A client is having a tonic-clonic seizure which is a priority nursing action

Seizures NCLEX review for nursing students. This review is part of a neuro review, so be sure to check out those other NCLEX reviews.

Don’t forget to take the quiz that contains seizures NCLEX questions.

Lecture on Seizures

Seizures NCLEX Review

What are seizures? Seizures occur when abnormal electrical signals are being rapidly fired for neurons in the brain. This can happen throughout the brain affecting both sides (generalized seizure) or being located in a specific area of the brain (partial or focal seizure).

Seizures can occur in anyone (children and adults) due to a severe acute condition, such as a high fever, illness (especially central nervous system types like bacterial meningitis), hypoglycemia, acid-base imbalances like acidosis, alcohol withdraw, brain tumor etc. Once the condition is corrected the seizures tend to stop.

However, some patients can experience epilepsy. Epilepsy is where the patient has frequent seizures due to a chronic condition of some type like congenital brain defect, stroke, traumatic brain injury, long-lasting effects of an infection etc.

Simplified Patho of Seizures

In the brain, our neurons are tasked with handling and transmitting information. There are two types of neurons I want to discuss. These are excitatory and inhibitory neurons.

Just like their name says, excitatory neurons produce “an action” or cause “excitement” by releasing a neurotransmitter called glutamate (this is an excitatory neurotransmitter).

Inhibitory neurons “stop an action” or cause inhibition by releasing an inhibitory neurotransmitter called GABA.

***For seizure activity not to occur in a healthy brain, there needs to be a proper balance between these two types of neurons. If there is an imbalance of excitatory neurons vs. inhibitory neurons seizures will occur. For example, if there is not enough GABA (remember this is the inhibitory neurotransmitter) being released, too much excitation will occur leading to seizure activity.

The reason I cover this is to help you understand how some of the anti-seizure drugs work to treat seizures. For instance, barbiturates stimulate GABA receptors which help control excitation and decreases seizure activity (more about medications below).

Types of Seizures

**remember these types for exams, especially their characteristics, expected duration, post ictus phase etc. 

Generalized: seizure is affecting both parts of the brain

• Tonic-clonic (formerly called grand -mal): most common type of generalized seizure
  • May experience AURA (warning a seizure is about to happen)
  • Loses consciousness (at risk for injury)
    • Will experience a tonic phase: body stiffens (may bite inside of the cheek or tongue….may see blood leaving mouth with foaming of saliva), breathing stops followed by cyanosis)
    • Then a clonic phase: recurrent jerking (spasm and relaxation back-to-back) of extremities (patient may have incontinence of stool or/and urine)
  • Usually lasts no more than 3 minutes…..at risk for status epilepticus with this type of seizure
    • ****if greater than 5 minutes or having multiple seizures in a row…activate emergency response team (will need immediate treatment to stop seizure (more on this in the nursing interventions)
  • Post ictus (duration: hours to days): this is the recovery period: patient will feel very tired, extremely sore from muscle stiffening and jerking, can’t remember what happened.

Tonic seizure: (stiffening of the body….risk for falling) or Clonic seizure: (jerking….can be symmetrical or asymmetrical )

Absence Seizure (formerly called petit-mal)

• Most common in pediatric patients and Hallmark is a staring like state
  • It will be like the child is just daydreaming but can’t be snapped out of it….can go unnoticed by others for a while because it short and the child won’t remember it. The person will look confused and won’t be able to talk during the even.
• Very short…..seconds
• Post Ictus: immediate…doesn’t remember staring off

Atonic (drop attacks):

• “A” means without and when you put the word tonic after it the meaning is: WITHOUT MUSCLE TONE
  • The patient goes limp and falls if standing or slumps over if sitting…at risk for head injury (may need helmet)
• Usually not aware during event….post ictus: immediate…regains consciousness

Myoclonic:

• Quick duration of jerking of the muscles
• Patient usually aware and conscious (this is what makes it different from a clonic seizure)
• Very short….few seconds

Focal (also called partial): affects a specific part of the brain

Two types: know the main differences which is that with focal onset aware (simple partial) the patient is AWARE of their surroundings but with focal impaired awareness (complex partial) the patient is NOT aware of their surroundings AND will have motor symptoms called automatisms.

Focal Onset AWARE (simple partial): symptoms vary depending on where the seizure is located

• It tends to be a small area of a lobe…but patient is AWARE…example: occipital region the person may have vision changes
• Also sometimes called an aura too because it can happen right before focal impaired awareness (complex partial)

Focal Impaired AWARENESS (complex partial): alternation in awareness and has motor symptoms

• Temporal lobe most commonly involved
• Focal onset aware (aura) can happen before it
• Automatisms present: this is where they are performing an action without knowing they are doing it like lip smacking, rubbing hands together, or grasping for something that isn’t there

Stages of Experiencing a Seizure

We can divide how a person experiences a seizure into stages (it varies depending on the seizure type, so remember that)

Prodromal: when symptoms start to appear prior to the big event (hence seizure)

• can start days before a seizure happens
• mood changes (depression, anger, issues sleeping, anxiety, GI and urinary issues etc.)

Aura: doesn’t happen with all types

• happens at the very beginning of the seizure (what type: focal seizures OR in a tonic-clonic seizure)
• happens within seconds to minutes before a seizure
• many times it gives the patient time to prepare self for seizure. As the nurse (if you are present) help the patient lay down onto their side with a pillow under the head.
• Symptoms vary among patients but can include: sudden weird smell or taste, déjà vu feeling, feeling anxious like something bad is about to happen, altered vision (lights or spots in vision) or hearing (hallucination type sounds or increased ability to hear sounds), dizzy (different for every person), inability to speak etc.

Ictus: (word means seizure) this is the actual seizure

• Usually lasts anywhere from 1 to 3 minutes
• Time the seizure
  • seizures greater than 5 minutes or if the patient starts having seizure back-to-back, the patient may be experiencing status epilepticus (will need medical care and medication to make the seizure stop…it will unlikely stop on its own)

Post Ictus: (after the seizure) brain is going to rest and recover from the seizure

• usually last hours to days (tonic clonic)…..for some patients it is immediate (absence)
• may feel extremely tired, sleepy, confused, headache etc.

Nursing Interventions for Seizures

Assess risk factors for seizure (remember any patient can experience this if any of the causes mentioned above are presenting…you want to be prepared. If risk factors present initiate seizure precautions:

• Seizure precautions may include:
  • at bedside have suction and oxygen ready
  • IV access (to given anti-seizure medication, if needed)
  • padded side rails
  • pillow under head (to protect head)
  • bed in the lowest position
  • remove objects that can cause injury (remove any restrictive clothing or items the patient may be wearing….eye glasses etc. )

Assess if your patient has a history of seizures in the past and if so what type of seizure, ask if the patient experiences prodromal signs and symptoms or an aura before the seizure, how long does the seizure last?

If patient is able to report prodromal or aura….help patient prepare by getting the patient in a safe position by lying down on their side.

What to do when your patient has a seizure?

Protect patient if they are standing-up or sitting down by:

• gently lying the patient down and turning them onto their side. WHY? This helps prevent the tongue from covering the airway and helps saliva and blood drain from the mouth.
• DO NOT restrain patient or try to hold the patient down
• Protect their head and extremities (pillow and bed pads will help with this)
• DO NOT put anything in the patient’s mouth
• Remove anything that can impede breathing or break (eye glasses, tight clothing etc. ).

****Questions to be asking yourself during the seizure****

• Note the time it started and time it stopped (VERY IMPORTANT: if greater than 5 minutes or another seizure happens…THINK: status epilepticus and activate the emergency system response team. You will notify the MD of the seizure regardless because the seizure needs to be investigated….is the patient’s drug level for anti-seizure medications too low?
• When the seizure started what was the patient’s behavior right before and during it? (did they cry out, become confused, report an aura, become unconscious) and the characteristics of the body movements (if any) presented at the beginning and throughout the seizure…..stiffening of the whole body or just the extremities and then jerking or just jerking, was it on just one side or both sides of the body….be sure to be as detailed as possible…this helps the healthcare team determine what type of seizure this was and what treatment may be needed
• Did the patient become incontinent of urine or stool? Oxygen status (cyanosis present)

Your role during the Post Ictus stage:

Note the time the seizure stopped and how the patient is behaving afterwards:

• Are they tired (let them sleep and rest), confused, can’t think or talk, have a headache (ask where it is located and pain rating), has any injuries (some patienst may bite their tongue or cheek)
• Maintain airway (suction, administer oxygen)
• If a tonic-clonic seizure, the patient will be very sleepy, won’t remember what happened.
• Assess vital signs and neuro status: pupils, reflexes, is patient confused or oriented
• Clean patient if incontinence was experienced.
• Document and report it to the physician… is this your patient’s first seizure, are they on anything for seizures (is drug level not therapeutic….may need to draw a drug level if ordered by MD)

EEG may be ordered:

What’s an EEG?: assesses brain activity

• Painless
• Hold seizure medications or medications that are stimulants or depressants prior to EEG (these medications can prevent the proper assessment of abnormal brain waves associated with a seizure)
• No caffeine products (a stimulant) 8 hours before
• Can eat before
• Make sure patient’s hair is clean (needs good attachment to scalp)
• Different types of EEGs: some patients will need to experience sleep deprivation before the test by not sleeping the night before the test or only part of the night….always ask about this

Education to patient about factors that can trigger a seizure:

“Stop Seizure”

Stress

Trauma to the head

Overexertion

Period, pregnancy (hormones)

Sleep depravation

Electrolyte and metabolic issues (hypoglycemia, dehydration, acidosis)

Illness (high fever)

VisualiZation disturbances (strobe lights, certain smells or sounds)

Under medicated with seizure med (remind patient importance of taking and coming to office visits to get drug levels drawn)

Recreational drugs

ETOH use

Medications/Treatments

Medications treat based on type of seizure:

Barbiturates: Phenobarbital (used tonic-clonic or focal seizures & status epilepticus)

• stimulates GABA receptors & this helps inhibitory neurotransmission
• side effects: drowsiness, uncoordinated movements (ataxia) etc.
• watch for: respiratory depression and hypotension
• drug level 15 to 40 mcg/mL

Hydantoins: Phenytoin (used in tonic-clonic or focal seizures)

• watch the gums: will enlarge and easily bleed (called gingival hyperplasia….teach about good mouth care
  
• may cause bone marrow suppression (watch platelets and WBCs)
• tell patient to watch for rash or Steven-Johnson’s Syndrome and to REPORT it to their doctor immediately
• don’t give with milk or antacids (interferes with absorption)
• 10 to 20 mcg/mL

Benzodiazepines: absence seizures, tonic clonic, focal

• Diazepam or Lorazepam: status epilepticus (fast acting)
• Very drowsy, tolerance can develop where it isn’t as effective, impair liver (monitor liver studies)
• Reversal agent: Flumazenil (*used with extreme caution due to its risks)

Valproates: Valproic Acid

• all types….monitor liver, WBC and platelets, GI issues

• surgery: to remove an area of the brain that is causing the seizure….example: focal seizures that arise from temporal lobe (temporal lobectomy)
• Meds not working: placement of a vagus nerve stimulator: an electrical device that sends electrical signals to the vagus nerve
• Ketogenic diet (used in pediatric patient who have epilepsy): high fat, low carb, diet….used when seizures not controlled by medication
  

References:

National Institute of Health. NIH Clinical Center Patient Education Materials Electroencephalogram (EEG) [Ebook] (pp. 1-2). Retrieved from https://clinicalcenter.nih.gov/ccc/patient_education/procdiag/eeg.pdf

Seizure First Aid | Epilepsy | CDC. Retrieved from https://www.cdc.gov/epilepsy/about/first-aid.htm

The Epilepsies and Seizures: Hope Through Research | National Institute of Neurological Disorders and Stroke. Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Epilepsies-and-Seizures-Hope-Through

What should be the first nursing action for patient having seizure?

What is the priority action for a client experiencing a seizure?

What are the nursing interventions for clients having seizure?