Hello, welcome to Nursing School Explained!
Today's topics are seizures. So let's take a look at this. So seizures
are defined as a transient, uncontrolled electrical discharge of
neurons that can be spontaneous and without
apparent cause. So there's something going on in
the brain that causes the brain cells to be
extra excitable and then that impulse spreads
around other, to other brain cells. And then when we talk about seizures
another term that often comes up is epilepsy.
So epilepsy is defined as the continued predisposition to seizures.
So that is somebody that although they're on medication
and they're being treated for whatever the underlying cause might be,
they continue to have episodes of seizures, and we'll look into the
different types of seizures here in a little bit. So the pathophysiology
these hyperexcitable neurons fire abnormally,
and this can be due to any kind of malformation, so that might be a brain
tumor, that might be an arteriovenous
malformation in the brain, that might be scar tissue from a stroke for example, or
from a traumatic head injury. So all kinds of structural changes in
the brain can predispose a patient to having
seizures. And it, seizures are an abrupt
imbalance between excitatory and inhibitory neurons.
Keep in mind that usually we have this nice balance of
excitation and inhibition with all the way that the neurotransmitters
function, but in seizures we have this imbalance and then the
excitatory neurons, they win in this imbalance, which causes
the electrical impulse to spread to other areas of the brain
and then if the patient has prolonged or recurring
seizures, so that happen continuously, different episodes,
they're are increased for risk for future seizures.
So unfortunately this is something that the patients will be predisposed
to. So then let's look at the different types of seizures. So we need
to distinguish between partial, which are also called focal,
and also generalized seizures. So simple seizures are basically, there
is no change in level of consciousness and this is something that
we have to keep in mind whenever we talk about seizures.
Is there any alteration in consciousness? So is there any loss of consciousness,
changes in in mental status. So for simple seizures or
partial focal seizures, the simple ones, there is no change
in any kind of consciousness, and there might be a sudden change in
mood. So let's say the patient, they might all of
a sudden hear things or taste things or see things that are not real.
Complex seizures - so the patient will have some sort of
alteration in mental status, so a positive
change in or a loss of consciousness. And the patient remains with eyes open
and there might be purposeful movements but the patient is unable
to interact with the environment or with the person
that's trying to determine: are they having a seizure or what is going on?
There might be some lip smacking, some repetitive motion
such as hitting something repetitively, or
continuously smacking their lips and they are not able to interact
with the person that might try to get them out of this seizure activity.
And these typically last about one to three minutes.
Now generalized seizures, as you can imagine,
a bigger area of the brain is affected here,
which means that these excitatory impulses
spread through a generalized area of the brain
and therefore they are a little bit more severe.
So first of all we have absence seizures. And these usually
occur in children, and this might be somebody,
sometimes classified as daydreaming. So these are children that all of a
sudden might just stare off and you think that they're daydreaming,
but actually what they're experiencing is a
seizure. Then there are myoclonic seizures. So there's no
altered mental status. So this might be somebody
who all of a sudden starts to have a jerk of their shoulder or any kind of
their body part that they just are unable to
control that muscle part, the myoclonic seizures of their body. And then we have
atonic seizures and atonic basically meaning "without tone".
So the patient will have an alteration in mental status
and they are also called drop attacks. So these are all of a sudden,
they become completely atonic so they just kind of drop to the
ground because their body is just not responding at all.
And then we have the most important or the most severe ones, which are tonic-clonic
seizures. So these are the ones that
most people think about when they think about seizures.
Now the patient will have altered mental status
and this tonic phase is usually characterized by some sort of
stiffening that lasts for a few seconds, about 10 to 20 or so,
and then it's followed by a jerking movement that's that clonic phase of the
seizure. And that can last from several seconds
up to some minutes. And so imagine when there's
all these neurons that are hyper- excitable
that are firing continuously to neighboring brain tissues that
involves basically malfiring and no control over the body with the
stiffening and then this jerking movement,
there is some significant effect to the patient's
body. So when they finally stop seizing it's called they're in a post-ictal phase.
And that just basically means post seizure.
And because the patient, no matter how long this tonic seizure
has lasted, because they have been in this,
in this, hyper-excitable state, they will be very
slow to regain consciousness. What also happens with these tonic-clonic
seizures, the patient might be incontinent of
urine or stool, they may be biting their tongue so we
have to be extra careful in protecting their airway,
or they might have any kind of other trauma as you can imagine from these
jerking movements that they're experiencing.
So post-icatl phase here, is this phase where the patient comes out very slowly
and then slowly, over maybe half an hour, up to two hours,
they regain consciousness and all of a sudden they're completely back
to being oriented as usual.
Now complications of seizures: is called status epilepticus.
Just like a complication of asthma is status asthmaticus,
in seizures it's called status epilepticus.
And these are seizures that can last for up to or greater than five minutes.
So imagine what's going on in the patient's brain and body when there's
this continued jerking movement for this prolonged period of time. The
patient might be unable to protect the airway so
they might turn cyanotic, they might completely stop breathing,
and they might go into respiratory failure
because they basically just stop breathing because
their body is so hyper-excitable, they're not able to protect their airway.
They might be producing phlegm or maybe they are bleeding because they bit their
tongue cause that their jaw is so tight. So this is a
significant, significant problem that patients can die from.
Now how are seizures diagnosed? So first and foremost we need to perform an
EEG, an electroencephalogram, which basically
means that a multitude of electrodes are
hooked up to the patient's head and then a special machine
will measure the brain waves to try and identify where this
area of these excitatory neurons is located. And then they can determine
the types of seizures that the patients might be having,
and then initiate treatment from there. Another diagnostic
test would be a cat scan or an MRI, because remember we talked about
that structural changes might be causing seizures such as scar tissue
from strokes, or head injuries, or brain tumors or any of these
other things, so imaging here will definitely help determine this.
Now blood glucose is always important because remember when the blood glucose
goes low, so when the patient is hypoglycemic, the
patient might be experiencing seizures so it is very important to rule
out blood glucose as a
cause of the seizure, because the patient might not have anything else going on in
their brain, the reason for their seizure is just that the blood
glucose is low. Additionally, diagnostic tests,
let's write down here: BMP, because you might recall there are
certain electrolytes that can, that are also important with
neurotransmitter regulation, and so when the patient's sodium level
goes either high or really low, they are prone to having seizures. So
certainly we're going to want to check that on a metabolic panel.
And the other cause i haven't talked about before for seizures,
that are not related to the neurons or any kind of structural deficiencies,
is alcohol withdrawal. So if the patient is used to consuming a certain amount of
alcohol each day and then suddenly they're
unable to, or they are not consuming this
specific level of alcohol that their body has now become accustomed to,
they are prone to having alcohol withdrawal seizures.
So then they're going to require a whole lot of other
interventions to make sure that this doesn't continue to happen.
And then if we look at neonates, so i wrote down here:
we have to rule out TORCH infections. And so when neonates are born
they can have seizures as well. And again, we have to consider structural
abnormalities such as hydrocephalus, for example, or spina
bifida, but also certain kind of infections that
could have been transmitted from the mother to the neonate could cause
seizures. And so this acronym TORCH is very
helpful here. And it stands for toxoplasmosis, other
infections, rubella, cytomegalovirus, or
HSV, or herpes simplex virus. So then the child will get tested for
all these infections to see if that's the cause
of their seizure. Now as for treatment when it's determined that this is a
not a structural abnormality or even if it is the patient might need to take an
anti-convulsant, and anti-seizure medication,
anti-convulsants. Now there is a list of different medications, a
variety of different medications available,
but for our purposes here I wrote down Dilantin or Phenytoin,
which is a very commonly used, kind of an old-fashioned but still very
applicable anti-seizure medication. And this always comes up on NCLEX exam,
so i wrote down here side effect is gingival hyperplasia. So basically
their gum tissue will overgrow, so they will be extra
kind of large and you will see the gum tissue, after years of consumption of
course, the gum tissue will become large and
kind of overgrow on the teeth, so for these patients a
nursing education measure is always to educate the patient
on proper dental hygiene, regular dental checkups
as well as daily flossing and brushing. So that always likes to come up. Now
Dilantin is a medication that
needs to be administered through filter tubing if it is administered in the IV -
keep that in mind because there are certain crystals and particles in there
that otherwise could enter the patient's bloodstream
and cause some problems. And then when the patient is
experiencing a seizure, so one of those tonic-clonic seizures, and maybe even
status epilepticus, we need to do something to stop the seizures. And the
medications that we use here are benzodiazepines. Those are the
ones that end in -pam. So that will be your Lorazepam, which is
also Ativan, or Diazepam, which is Valium.
Now benzodiazepines, as you can imagine if the patient is having tonic-chronic
seizures, they're not going to be able to take
that medication by mouth and we're not going to want to wait 45
to 60 minutes for this medication to take effect, so
benzodiazepines are also available rectally, IV and IM.
So certainly, if the patient is having status epilepticus
or tonic-clonic seizures and they're at the hospital,
we need to make sure that we administer this benzodiazepine
in the IV to stop the seizure. Now nursing care during a seizure: So
first of all, if we know that the patient either has a history of
seizures, has been admitted to rule out seizures,
or has any kind of structural change in the brain such as a brain tumor and
stroke or brain injury, we need to make sure
that we always, always, always have suction and oxygen
equipment at the bedside, because, like i talked
before, the patient might bite their tongue or
they might have excessive secretions and then they're at
risk for aspiration. So we need to be able to suction their mouth
as well as if they're not able to control
their respiratory status, then they're at risk
for basically, stopping breathing. So we need to make sure that we have
oxygen available at the bedside. And this needs to be
via like a non-rebreather mask, some high flow delivery system. We certainly want
to initiate seizure precautions, and those usually mean that there is padded
side rails. So certain hospitals have
seizure pads, they're kind of thicker pads, almost think about like a gym mat,
there are cushions that can be kind of hung
over the side rails, so in case the patient is having that tonic-clonic
seizure and they're moving around in bed, they
don't get hurt by by hitting their arm or leg or maybe
even their head on that usually pretty tough side rail.
And then, if the patient is experiencing this tonic-clonic seizure, we want to
make sure we protect their head to protect them from injury. We want to
turn them to the side so that any kind of secretions or blood
from biting their tongue doesn't just go straight down their airway but rather
kind of moves out to the side. We want to loosen their clothing
so that they're not constricted and choking on any clothing item.
And we want to ease them to the floor. So this is something that could happen, for
example, if you're at an airport or anywhere in the general public, where all
of a sudden somebody's having a tonic-clonic seizure,
and let's say this is somebody who's wearing a tie.
So you want to make sure that you loosen their clothing and then gently ease them
to the floor, and then turn them to their side so the
airway can be protected and hopefully will protect them from
having any kind of injuries. And then things that we DO NOT want to
do, DO NOT want to do is restrain the
patient or put anything in their mouth. These are
kind of old wives tales and practices that have been established
many, many years ago that are still kind of
out there but this is something that we don't want to do. And so if we logically
think about that, if the patient is having uncontrolled,
jerking movements, we don't want to hold them down because if they have
these movements they might dislocate a shoulder,
they might break an arm or a leg, and certainly
if they're already having issues with their airway, we don't want to put
anything in their mouth. We want to keep that airway open as much as we can
and have that suction equipment readily available
so that we can help them clear their airway in case there is a problem. So
thank you for watching this video on seizures.
I'll be posting more videos on pediatric neurological
problems here shortly. Please subscribe to my channel
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