Surgical intervention may be recommended for patients with chronic drug-resistant cluster headaches. Invasive ambulatory care procedures, such as percutaneous stereotactic rhizotomy (PSR), are performed with varying success rates. Information about this procedure is found in Chapter 46 in the Trigeminal Neuralgia section. Long-term high-frequency electrical stimulation of the posterior hypothalamus, also known as deep brain stimulation, may reduce or eliminate pain (see discussion on p. 946 in the Parkinson Disease section). It has not been approved by the FDA but is being investigated. Both of these procedures have major complications that can cause permanent brain or nerve damage. Therefore they are done as a last resort.

Seizures and Epilepsy

Pathophysiology

A seizure is an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness (LOC), motor or sensory ability, and/or behavior. A single seizure may occur for no known reason. Some seizures are caused by a pathologic condition of the brain, such as a tumor. In this case, once the underlying problem is treated, the patient is often asymptomatic.

Epilepsy is defined by the National Institute of Neurological Disorders and Stroke as two or more seizures experienced by a person. It is a chronic disorder in which repeated unprovoked seizure activity occurs. It may be caused by an abnormality in electrical neuronal activity; an imbalance of neurotransmitters, especially gamma aminobutyric acid (GABA); or a combination of both (McCance et al., 2010).

Types of Seizures

The International Classification of Epileptic Seizures recognizes three broad categories of seizure disorders: generalized seizures, partial seizures, and unclassified seizures.

Six types of generalized seizures may occur and involve both cerebral hemispheres. The tonic-clonic seizure lasting 2 to 5 minutes begins with a tonic phase that causes stiffening or rigidity of the muscles, particularly of the arms and legs, and immediate loss of consciousness. Clonic or rhythmic jerking of all extremities follows. The patient may bite his or her tongue and may become incontinent of urine or feces. Fatigue, acute confusion, and lethargy may last up to an hour after the seizure.

Occasionally, only tonic or clonic movement may occur. A tonic seizure is an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes. The clonic seizure lasts several minutes and causes muscle contraction and relaxation.

The absence seizure is more common in children and tends to run in families. It consists of brief (often just seconds) periods of loss of consciousness and blank staring as though the person is daydreaming. The patient’s eyes may flutter, and automatisms (involuntary behaviors) such as lip smacking and picking at clothes may also occur. He or she is not aware of these behaviors. The patient returns to baseline immediately after the seizure. Left undiagnosed or untreated, the seizures may occur frequently throughout the day, interfering with school or other daily activity.

The myoclonic seizure causes a brief jerking or stiffening of the extremities that may occur singly or in groups. Lasting for just a few seconds, the contractions may be symmetric (both sides) or asymmetric (one side).

In an atonic (akinetic) seizure, the patient has a sudden loss of muscle tone, lasting for seconds, followed by postictal (after the seizure) confusion. In most cases, these seizures cause the patient to fall, which may result in injury. This type of seizure tends to be most resistant to drug therapy.

Partial seizures, also called focal or local seizures, begin in a part of one cerebral hemisphere. They are further subdivided into two main classes: complex partial seizures and simple partial seizures. In addition, some partial seizures can become generalized tonic-clonic, tonic, or clonic seizures. Partial seizures are most often seen in adults and generally are less responsive to medical treatment when compared with other types.

Complex partial seizures may cause loss of consciousness (syncope), or “black out,” for 1 to 3 minutes. Characteristic automatisms may occur as in absence seizures. The patient is unaware of the environment and may wander at the start of the seizure. In the period after the seizure, he or she may have amnesia (loss of memory). Because the area of the brain most often involved in this type of epilepsy is the temporal lobe, complex partial seizures are often called psychomotor seizures or temporal lobe seizures.

Considerations for Older Adults

Complex partial seizures are most common among older adults (Vacca & Olson, 2007). These seizures are difficult to diagnose because symptoms appear similar to dementia, psychosis, or Alzheimer’s disease (AD), especially in the postictal stage (after the seizure). New-onset seizures in older adults are typically associated with conditions such as hypertension, cardiac disease, diabetes mellitus, stroke, and Alzheimer’s disease.

The patient with a simple partial seizure remains conscious throughout the episode. He or she often reports an aura (unusual sensation) before the seizure takes place. This may consist of a “déjà vu” (already seen) phenomenon, perception of an offensive smell, or sudden onset of pain. During the seizure, the patient may have one-sided movement of an extremity, experience unusual sensations, or have autonomic symptoms. Autonomic changes include a change in heart rate, skin flushing, and epigastric discomfort.

Unclassified, or idiopathic, seizures account for about half of all seizure activity. They occur for no known reason and do not fit into the generalized or partial classifications.

Etiology and Genetic Risk

Primary or idiopathic epilepsy is not associated with any identifiable brain lesion or other specific cause; however, genetic factors most likely play a role in its development. Secondary seizures result from an underlying brain lesion, most commonly a tumor or trauma. They may also be caused by:

• Metabolic disorders

• Acute alcohol withdrawal

• Electrolyte disturbances (e.g., hyperkalemia, water intoxication, hypoglycemia)

Seizures resulting from these problems are not considered epilepsy. Various risk factors can trigger a seizure, such as increased physical activity, emotional stress, excessive fatigue, alcohol or caffeine consumption, or certain foods or chemicals.

Patient-Centered Collaborative Care

Drug Therapy.

Drug therapy is the major component of management (Chart 44-3). The health care provider introduces one antiepileptic drug (AED) at a time to achieve seizure control. If the chosen drug is not effective, the dosage may be increased or another drug introduced. At times, seizure control is achieved only through a combination of drugs. The dosages are adjusted to achieve therapeutic blood levels without causing major side effects.

Chart 44-3 Common Examples of Drug Therapy

Antiepileptic Drugs

DRUG	INDICATION FOR USE	NURSING INTERVENTIONS
Carbamazepine (Tegretol, Tegretol-XR, Carbatrol)	Partial, generalized tonic-clonic seizures	Monitor for headache, dizziness, diplopia or blurred vision, N/V, and leukopenia. Monitor CBC. Do not crush or chew sustained-release capsules.
Clonazepam (Klonopin)	Absence, myoclonic, and akinetic seizures	Monitor results of liver function tests.
Clorazepate dipotassium	Adjunctive management of partial seizures	Give with food. Monitor blood pressure.
Diazepam (Valium, Apo- Diazepam ), lorazepam (Ativan), Diastat (diazepam rectal gel delivery system)	Status epilepticus	Monitor airway, breathing, circulation (ABCs).
Divalproex (Depakote), valproic acid (Depakene)	All types of seizures	Monitor for hair loss, tremor, increased liver enzymes, bruising, and N/V. Monitor CBC, PT, PTT, and AST.
Ethosuximide (Zarontin)	Absence seizures	Watch for N/V, skin rash, lethargy, and anorexia. Monitor CBC and liver function tests. (Drug used infrequently.)
Felbamate (Felbatol)	Adjunctive therapy for intractable complex partial seizures	Note that aplastic anemia and liver failure are major sequelae of treatment. Patient must sign consent for use, acknowledging risk for aplastic anemia and liver failure. Monitor CBC. Monitor liver function tests. Watch for anorexia and weight loss.
Gabapentin (Neurontin)	Partial seizures	Watch for increased appetite and weight gain. Monitor for ataxia, irritability, dizziness, and fatigue.
Lamotrigine (Lamictal)	Partial seizures	Watch for diplopia, headaches, dizziness, drowsiness, ataxia, N/V, and life-threatening rash when given with valproic acid.
Levetiracetam (Keppra)	Adjunct management of partial seizures	Monitor renal function carefully. Notify health care provider for gait or coordination problems.
Oxcarbazepine (Trileptal)	Partial seizures	Monitor for hyponatremia.
Phenobarbital (Barbita, Luminal)	Generalized tonic-clonic seizures, partial seizures	Note that this is less desirable than other antiepileptic drugs (AEDs) because of sedation. Be aware that overdose can be fatal. Monitor for drowsiness, sleep disturbances, cognitive impairment, and depression.
Phenytoin (Dilantin), fosphenytoin (Cerebyx)	All types, except absence, myoclonic, and atonic seizures; for status epilepticus	Monitor for gastric distress, gingival hyperplasia, anemia, ataxia, and nystagmus. Check CBC and calcium levels; monitor for therapeutic drug levels (10-20 mcg/mL) and toxic levels (>30 mcg/mL). For IV phenytoin, flush catheter with saline before and after administration. For fosphenytoin, use phenytoin equivalent for dosing.
Primidone (Mysoline, Sertan )	Partial seizures, generalized tonic-clonic seizures	Monitor for vertigo and lethargy. Watch for drug interactions with phenobarbital and isoniazid.
Tiagabine (Gabitril)	Partial seizures	Monitor for dizziness, weakness, nervousness, psychomotor slowing, nystagmus, and paresthesias. Administer with food.
Topiramate (Topamax)	Adjunctive therapy for intractable partial seizures	Monitor for ataxia, confusion, dizziness, and fatigue. Be aware of increased risk for renal calculi.
Valproate (Depakote), valproate sodium injection (Depacon)	Simple and complex absence seizures Adjunct therapy for partial complex and generalized tonic-clonic seizures	Monitor for hair loss, tremor, increased liver enzymes, bruising, and N/V. Monitor CBC, PT, PTT, AST.
Zonisamide (Zonegran)	Adjunctive therapy for partial seizures	Monitor CBC, platelets, and renal function. Assess mental status, especially memory.

AST, Aspartate aminotransferase; CBC, complete blood count; N/V, nausea and vomiting; PT, prothrombin time; PTT, partial thromboplastin time.

Teach patients to take their drugs on time to maintain therapeutic blood levels and maximum effectiveness. Emphasize the importance of taking their antiseizure medications as prescribed. Instruct patients that they can build up sensitivity to the drugs as they age. If sensitivity occurs, tell them they will need to have blood levels of this drug checked frequently to adjust the dose. In some cases, the antiseizure effects of drugs can decline and will lead to an increase in seizures. Because of this potential for “drug decline and sensitivity,” patients need to keep their scheduled laboratory appointments.

Be aware of drug-drug and drug-food interactions. For instance, warfarin (Coumadin, Warfilone ) should not be given with phenytoin (Dilantin). Document side and adverse effects of the prescribed drugs, and report to the health care provider. Patients should be taught that some citrus fruits, such as grapefruit juice, can interfere with the metabolism of these drugs. This interference can raise the blood level of the drug and cause the patient to develop drug toxicity.

Considerations for Older Adults

The health care provider prescribes AEDs for the older adult that (Vacca & Olson, 2007):

Teaching for Self-Management.

Provide an educational program for the patient and family (Chart 44-4). Ask them what they understand about the disorder, and correct any misinformation. As new information is presented, be sure that the patient and family can understand it. Refer patients and families to the Epilepsy Foundation of America (www.epilepsyfoundation.org) for more information and community support groups.

Chart 44-4 Patient and Family Education

Preparing for Self-Management: Health Teaching for the Patient with Epilepsy

• Drug therapy information:

• Name, dosage, time of administration

• Actions to take if side effects occur

• Importance of taking drug as prescribed and not missing a dose

• What to do if a dose is missed or cannot be taken

• Importance of having blood drawn for therapeutic or toxic levels as requested by the health care provider

• Do not take any medication, including over-the-counter drugs, without asking your health care provider.

• Wear a medical alert bracelet or necklace, or carry an ID card indicating epilepsy.

• Follow up with your neurologist, physician, or other health care provider as directed.

• Be sure a family member or significant other knows how to help you in the event of a seizure and knows when your health care provider or emergency medical services should be called.

• Investigate and follow state laws concerning driving and operating machinery.

• Avoid alcohol and excessive fatigue.

• Contact the Epilepsy Foundation (www.epilepsyfoundation.org) or other organized epilepsy group for additional information. Epilepsy Canada (www.epilepsy.ca) also provides resources and support.

Emphasize that AEDs must not be stopped even if the seizures have stopped. Discontinuing these drugs can lead to the recurrence of seizures or the life-threatening complication of status epilepticus (discussed below). Some patients may stop therapy because they do not have the money to purchase the drugs. Refer limited-income patients to the social services department for assistance or to a case manager to locate other resources.

A balanced diet, proper rest, and stress-reduction techniques usually minimize the risk for breakthrough seizures. Encourage the patient to keep a seizure diary to determine whether there are factors that tend to be associated with seizure activity. Patients should follow state law concerning allowances for driving a motor vehicle.

All states prohibit discrimination against people who have epilepsy. Patients who work in occupations in which a seizure might cause serious harm to themselves or others (e.g., construction workers, operators of dangerous equipment, pilots) may need other employment. They may need to decrease or modify strenuous or potentially dangerous physical activity to avoid harm, although this varies with each person. Various local, state, and federal agencies can help with finances, living arrangements, and vocational rehabilitation.

Seizure Precautions.

Precautions are taken to prevent the patient from injury if a seizure occurs. Specific seizure precautions vary depending on health care agency policy.

Nursing Safety Priority

Action Alert

Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available. If the patient does not have an IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.

Siderails are rarely the source of significant injury, and the effectiveness of the use of padded siderails to maintain safety is debatable. Padded siderails may embarrass the patient and the family. Follow agency policy about the use of siderails because they may be classified as a restraint device. Other methods to protect the patient, such as placing a mattress on the floor, may be used instead of siderails.

Padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient’s mouth because the jaw may clench down as soon as the seizure begins! Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk for aspirating tooth fragments than prevent the patient from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway.

Seizure Management.

The actions taken during a seizure should be appropriate for the type of seizure (Chart 44-5). For example, for a simple partial seizure, observe the patient and document the time that the seizure lasted. Redirect the patient’s attention away from an activity that could cause injury. Turn the patient on the side during a generalized tonic-clonic or complex partial seizure because he or she may lose consciousness. If possible, turn the patient’s head to the side to prevent aspiration and allow secretions to drain. Remove any objects that might injure the patient.

Chart 44-5 Best Practice for Patient Safety & Quality Care

Care of the Patient During a Tonic-Clonic or Complete Partial Seizure

• Protect the patient from injury.

• Do not force anything into the patient’s mouth.

• Turn the patient to the side to keep the airway clear.

• Loosen any restrictive clothing the patient is wearing.

• Maintain the patient’s airway and suction as needed.

• Do not restrain or try to stop the patient’s movement; guide movements if necessary.

• Record the time the seizure began and ended.

• At the completion of the seizure:

• Take the patient’s vital signs.

• Perform neurologic checks.

• Keep the patient on his or her side.

• Allow the patient to rest.

• Document the seizure (see Chart 44-6).

It is not unusual for the patient to become cyanotic during a generalized tonic-clonic seizure. The cyanosis is generally self-limiting, and no treatment is needed. Some health care providers prefer to give the high-risk patient (e.g., older adult, critically ill, or debilitated patient) oxygen by nasal cannula or facemask during the postictal phase. He or she is not restrained because this may cause injury and may worsen the situation, causing more seizure activity. For any type of seizure, carefully observe the seizure and document assessment findings (Chart 44-6).

Chart 44-6 Focused Assessment

Seizures: Nursing Observations and Documentation

• How often the seizures occur:

• Date, time, and duration of the seizure

• Description of each seizure:

• Tonic, clonic

• Staring spells, blinking

• Automatism

• Whether more than one type of seizure occurs

• Sequence of seizure progression:

• Where the seizure began

• Body part first involved

• Observations during the seizure:

• Changes in pupil size and any eye deviation

• Level of consciousness

• Presence of apnea, cyanosis, and salivation

• Incontinence of bowel or bladder during the seizure

• Eye fluttering

• Movement and progression of motor activity

• Lip smacking or other automatism

• Tongue or lip biting

• How long the seizures last

• When the last seizure took place

• Whether the seizures are preceded by an aura:

• Dizziness, numbness, or visual disturbances

• Gustatory (taste) or auditory disturbances

• What the patient does after the seizure:

• Feels drowsy or weak

• May resume normal behavior

• May be unaware that the seizure took place

• How long it takes for the patient to return to pre-seizure status

Emergency Care: Acute Seizure and Status Epilepticus Management.

Seizures occurring in greater intensity, number, or length than the patient’s usual seizures are considered acute. They may also appear in clusters that are different from the patient’s typical seizure pattern. Treatment with lorazepam (Ativan, Apo-Lorazepam ) or diazepam (Valium, Meval , Vivol , Diastat [rectal diazepam gel]) may be given to stop the clusters to prevent the development of status epilepticus. IV phenytoin (Dilantin) or fosphenytoin (Cerebyx) may be added.

Status epilepticus is a medical emergency and is a prolonged seizure lasting longer than 5 minutes or repeated seizures over the course of 30 minutes. It is a potential complication of all types of seizures. Seizures lasting longer than 10 minutes can cause death! Common causes of status epilepticus include:

• Sudden withdrawal from antiepileptic drugs

• Infections

• Acute alcohol or drug withdrawal

• Head trauma

• Cerebral edema

• Metabolic disturbances

Nursing Safety Priority

Critical Rescue

Convulsive status epilepticus must be treated promptly and aggressively! Establish an airway and notify the health care provider or Rapid Response Team immediately if this problem occurs! Establishing an airway is the priority for this patient’s care. Intubation by an anesthesia provider or respiratory therapist (RT) may be necessary. Administer oxygen as indicated by the patient’s condition. If not already in place, establish IV access with a large-bore catheter, and start 0.9% sodium chloride. The patient is usually placed in the intensive care unit for continuous monitoring and management.

Blood is drawn to determine arterial blood gas levels and to identify metabolic, toxic, and other causes of the uncontrolled seizure. Brain damage and death may occur in the patient with tonic-clonic status epilepticus. Left untreated, metabolic changes result, leading to hypoxia, hypotension, hypoglycemia, cardiac dysrhythmias, or lactic (metabolic) acidosis. Further harm to the patient occurs when muscle breaks down and myoglobin accumulates in the kidneys, which can lead to renal failure and electrolyte imbalance. This is especially likely in the older adult.

The drugs of choice for treating status epilepticus are IV push lorazepam (Ativan, Apo-Lorazepam ) or diazepam (Valium). Diazepam rectal gel (Diastat) may be used instead. Lorazepam is usually given as 4 mg over a 2-minute period. This procedure may be repeated, if necessary, until a total of 8 mg is reached.

To prevent additional tonic-clonic seizures or cardiac arrest, a loading dose of IV phenytoin (Dilantin) is given and oral doses administered as a follow-up after the emergency is resolved. Initially, give phenytoin at no more than 50 mg/min using an infusion pump. An alternative to phenytoin is fosphenytoin (Cerebyx), a water-soluble phenytoin prodrug. It is compatible with most IV solutions. It also causes fewer cardiovascular complications than phenytoin and can be given in an IV dextrose solution. After administration, fosphenytoin converts to phenytoin in the body. Therefore the FDA requires the dosage to be written as a phenytoin equivalent (PE): 150 mg of fosphenytoin equals 100 mg of phenytoin. Give fosphenytoin at a rate of 100 to 150 mg/min IV piggyback.

Serum drug levels are checked every 6 to 12 hours after the loading dose and then 2 weeks after oral phenytoin has started. Teach the patient about the side and adverse effects of any AED that is prescribed (see Chart 44-3).

Nclex Examination Challenge

Safe and Effective Care Environment

A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply.

A. Padded tongue blade

B. Oxygen setup

C. Nasogastric tube

D. Suction setup

E. Artificial oral airway

Surgical Management

Patients who cannot be managed effectively with drug therapy may be candidates for surgery, including vagal nerve stimulation (VNS) and conventional surgical procedures. VNS is a fairly new procedure that has been very successful for many patients with epilepsy.

Vagal Nerve Stimulation.

Vagal nerve stimulation (VNS) may be performed for control of continuous simple or complex partial seizures. Patients with generalized seizures are not candidates for surgery because VNS may result in severe neurologic deficits. The stimulating device (much like a cardiac pacemaker) is surgically implanted in the left chest wall. An electrode lead is attached to the left vagus nerve, tunneled under the skin, and connected to a generator. The procedure usually takes 2 hours with the patient under general anesthesia. The stimulator is activated by the physician either in the operating room or, more commonly, 2 weeks after surgery. Programming is adjusted gradually over a period of time. The pattern of stimulation is individualized to the patient’s tolerance. The generator runs continuously, stimulating the vagus nerve according to the programmed schedule.

The patient can activate the VNS with a handheld magnet when experiencing an aura, thus aborting the seizure. Patients experience a change in voice quality, which signifies that the vagus nerve has been stimulated. They usually report a relief in intensity and duration of seizures and an improved quality of life.

Observe for complications after the procedure such as hoarseness (most common), cough, dyspnea, neck pain, or dysphagia (difficulty swallowing). Teach the patient to avoid MRIs, microwaves, shortwave radios, and ultrasound diathermy (a physical therapy heat treatment).

Conventional Surgical Procedures.

A small percentage of patients with epilepsy cannot be fully controlled with drug therapy or VNS. When all other options are exhausted, conventional surgery may be needed to improve the patient’s quality of life. The largest group of conventional surgical candidates includes those with complex partial seizures in the frontal or temporal lobe.

Before surgery, the patient is admitted to a special inpatient observation unit. While there, he or she has continuous electroencephalogram (EEG) recording, close observation, and in many hospitals, video monitoring at all times except during personal care activities. The patient is taken off all AEDs. After the seizure area is identified, electrodes may be surgically implanted into the brain tissue to identify the extent of the focal area. This step is followed by additional continuous EEG and video monitoring, as well as close observation by the nursing staff. The area is surgically removed if vital areas of brain function will not be affected.

Preoperative care is similar to that described for patients undergoing a craniotomy (see Chapter 47). Preoperative diagnostic tests include MRI and single-photon emission computed tomography (SPECT)/positron emission tomography (PET) scans as described in Chapter 43. An intracarotid amobarbital test (Wada test) and neuropsychological testing are also done. The Wada test assesses hemispheric lateralization of language and memory after injection of amobarbital, a short-acting anesthetic. This procedure establishes the safety of surgery to preserve language memory. Neuropsychological testing evaluates memory, visuospatial function, language function, and intelligence quotient (IQ) to identify deficiencies in the brain that might correspond to areas believed to be the epileptic region. It is also used to compare preoperative and postoperative cognitive functioning.

Another surgical approach, the partial corpus callosotomy, may be used to treat tonic-clonic or atonic seizures in patients who are not candidates for other surgical procedures. The surgeon sections the anterior two thirds of the corpus callosum, preventing neuronal discharges from passing between the two hemispheres of the brain. This surgery usually reduces the number and severity of the seizures, making them more likely to respond to more conventional drug therapy. This procedure is not as commonly done as other surgeries but is very successful for some patients.

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