses thatarise in the epileptogenic focus.

a. forAbsence seizures: Ethosuxamide (Zarontin) Clonezepam (Clonopin) Valproic Acid(Depakane)

b. forotherseizuretypes: Phenytoin (Dilantin) Phenobarbital Carbamezapine (Tegretol) Valproic Acid(Depakane)

  1. forstatusepilepticus: IVOR intrarectalDiazepam (Valium)

IVLorazepam(Ativan)

2. Strategyfordrugtreatment-start with one drug and increase until seizures arecontrolled. Oncecontrolled, continue med for prolonged time. Blood levels help maintain optimum therapeutic levels. Repeat EEGq11/2-2years. WHEN MED IS DISCONTINUED, DOSAGE MUST BE REDUCED GRADUALLY OVER

1-2 WEEKS. SUDDEN WITHDRAWEL CAN CAUSE RECURRENCE OF SEIZURES.

3. Complications -Dilantin can cause gingival hyperplasia - frequent gum massage and good oral hygiene are indicated.

3/17

-The American Academy ofPediatrics stressesthatscreening teststodetect subtle intellectual and behavioral side effectsand studies to evaluate and compare theeffectsofanticonvulsant therapyareinorder toprevent detrimental effectson behavior and mental function.

C. Nursing Care (p.1476-1477- Hockenberry, 10thed.)

1. Nursing diagnoses: Risk for Injury, Altered Family Coping, Risk for Altered Self-Image, etc

2. nursing objectives:

a. protectchild during seizure

b. reduce/prevent seizures ifpossible c. help child family cope with stigma

d. help child develop positive self-image

e. identify triggers and assist withadjustments toprevent seizures

3. GENERAL OBSERVATIONSOFCHILD DURING SEIZURE: (p. 1475- Hockenberry, 10th ed.)

4. SEIZURE PRECAUTIONS (p.1478- Hockenberry, 10th ed.)

II. Febrile Seizures

1. Incidence: 3-5%ofchildren affected

2. Occurrence: Between 6monthsand 3years; unusual after5years.

Boysaffected2xmorethangirls. Possible genetic tendency.

3. Etiology: unknown, usually withfever38.8C (101.8F)

usually with URIorGIdisturbance

Roseola—viral infection with temp followed by maculopapular rash.

  1. Treatment:
    a. Preventincrease in temp with antipyretics
  • Acetaminophen 10-15mg/kg/dose
  • Ibuprofen 10mg/kg/dose
  • NO ASPIRIN
  • Light clothing—avoid blankets
  • Cool liquids
  • NOTE: Tepid sponge baths are no longer advocated because ofrisk ofshivering which increases themetabolic rate,thusincreasingtemperatureevenmore.

b. Anticonvulsants maybeprescribed; usually short-term

c. Treatunderlying cause

d. EEGmaybeordered

e. Teachparents the importance ofprevention!!

3/17