Nursing care

Nursing care of individuals with Epilepsy

In order to properly care for someone with epilepsy, the nurse should have an understanding of seizures as well as the medications, interventions, and monitoring strategies used to control seizures and to minimize their negative impact on the quality of life.  In order to establish optimal levels of seizure control, the cooperation of all team members, including the individual, is required. Because seizures frequently occur during the absence of professional staff, all staff involved with individuals who may have seizures must be trained in observing and recording seizure activity, and managing and protecting the individual during and after a seizure. In this section I will cover: initial interventions, assessment, reporting, documenting, planning, evaluation, and general guidelines for interventions at each stage.

What to do if a seizure occurs: at the time of seizure activity, staff observing the seizure activity should notify the nurse and provide an accurate description of the clinical presentation. If the individual continues to seize for more than 2 consecutive minutes or the individual experiences 2 or more generalized seizures without full recovery of consciousness between seizures, the nurse should be notified immediately. The nurse should assess the condition of the individual immediately after receiving the call for help. The nurse should continue to follow the procedures for Prolonged Seizure Activity. The nurse should document any action taken (including a request for medical consultation), reported observations, personal observations, actions taken, and the individual’s response to treatment in the nursing notes.

Nursing Assessment:of seizure activity should occur and be documented in the nursing notes. The nurse will assess (including the individual’s level of cardio-pulmonary risk).

The individual should be monitored during the postictal phase of the seizure. The individual’s risk factors and actual or potential health problems should be included in the health assessment report

Documentation: The nurse should document the reported observations in the nursing notes. The nurse should document any action taken (including a request for medical consultation), reported observations, personal observations, actions taken, and the individual’s response to treatment in the nursing notes (nursing notes should reflect that procedures were completed as ordered). Appropriate information about what occurred during the seizure should be documented. If the nurse does not actually witness the seizure, persons present should be consulted to obtain the information. The individual’s postictal condition and activity should be documented. Periodic review to identify trends and changes should be documented in the nursing notes.  Side effects and untoward interactions of medications should be documented in the nursing notes. Trends and changes in seizure activity (type and/or frequency) should be documented in the nursing notes.

Reporting: Significant or unusual findings should be reported immediately to the primary care prescriber. The decision of what to report is based on review of the seizure characteristics as well as the seizure history which includes: current seizure medications and past history, current frequency of seizures, date of last seizure, and type and characteristics of seizures, any complications or injuries related to the seizures,  neurological consultation reports including results of specified follow-up, EEG reports and results, and recent serum anticonvulsant levels.  Side effects and untoward interactions of medications should be reported immediately to the primary care prescriber. Trends and changes in seizure activity (type and/or frequency) should be reported to the primary care prescriber.

Planning: strategies related to seizure management should occur and be documented. The individual’s risk factors and actual or potential health problems should be included in the health assessment report. If the individual receives psychotropic medication, information about the individual's seizure status and anticonvulsant medications should be discussed and documented. Information regarding the type, frequency, and pattern of seizure activity; precipitating and associated factors; and trends in seizure activity should be included in the care plan. Information about the potential and actual side effects of the prescribed anticonvulsant medications should also be included. Specific nursing activities developed to eliminate and reduce seizures and to assist the person become more independent in management of the seizure disorder should be included (this may include activities related to prevention of injuries and secondary complications. Training sessions for direct care staff as well as other team members should occur. These sessions should include specific issues related to the individual’s seizures as well as overall observation, management, documentation, and safety issues related to seizure activity.

Implementation: care plans should be implemented. All orders for medication, treatment, and diagnostic procedures should be followed. Appropriate injury protective practices should be initiated as prescribed by the primary care prescriber or recommended by the Interdisciplinary Team.

Evaluation: of the seizure management plan should occur. The nurse should monitor the results of seizure management program and make recommendations to the primary care prescriber and interdisciplinary team for changes based on the progress noted. Side effects and untoward interactions of medications should be documented in the nursing notes and reported immediately to the primary care prescriber. Trends and changes in seizure activity (type and/or frequency) should be documented in the nursing notes and reported to the primary care prescriber. Seizure records should be reviewed on a regular basis for accuracy and completeness.

GENERAL GUIDELINES

Before a seizure occurs: If the person feels a seizure coming on, have them lie down. Determine if changes can be made in activities or situations that may trigger seizures.

To prevent injury, keep the bed in a low position with siderails up and use padded siderails as needed.

During a seizure (Ictal stage): When a seizure occurs, observe and document the following: Date, time of onset, duration, Activity at time of onset, Level of consciousness (confused, dazed, excited, unconscious), Movements: Body part involved, type of motor activity, eye deviation, twitching, respirations, heart (rate and rhythm), skin changes, gastrointestinal, changes in sensory awareness, presence of other unusual and/or inappropriate behaviors. Ensure adequate ventilation by loosening clothing, using postural support devices and/or restraints. Protect the person from injury by helping to break their fall and clearing the area of furniture. Turn the person into a side-lying position as soon as convulsing has stopped. (This will help the tongue return to its normal front-forward position and will also allow accumulated saliva to drain from the mouth.) Remain with the person and give verbal reassurance. Provide privacy and supportive therapy.

*DO NOT try to force an airway or tongue blade through clenched teeth. (Forced airway insertion can cause injury.) 

*DO NOT restrain movement. (Trying to hold down the person's arms or legs will not stop the seizure. Restraining movement may result in musculoskeletal injury.)  

After the Seizure (Postictal Stage): the nurse should record the presence of the following conditions and their duration in the individual’s record: gag reflex, headache, incontinence, injury, deficits, behavior changes, sleep pattern disturbance. Continue to assess until person returns to baseline. Allow the individual to sleep, reorient upon awakening. If the individual experiences amnesia, reorientation can help regain a sense of control and help reduce anxiety. Conduct a post seizure evaluation.

Precipitating factors:

There are many possible precipitating factors for seizures. These can be physical (overexertion, sleep deprivation, alteration in bowel elimination, fever, trauma, infections, illness, overhydration, excess caffeine or sugar intake), psychosocial/emotional (stress, depression, anxiety, psychosis, anger), metabolic and electrolyte imbalance (low blood glucose, sodium, calcium, or magnesium), Medical or chemical (withdrawal of alcohol or other sedatives, antihistamines, dopamine blocking agents, antipsychotics, antidepressants, immune suppressants, antibiotics, toxins), hormone variations (pregnancy, menstration), environmental (odors, music, flashing lights).

Considerations for Planning Daily Care:

General Health: Avoid constipation, excessive fatigue, hyperventilation and stress because they may trigger seizures. Environmental and recreational risk factors that should be avoided or minimized: Electric shocks, noisy environments, bright/flashing lights, poorly adjusted televisions or computer screens. Showers, rather than tubs baths, should be taken, when possible.

Diet: A well balanced diet should be eaten at regular times. Coffee and other caffeinated beverages should be limited to a moderate amount. Fluid intake should be between 1,000 to 1,500 ml per day (depending on the weather). Alcoholic beverages should be avoided.

Physical Activity: While regular activity and exercise are encouraged, as activity tends to inhibit rather than increase seizures, over-fatigue and hyperventilation should be avoided. If possible, individuals should exercise in climate controlled settings. Activities that could harm the patient should be avoided. The person may swim if accompanied by someone who knows what to do if a seizure occurs. The person should wear a life jacket and stay in relatively shallow water to facilitate seizure management should a seizure occur. Regular sleep patterns are important.

REFERENCES

http://ddsn.sc.gov/providers/manualsandguidelines/Documents/HealthCareGuidelines/NursingMgmtSeizures.pdf

American Association of Neuroscience Nurses (1997). Clinical guideline series: Seizure assessment. Author: Chicago.

Hickey, J.V. (2003). The clinical practice of neurological and neurosurgical nursing, (5th ed.). Philadelphia: Lippincott.

American Epilepsy Association (2004). Clinical Epilepsy. Retrieved on August 29, 2005 from http://www.aesnet.org/visitors/ProfessionalDevelopment/MedEd/ ppt/ppts03/clinicore.pdf