INAH KRIZIA O.

LAGUE BSN 2A

RECURRENT SEIZURES

- Recurrent means you have a seizure more than once. The cause of your seizures may not be
known. Recurrent seizures may occur if you do not take antiseizure medicine as directed.

 Classification of Seizures

The New Basic Classification

The basic classification is a simple version of the major categories of seizures. The new basic seizure
classification is based on 3 key features.

a) Where seizures begin in the brain

b) Level of awareness during a seizure
c) Other features of seizures

Defining Where Seizures Begin

The first step is to separate seizures by how they begin in the brain. The type of seizure onset is
important because it affects choice of seizure medication, possibilities for epilepsy surgery, outlook, and
possible causes.

Focal seizures: Previously called partial seizures, these start in an area or network of cells on one side of
the brain.

Generalized seizures: Previously called primary generalized, these engage or involve networks on both
sides of the brain at the onset.

Unknown onset: If the onset of a seizure is not known, the seizure falls into the unknown onset
category. Later on, the seizure type can be changed if the beginning of a person’s seizures becomes
clear.

Focal to bilateral seizure: A seizure that starts in one side or part of the brain and spreads to both sides
has been called a secondary generalized seizures. Now the term generalized refers only to the start of a
seizure. The new term for secondary generalized seizure would be a focal to bilateral seizure.

Describing Awareness

Whether a person is aware during a seizure is of practical importance because it is one of the main
factors affecting a person’s safety during a seizure. Awareness is used instead of consciousness, because
it is simpler to evaluate.

Focal aware: If awareness remains intact, even if the person is unable to talk or respond during a
seizure, the seizure would be called a focal aware seizure. This replaces the term simple partial.

Focal impaired awareness: If awareness is impaired or affected at any time during a seizure, even if a
person has a vague idea of what happened, the seizure would be called focal impaired awareness. This
replaces the term complex partial seizure.
Awareness unknown: Sometimes it’s not possible to know if a person is aware or not, for example if a
person lives alone or has seizures only at night. In this situation, the awareness term may not be used or
it would be described as awareness unknown.

Describing Motor And Other Symptoms In Focal Seizures

Many other symptoms may occur during a seizure. In this basic system, seizure behaviors are separated
into groups that involve movement.Focal motor seizure: This means that some type of movement
occurs during the event. For example twitching, jerking, or stiffening movements of a body part or
automatisms (automatic movements such as licking lips, rubbing hands, walking, or running).

Focal non-motor seizure: This type of seizure has other symptoms that occur first, such as changes in
sensation, emotions, thinking, or experiences.

It is also possible for a focal aware or impaired awareness seizure to be sub-classified as motor or non-
motor onset.

Auras: The term aura, which describes symptoms a person may feel in the beginning of a seizure, is not
in the new classification. Yet people may continue to use this term. It’s important to know that in most
cases, these early symptoms may be the start of a seizure.

Describing Generalized Onset Seizures

Seizures that start in both sides of the brain, called generalized onset, can be motor or non-motor.

Generalized motor seizure: The generalized tonic-clonic seizure term is still used to describe seizures
with stiffening (tonic) and jerking (clonic). This loosely corresponds to “grand mal.” Other forms of
generalized motor seizures may happen. Many of these terms have not changed, and a few new terms
have been added. (see image below)

Generalized non-motor seizure: These are primarily absence seizures, and the term corresponds to the
old term "petit mal." These seizures involve brief changes in awareness, staring, and some may have
automatic or repeated movements like lip smacking.

 Seizures in the Newborn Period

Neonatal Seizures

A seizure is caused by sudden, abnormal and excessive electrical activity in the brain. By definition,
neonatal seizures occur during the neonatal period for a full-term infant, the first 28 days of life. Most
occur in the first one to two days to the first week of a baby's life. Premature or low birth weight babies
are more likely to suffer neonatal seizures.

Signs and symptoms

Seizures in the neonatal population often present differently than in other age groups due to brain
immaturity. Electroclinical seizures are defined by evidence of seizure activity on electroencephalogram
as well as clinical signs or symptoms. However, in neonates there may be no clinical movement
abnormality (either because the seizures are subclinical or because they were not witnessed), so the
only symptom may be abnormal level of consciousness. When motor movements due occur, they
cannot be suppressed by gentle restraint by a nurse or caregiver. Classification systems have been
developed based on neonatal seizure motor manifestations :

- Focal or multifocal clonic

Clonic seizures are defined by repetitive contractions of groups of muscles, typically of the limbs or face.
These may involve one group of muscles (focal) or the multiple groups of muscles (multifocal). An
isolated focal seizure can move or spread, and can even alternate from one side of the body to the
other. Due to the neonatal brain's immaturity, the typical Jacksonian march may not occur. Focal
seizures typically have very close correlates on EEG, with measurable EEG abnormalities with each
seizure movement. The rhythm of the clonic movements and EEG abnormalities is usually slow, at 1-3
movements per second.

- Focal tonic

Focal tonic seizures are characterized by sustained muscle contraction of muscle groups, and thus often
appear as abnormal posturing of a single limb or eye deviation.

- Generalized tonic

A focal tonic seizure can generalize, or the first seizure can occur as a generalized seizure, or seizures
that impair the neonate's level of consciousness. Generalized tonic seizures typically appear as
symmetric and sustained posturing of limbs in either an extensor or flexor distribution. Generalized
tonic seizures often manifest with tonic extension of the upper and lower limbs and also may involve the
axial musculature in an opisthotonic fashion. Generalized tonic seizures mimic decorticate posturing; the
majority are not associated with electrographic seizures.

- Myoclonic

Myoclonic movements can either be caused by seizures or be benign neonatal sleep myoclonus, a
common mimicker of seizures in neonates. Myoclonic seizures are characterized by isolated and fast
contractions of muscle groups. These movements typically occur in the limbs or face, and do not repeat.
Stimulation can provoke myoclonic seizures.

- Subtle

Some clinicians use the term subtle seizures to describe seizures if there is an absence of distinct tonic
or clonic movements but presence of abnormal eye movements, stereotyped lip smacking, or apneic
events.

- Benign

Benign neonatal seizures are not classified as epilepsy.

Causes

Hypoxic-Ischemic Encephalopathy
Perinatal Arterial Stroke

Central Nervous System Infection:

Congenital central nervous system malformations

Inborn Errors of Metabolism

Electrolyte abnormalities

Substance-Related: Neonatal abstinence syndrome 

 Seizures in the infant and toddler Period

Seizures commonly seen in this age group are infantile Spasms , a form Of generalized seizure often
called "salaam" jackknife" seizures, or infantile myoclonic seizures. These are characterized by very
rapid movements of the trunk with sudden strong contractions of most of the body, including flexion
and adduction of the limbs, or the infant suddenly slumps forward from a sitting position or falls from a
standing position. The episode may occur singly or in clusters as frequently as 100 times a day.

In approximately 50% of affected children, there is an identifiable cause such as trauma, a metabolic
disease such as phenylketonuria, or a viral invasion such as herpes or cytomegalovirus. In other children,
the spasms apparently result from a failure of normal organized electrical activity in the brain.
Approximately 90% of infants with this type of involvement will be developmentally delayed as
intellectual development appears to halt and even regress after the pattern of seizures begins. Most
children with infantile spasms show high-amplitude slow waves and spikes, a. chaotic discharge called
hypsarrhythmia on an EEG tracing.

These seizures occur slightly more often in males than females, occur in 2 to 3 per 10,000 live births,
have a family history in 3% to 6% of cases, and only spontaneously stop in 30% of children (Go, Mackay,
Weiss, et al., 2012). Because the response to treatment with antiseizure therapy tends to be poor,
parenteral adrenocorticotropic hormone (ACT H) therapy,prednisone, or high-dose vigabatrin, an amino
acid, are used in its place. High-dose valproate or a newer antiseizure agent such as topiramate
(Topamax) may be used in children who do not respond to usual therapy, as well as pyridoxine (vitamin
B6) or a ketogenic diet (see following discussion),but research shows none to be as effective as ACTH,
especially for preserving neurodevelopmental outcomes (Go et al., 2012). In most children, the seizure
phenomenon seems to "burn itself out" by 2 years of age. Any associated cognitive or developmental
delay remains, however, so children need good follow-up planning and care.

 Seizures in Children Older than 3 Years of Age

 Febrile Seizures

Seizures associated with high fryer (102 degrees to 104 ᵒF [38.9 ᵒto 40.0ᵒC ]) are the most common type
seen in preschool children, although these can occur as late as 7 years of . They are most serious if they
occur under 6 months of age. Such seizures may occur after immunization with live vaccines because
these most commonly produce fevers. The seizure is usually a generalized tonic—clonic pattern, which
lasts for 5 to 20 seconds. An EEG tracing afterward is usually normal. There also is usually a history of
other family members having had similar seizures.The seizure is due to a sudden spike of temperature
not a gradual incline. The seizure only lasts 1 to 2 minutes' or less. Further evaluation is necessary after a
febrile seizure to exclude underlying conditions or infections (Sidhu et al.. 2013).

Prevention of Febrile Seizures

Because these seizures arise with high fever, they are largely preventable. If ibuprofen or
acetaminophen is given to keep a developing fever below 101 ᵒF (38.46ᵒC), the seizures rarely

occur. They happen most often when a child develops a fever at night when a parent is not aware of it,
or when a parent is reluctant to give ibuprofen or acetaminophen in large enough doses to be
therapeutic. Because the recommended doses of these medicines vary with the type (liquid or pills),
caution parents to read the bottle label carefully before administration to be certain they are
administering the correct dosage. Family history and younger age at onset of first seizure are risk factors
for reoccurrence of a febrile seizure. Teach parents that every child who has a febrile seizure must be
seen by a healthcare provider to rule out meningitis.

Therapeutic Management

After a febrile seizure subsides, parents should sponge the child with tepid water to reduce the fever
quickly. Advise them not to put the child in a bathtub of water to do this because it would be easy for
the child to slip under water should a second seizure occur. Caution parents not to apply alcohol or cold
water because extreme cooling causes shock to an immature nervous system; in addition, alcohol can be
absorbed by the skin or the fumes can be inhaled in toxic amounts,compounding the child's problems.
Parents should not attempt to give oral medications such as acetaminophen because the child will be in
a drowsy or postictal, state after the seizure and might aspirate the medicine. Suppositories may be
given at the appropriate dose. If attempts to reduce the child's temperature by sponging are
unsuccessful, advise parents to put cool washcloths on the child's forehead, axillary and groin areas.
Many parents need to be reassured that febrile seizures do not led to brain damage and that the child is
almost always completely well afterward.

 Complex Partial (Psychomotor or Temporal Lobe) Seizures

More than half of children who develop recurrent seizures during school age have an idiopathic type or
the cause of the seizures cannot be discovered. Despite this, medication can effectively control these
seizures in almost all affected children. Some seizures in this age group occur because of organic causes
such as laceration of brain tissue from an automobile accidentor fall, an enlarging brain tumor,
hemorrhage due to a blood dyscrasia, infection (meningitis or encephalitis), anoxia, or toxic conditions
such as lead poisoning that have left residual damage. The possibility that brain trauma could have been
caused by child maltreatment is always another possibility to consider.

Complex partial (psychomotor) seizures vary greatly in extent and symptoms and tend to be a difficult
type to control.The child may notice a slight aura, or sensation a seizure is about to occur, but this is
rarely as definite as that seen with tonic—clonic seizures. Results ofa CT or MRI scan and EEG will
invariably be normal.

This type of seizure often begins with a sudden change in posture, such as an arm dropping suddenly to
the side. Other motor, sensory, and behavioral signs might include automatisms (complex purposeless
movements, such as lip smacking, fumbling hand movements, intense running, or screaming). A few
children may then slump to the ground,unconscious. Circumoral pallor develops due to a halt in
respirations. The child begins breathing again almost immediately and usually regains consciousness in
less than 5 minutes. He or she may feel slightly drowsy afterward but does not have an actual postictal
stage or a period of sustained unconsciousness as seen with tonic—clonic seizures.Common drugs used
to treat this type of seizure include carbamazepine (Tegretol) or valproate (Depakene).

 Partial (Focal) Seizures

Partial seizures originate from a specific brain area. A typical partial seizure with motor signs begins in
the fingers and spreads to the wrist, arm, and face in a clonic contraction.

If the movement remains localized, there will be no loss of consciousness. If the spread is extensive, the
seizure can cross the midline and become generalized and, at that point, is impossible to differentiate
from a full generalized tonic—clonic seizure. This makes it important, therefore, to observe children
careållly as a seizure begins to distinguish whether it

began with local signs such as numbness, tingling, paresthesia,or pain all associated with one brain area.

 Absence Seizures

Absence seizures are one form of generalized seizures, merly known as petit mal seizures (Sidhu et ale,
2013) occur more often in girls than boys, usually occur in school-age children between 4 and 12 years,
and consist of a spell that lasts for a few seconds. A child might be reciting in class, for example, when he
or she pauses and stares for I to 5 seconds and then continues the recitation as if he or she is unaware
time has passed. Rhythmic blinking and twitching of the mouth or an extremity may accompany the
staring. As many as 100 seizures can occur during a day. Children with absence episodes usually have
normal intelligence but may have failing school marks, be accused of daydreaming in school, or be
referred to the school nurse behavior problems because they miss so many of a teacher`s Instructions.

If the child is susceptible to such seizures, he or she typically breathes in and Out deeply, possibly 10
times, stops and stares for 3 seconds, and then continues to hyperventilate and count, unaware that he
or she paused. NO first aid measures are necessary for absence seizures, and downplaying the
importance Of these episodes helps children maintain a positive self-image. They can be controlled by
ethosuximide (Zarontin), valproate, Or "off-label" lamotrigine . Approximately one third to one half of all
children with absence seizures "outgrow" them by adulthood.

 Tonic—Clonic Seizures

Typical tonic—clonic seizures (formerly termed grand mal seizures) are generalized seizures usually
consisting of three stages: a prodromal period of hours or days or an aura, or warning, immediately
before the seizure that a seizure is about to occur; a tonic—clonic stage; and, finally, a postictal stage.
Children with this type of seizure may or may not have an abnormal EEG pattern. Therapy includes the
daily administration of an antiseizure medication such as valproate (Depakene) and carbamazepine
(Tegretol). Phenobarbital may be administered to young children.Medications are usually continued
until the child has been seizure free for 2 to 3 years. NO antiseizure medication should be stopped
suddenly (it should be tapered) because rapid withdrawal may precipitate a seizure. In addition to
medication, some children may be prescribed a ketogenic diet Or a diet high in fat and low in protein
and carbohydrate.

 Status Epilepticus

Status epilepticus refers to a seizure that lasts continuously for longer than 30 minutes or a series of
seizures from which the child does not return to the previous level of consciousness. This is an
emergency situation requiring immediate treatment before exhaustion, respiratory failure, permanent
brain injury, or death occurs. An IV benzodiazepine drug such as diazepam (Valium) or lorazepam
(Ativan) halts seizures dramatically.

Individual insight and remarks

 Many people have seizures but they have different effects on them..Seizures occur when abnormal
signals from the brain and changes the way the body functions. Some people have a little shaking of
their hands and do not lose consciousness, while others have a lot of shaking and do lose consciousness.
While seizures have a range of life changing effects for adults, more needs to be focus on children. There
are different kinds of seizures, each having different effects and can happen to anyone of any age.
Before, I`ve always thought seizures and epilepsy are the same thing , and growing up I realized I
was wrong . It’s common for people to confuse seizures and epilepsy or to assume that they’re
interchangeable. In fact, the distinction between the two conditions is a bit more complex than that.
Epilepsy is characterized by recurring seizures. However, not all seizures are epileptic in nature. Some
people may experience a seizure and not be diagnosed with epilepsy
Drug study of the following Medication:

Carbamazepine (Tegretol)

Classification - Therapeutic:anticonvulsants, mood stabilizers

Actions - Decreases synaptic transmission in the CNS by affecting sodium channels in neurons.

Indications - Treatment of tonic-clonic, mixed, and complex-partial seizures. Management of pain in

trigeminal neuralgia or diabetic neuropathy

Contraindications - Hypersensitivity; Bone marrow suppression; Concomitant use or use within 14 days
of MAO inhibitors; Concurrent use of nefazodone; OB: Use only if potential benefits outweigh risks to
the fetus; additional vitamin K during last weeks of pregnancy has been recommended; Lactation:
Discontinue drug or bottle feed.

Adverse Effects - CNS: suicidal thoughts, ataxia, drowsiness, fatigue, psychosis, sedation, vertigo. EENT:
blurred vision, corneal opacities, nystagmus. Resp: pneumonitis. CV: HF, edema, hypertension,
hypotension, syncope. GI: hepatitis,qliver enzymes, pancreatitis, weight gain. GU: hesitancy, urinary
retention. Derm: steven-johnson syndrome , toxic epidermal necrolysis, nail shedding, photosensitivity,
rash, urticaria. F and E: syndrome of inappropriate antidiuretic hormone (SIADH), hyponatremia. Hemat:
agranulocytosis , aplastic anemia , thrombocytopenia , eosinophilia, leukopenia, lymphadenopathy.
Misc: chills, fever, multi-organ hypersensitivity reactions

Nursing Considerations :

● Monitor closely for notable changes in behavior that could indicate the emergence

or worsening of suicidal thoughts or behavior or depression.

● Monitor for changes in skin condition in early therapy.

● Seizures: Assess frequency, location, duration, and characteristics of seizure activity.

● Trigeminal Neuralgia: Assess for facial pain (location, intensity, duration). Ask

patient to identify stimuli that may precipitate facial pain (hot or cold foods, bedclothes, touching face).

● Bipolar Disorder: Assess mental status (mood, orientation, behavior) and cognitive abilities before and
periodically during therapy.

● Monitor serum ionized calcium levels every 6 mo or if seizure frequency increases.

● Monitor ECG and serum electrolytes before and periodically during therapy.

● Implement seizure precautions as indicated.

● Administer medication with food to minimize gastric irritation.

● Instruct patient to take carbamazepine around the clock, as directed.

● Advise patients to avoid driving or other activities requiring alertness until response to medication is
known.

● Instruct patients that behavioral changes, skin rash, fever, sore throat,
mouth ulcers, easy bruising, petechiae, unusual bleeding, abdominal

pain, chills, rash, pale stools, dark urine, or jaundice should be reported to health care professional
immediately.

● Advise patient not to take alcohol or other CNS depressants concurrently with this

medication.

● Instruct patient to notify health care professional of medication regimen before

treatment or surgery.

● Seizures: Advise patients to carry identification describing disease and medication regimen at all times

Phenobarbital

Classification - Therapeutic:anticonvulsants, sedative/hypnotics

Pharmacologic: barbiturates

Actions - Produces all levels of CNS depression. Depresses the sensory cortex, decreases motor activity,
and alters cerebellar function. Inhibits transmission in the nervous system and raises the seizure
threshold. Capable of inducing (speeding up) enzymes in the liver that metabolize drugs, bilirubin, and
other compounds.

Indications - Anticonvulsant in tonic-clonic (grand mal), partial, and febrile seizures in children.
Preoperative sedative and in other situations in which sedation may be required. Hypnotic (short-term).

Contraindications - Hypersensitivity; Comatose patients or those with pre-existing CNS depression;

Severe respiratory disease with dyspnea or obstruction; Uncontrolled severe pain; Known alcohol
intolerance (elixir only); Lactation: Discontinue drug or bottle feed.

Adverse Effects - hangover, delirium, depression, drowsiness, excitation, lethargy, vertigo. Resp:
respiratory depression ,laryngospasm, bronchospasm. CV: IV— hypotension. GI: constipation, diarrhea,
nausea, vomiting. Derm: photosensitivity, rashes, urticaria. Local: phlebitis at IV site. MS: arthralgia,
myalgia, neuralgia. Misc: hypersensitivity reactions including angioedema and serum sickness, physical
dependence, psychological dependence.

Nursing Considerations :

● Monitor respiratory status, pulse, and BP and signs and symptoms of angioedema (swelling of lips,
face, throat, dyspnea) frequently in patients receiving phenobarbital IV.

● Seizures: Assess location, duration, and characteristics of seizure activity.

● Sedation: Assess level of consciousness and anxiety when used as a preoperative

sedative.

● Monitor serum folate concentrations periodically during therapy because of increased folate
requirements of patients on long-term anticonvulsant therapy with phenobarbital.

● Supervise ambulation and transfer of patients following administration.

● When changing from phenobarbital to another anticonvulsant, gradually decrease

phenobarbital dose while concurrently increasing dose of replacement medication to maintain

anticonvulsant effects.

Advise patient to take medication as directed.

● Advise patients on prolonged therapy not to discontinue medication without consulting health care
professional.

● Caution patient to avoid driving and other activities requiring alertness until response to medication is
known.

● Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication.

Phenytoin (Dilantin)

Classification - Therapeutic : antiarrhythmics (group IB), anticonvulsants

Pharmacologic: hydantoins

Actions - Limits seizure propagation by altering ion transport. May also decrease synaptic transmission.
Antiarrhythmic properties as a result of shortening the action potential and decreasing automaticity.

Indications - Treatment/prevention of tonic-clonic (grand mal) seizures and complex partial seizures.

Contraindications - Hypersensitivity; Hypersensitivity to propylene glycol (phenytoin injection only);

Alcohol intolerance (phenytoin injection and liquid only); Sinus bradycardia, sinoatrial block, 2nd- or 3rd-
degree heart block, or Stokes-Adams syndrome (phenytoin injection only).

Adverse Effects - Most listed are for chronic use of phenytoin CNS: suicidal thoughts, ataxia, agitation,
confusion, dizziness, drowsiness, dysarthria, dyskinesia, extrapyramidal syndrome, headache, insomnia,
weakness. EENT: diplopia, nystagmus. CV: hypotension (q with IV phenytoin), tachycardia. GI: gingival
hyperplasia, nausea, constipation, drug-induced hepatitis, vomiting.Derm: steven-johnson syndrome ,
toxic epidermal necrolysis, hypertrichosis, rash, exfoliative dermatitis, pruritus, purple glove syndrome.
Hemat: agranulocytosis , aplastic anemia, leukopenia, megaloblastic anemia, thrombocytopenia. MS:
osteomalacia, osteoporosis. Misc: fever, lymphadenopathy

Nursing Considerations :

● Monitor closely for notable changes in behavior that could indicate the

emergence or worsening of suicidal thoughts or behavior or depression.

● Assess oral hygiene.

● Assess patient for phenytoin hypersensitivity syndrome (fever, skin

rash, lymphadenopathy).

● Seizures: Assess location, duration, frequency, and characteristics of seizure activity. EEG may be
monitored periodically throughout therapy.

● Monitor BP, ECG, and respiratory function continuously during administration of

IV phenytoin and throughout period when peak serum phenytoin levels occur

(15– 30 min after administration).

● Arrhythmias: Monitor ECG continuously during treatment of arrhythmias.

● Lab Test Considerations: Monitor CBC, serum calcium, albumin, and

hepatic function tests prior to and monthly for the first several months,

then periodically during therapy.

● Monitor serum folate concentrations periodically during prolonged therapy.

● Implement seizure precautions.

● When transferring from phenytoin to another anticonvulsant, dosage adjustments

are made gradually over several weeks.

● Administer with or immediately after meals to minimize GI irritation.

● If patient is receiving enteral tube feedings, 2 hr should elapse between feeding

and phenytoin administration.

● Instruct patient to take medication as directed, at the same time each day.

●. Caution patient to avoid driving or other activities requiring alertness until response to medication is
known.

● Caution patient to avoid alcohol and CNS depressants.

● Instruct patient on importance of maintaining good dental hygiene and seeing

dentist frequently for teeth cleaning to prevent tenderness, bleeding, and gingival

hyperplasia.

● Advise patient not to take phenytoin within 2– 3 hr of antacids.