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Introduction
A seizure is a neurological disorder that affects any age, gender, race or socioeconomic status. Health care providers will most likely be exposed to a patient with seizures or one who is at risk for seizures. The causes for seizures can vary by age although, there is strong evidence to suggest a genetic link (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). In child neurology, seizures are the most common disorder found (Grossman & Porth, 2014). In patients under 20 years of age, the causes of seizures can be from injury, trauma, or genetic disorders (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). In 20 to 30-year-olds, causes of seizures can be trauma or brain and cardiac disorders (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). For patients over 50, the seizures usually stem from stroke, and brain disorders such as tumors (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Seizures can occur across the lifespan and present with several different symptoms. A knowledgeable health care provider can help patients with a seizure condition live a productive life.
What is a Seizure?
There are several theories as to the actual mechanism that happens in the brain for a seizure to occur. A seizure appears to happen because of the abnormal firing of neurons in the brain that spread throughout the body. When seizures are reoccurring, the person may be diagnosed with epilepsy. In the US, over five million children and adults suffer from epilepsy (“Epilepsy Fast Fact,” 2016).
A seizure happens when neurons in the brain fire abnormally. This electrical discharge causes a chain reaction throughout the body which can cause involuntary movements (Grossman & Porth, 2014). The movements caused by the abnormal firing of the neurons can be seen as a sensory, motor, autonomic, or a psychiatric event. In other words, the involuntary movements can be in any body part or the seizure can be associated with a smell, taste or vision problem. A seizure can occur due to any serious illness or injury where the brain is affected. This can include metabolic disorders, infections, drug abuse, cerebrovascular problems, or brain injuries. However, a seizure can also be due to an emotional response to a stimulus.
Seizures are classified by the International League Against Epilepsy into general and focal. The type of seizure is determined by where the seizure is starting in the brain (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Depending on the type of seizure, the patient may move through several phases (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014):
- The prodromal phase gives the patient a feeling that a seizure is about to happen. This may be described as a sense of something about to happen.
- The aural phase is a sensory warning before a seizure such as smell, sweating or seeing a bright light.
- The ictal phase is the actual seizure occurring
- The postictal phase is the recovery or post-seizure phase.
Although each phase does not always occur in every type of seizure, the health care provider can educate the patient on the phases and assist the patient through the phases that do occur.
Focal Seizures
Focal seizures begin in a specific part of the brain and are the most common type of seizure (Trinka et al., 2015). Patients can be aware of a focal seizure, which is called a focal seizure, without impairment or awareness (Grossman & Porth, 2014). This means that the seizure occurs with the patient being aware of what is happening. Often these patients will say they know the seizure is coming. This sensation is the prodromal or aural phase (Grossman & Porth, 2014). The patient may have a sudden flood of emotions such as joy or anger. They may also report hearing, smelling or tasting something that is not really there (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
A focal seizure can also occur with impairment of awareness (Grossman & Porth, 2014). In this type of seizure, the patient will lose consciousness and does not remember the seizure (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The seizure may begin locally but can progress throughout the brain and body. Often times, there will be repetitive, not purposeful, movements such as lip-smacking, rubbing of clothing, or grimacing (Grossman & Porth, 2014). The patient may exhibit confusion, hallucinations, uncontrollable fear, a flood of ideas, or seem to be daydreaming (Grossman & Porth, 2014). Often the seizures will progress to tonic-clonic seizure activity. Typically, these patients do not have a warning or aura phase as in the focal seizures without impairment in awareness.
Focal seizures begin in a specific part of the brain and are the most common type of seizure (Trinka et al., 2015). Patients can be aware of a focal seizure, which is called a focal seizure, without impairment or awareness (Grossman & Porth, 2014). This means that the seizure occurs with the patient being aware of what is happening. Often these patients will say they know the seizure is coming. This sensation is the prodromal or aural phase (Grossman & Porth, 2014). The patient may have a sudden flood of emotions such as joy or anger. They may also report hearing, smelling or tasting something that is not really there (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
A focal seizure can also occur with impairment of awareness (Grossman & Porth, 2014). In this type of seizure, the patient will lose consciousness and does not remember the seizure (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The seizure may begin locally but can progress throughout the brain and body. Often times, there will be repetitive, not purposeful, movements such as lip-smacking, rubbing of clothing, or grimacing (Grossman & Porth, 2014). The patient may exhibit confusion, hallucinations, uncontrollable fear, a flood of ideas, or seem to be daydreaming (Grossman & Porth, 2014). Often the seizures will progress to tonic-clonic seizure activity. Typically, these patients do not have a warning or aura phase as in the focal seizures without impairment in awareness.
Generalized Seizures
Generalized seizures happen when both hemispheres of the brain are involved (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Typically, these patients will lose consciousness and exhibit body and limb movement during the seizure. However, there are types of generalized seizures that involve only a brief episode of altered consciousness, repetitious movements, or lack of muscle tone. Generalized seizure activity tends to be varied due to more brain involvement. These seizures are further divided into six categories: tonic-clonic, absence, myoclonic, clonic, tonic and atonic (Trinka et al., 2015).
A tonic-clonic seizure, formally known as a grand mal seizure, is the most common type of generalized seizures. The patient will experience a loss of consciousness, contraction of the muscle group (tonic) for a short period then jerking of the extremities (clonic). The patient may also show signs of cyanosis due to the muscles of the respiratory system contracting, incontinence, tongue biting, and excessive salivation (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Seizures of this type usually last 60 to 90 seconds (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The patient may be exhausted and sleep for hours afterward. They may not feel normal for several days and have no memory of the seizure (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
Absence seizures are non-convulsive events. These were formally referred to as petite mal seizures. These typically occur in children and rarely continue beyond adolescence. (Grossman & Porth, 2014). Absence seizures are characterized as a blank stare, motionless, and unresponsiveness. However, there can be motion in areas such as lip-smacking, eyelids, or lack of postural tone. The seizures typically last only a few seconds and then the child is able to resume normal activity (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Sometimes the seizures are very subtle and may even go unnoticed. The child may complain of seeing flashes of light or may hyperventilate (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). They may also appear to be daydreaming. Although the seizures do not last long, if untreated, may occur up to 100 times a day (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
Myoclonic seizures are brief muscle contractions. They are seen as bilateral jerking of muscles typically of the face, trunk, or one or more extremities (Grossman & Porth, 2014). Sudden and excessive jerk of the body and extremities can be seen. These seizures can also happen in clusters and can progress to tonic-clonic seizures (Grossman & Porth, 2014).
Clonic seizures typically begin with a loss of consciousness and sudden hypotonia. The seizure is then seen as limb jerking that may not be symmetrical (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
Tonic seizures are seen as sudden onset of increased tone which is held typically in extensor muscles. These seizures are often associated with falling (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
Atonic seizure is the sudden split-second loss of muscle tone leading to a slackening of the jaw, drooping of the eye, or falling on the ground (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). The seizures are also known as drop attacks. They tend to start suddenly and the patient loses consciousness. However, consciousness returns usually as a person is falling. They can resume normal activity immediately (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
Impact on lifestyle
Patients with seizures usually cannot drive and have difficulty finding employment. Independence of the patient is an issue that can lead to depression and anxiety. Community resources and services can help the patient maintain a productive life(“Managing my seizures 101,” 2014). The caregiver can help the patient express their feelings and find alternative methods to maintain daily activities.
Patients and parents of children who have seizures experience stress, fear, and possibly psychological comorbidities such as anxiety and depression (Wu, Follansbee-Junger, Rausch, & Modi, 2014). Children may have problems in school and socializing with their peers. The caregiver of a child with seizures or epilepsy may suffer from fear of their child being stigmatized and from significant family stress related to their child’s well-being (Wu, Follansbee-Junger, Rausch, & Modi, 2014). A caregiver can help connect the parents with resources and help alleviate fears by allowing them to express their feelings.
What Can The CNA Do to Help?
The overall goals are to keep the patient safe, free from injury, and maintain daily activities.
Help the family and the patient express their feelings about the disorder. There may be stigmatism concerns or anxiety about the next seizure. Help the family or patient seek out community resources to aid in daily activities such as getting to the store or appointments. Make sure the patient or the caregiver can identify any signs that may indicate an impending seizure and what to do if a seizure occurs.
The risk of injury and trauma during a seizure is a concern. Be sure they understand to move furniture or objects away from the patient when a seizure occurs. Educate the patient and caregiver on the possibility of falls and breathing problems during a seizure. If the patient has a medical bracelet, ask that they wear it when in public. Preparing the patient and the caregiver for seizures can help decrease the likelihood of injuries.
Most patients with seizures are taking one or more medications. Review signs of toxicity or adverse reactions that may occur. Adverse reactions can include, lethargy, confusion, sleep problems, slurred speech, nausea, vomiting, diarrhea or vision problems. Poor hand and gait coordination, lowered cognitive functioning, and decrease general alertness may also be signs of a problem. If any of these signs occur, report them to the nurse.
Make sure the patient or caregiver understands the treatment regimen. Some patients require blood work to be done regularly to monitor the levels of medication in their bloodstream. Ask if the patient is getting blood work done regularly and when the last blood draw occurred.
Ask the patient about their daily routine. The patient needs to stay hydrated, eat well and take all medications as prescribed. Be sure to remind them to avoid alcohol and drugs.
Observe for any signs that a seizure has occurred. This can be seen as an abnormal respiratory rate, bitten tongue or cheek, cyanosis, high blood pressure, incontinence, or weakness. Report any findings to the nurse.
What if The Patient has a Seizure While I am There?
Some patients know that a seizure is coming. They may report a flashing light. Sweating, flushing, dilated pupils, altered level of consciousness, or a dream-like state may be observed as well. A blank stare or eyes rolling to the back of the head may also signal an absence seizure. Brief involuntary muscle jerks may signal a myoclonic seizure. A tonic-clonic seizure may be signaled by sudden body stiffening then the relaxation of muscles, labored breathing, cyanosis, tongue biting, or incontinence. After a seizure, particularly a tonic-clonic seizure, the patient may be drowsy, weak, confused, have difficulty talking, complain of headaches or muscle aches (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014).
Note the time the seizure started and when it stopped. If it has been determined the patient about to have a seizure, help them to the floor if they are standing, loosen constrictive clothing, and do not restrain them. Call for help. Move furniture or objects away from the patient. Do not put any objects in their mouth but you may try to hold the patient’s head for support or place something soft beneath their head. Once the seizure is over, turn them on their side to prevent choking. Report the incident immediately to the nurse. Make the patient comfortable. They may be embarrassed and tired (Pulliam, 2012; Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014). Comfort them and assure them they are safe and help is on the way.
What to Report to the Nurse
Immediately report any seizure activity (Pulliam, 2012). The report should include how long the seizure lasted, description or type of seizure, and if any injury occurred. If the patient reported any aura or if you observed any changes in the patient before the seizure happened, be sure to tell the nurse. Report vital signs and if the patient is resting comfortably after the seizure. If the patient was transported to the hospital, be sure to report the name of the hospital.
Also, report any adverse reactions to medication. Discuss any concerns the patient or caregiver has regarding the medication regiment. Report any observations you may make while with the patient that is different from their baseline. This may include the level of consciousness, gait changes, increased seizure activity, changes in vital signs, or changes in physical appearance (Pulliam, 2012).
Conclusion
Seizures can have a devastating effect on a person’s life and activities. Stigma, anxiety, and fear can be an issue and cause the patient to develop unhealthy activities. The CNA can provide care by understanding the different types of seizures, and the impact this disorder can have on the patient and the family. Remaining open to discussion and encouraging expression of their concern can help the patient and the family cope with this disorder. Also, understanding how to keep a patient safe during a seizure and caring for the patient afterward are important skills to know when working with patients. Supporting the patient and the family can decrease their concerns and fears as well as promote productive functioning of daily activities.
CASE ONE:
Mrs. Johnson is a 72-year-old female with a history of absence seizures and has recently been diagnosed with epilepsy. She currently lives with her husband who has been taking care of her. Recently, Mrs. Johnson has had several new tonic-clonic seizures. You have been assigned as her new home health caregiver. Upon entering the home, Mrs. Johnson’s husband rushes over to you and tells you his wife is having a bad seizure. When you enter the room, you find Mrs. Johnson on the floor in a clonic reaction. What should you do first? What are the other steps you need to take?
First, call for help. If possible, ask Mr. Johnson to help you move objects away from her to help keep her safe. Either hold her head in your lap or place a towel or something similar under her head. Loosen clothing, especially around her throat. Be sure to observe the time you found her and the time when the seizure stopped. Obtain vital signs and sit with Mrs. Johnson keeping her comfortable until help arrives. Call your nurse and report the incident.
CASE TWO:
Mr. Smith is a 50-year-old male who has been recently discharged from the hospital due to a car accident. You are in the home for a follow-up visit. His wife is with him. She tells you that her husband has been acting oddly. She tells you he seems disoriented at times; he will smack his lips and grimaces for several minutes. She tells you he seems confused as well. Mr. Smith tells you his wife is imagining things. He feels fine. What is happening with Mr. Smith and why? What are your next steps?
Mr. Smith may be having focal seizures. This can sometimes happen in adults after a trauma has occurred. The injured area of the brain has neurons that are firing abnormally. This causes a chain reaction throughout the body which can cause seizures to occur.
Write down what Mrs. Johnson has reported. You will also want to include what Mr. Johnson has said as well. Obtain vital signs and observe for any injuries including tongue or cheek biting. Review Mr. Johnson’s medications and when he takes each one. You will also ask if he is sleeping well, if he is eating, and getting enough fluid. You can educate both Mr. and Mrs. Johnson on seizures. There are types of seizures where the patient is not aware they are having a seizure and are able to resume their daily activity immediately. This type of seizure still needs to be monitored and treated. Education of when to seek help and if community resources are available will be helpful to Mr. and Mrs. Johnson
References
Epilepsy Fast Facts. (2016). Retrieved April 17, 2016. (Visit Source)
Grossman, S., & Porth, C. (2014). Porth’s pathophysiology: Concepts of altered health states (9th ed.). United States: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M. M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing: Assessment and management of clinical problems, single volume / edition 9 (9th ed.). Philadelphia, PA: Elsevier Health Sciences.
Managing my seizures 101. (2014, October ). Retrieved April 16, 2016. (Visit Source)
National Stroke Association. (2015, November 16). Seizures and epilepsy. Retrieved April 17, 2016. (Visit Source)
Pulliam, J. (2012). The nursing assistant: Acute, Subacute, and long-term care (5th ed.). United States: Prentice Hall.
Trinka, E., Cock, H., Hesdorffer, D., Rossetti, A. O., Scheffer, I. E., Shinnar, S., ... & Lowenstein, D. H. (2015). A definition and classification of status epilepticus–Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia, 56(10), 1515-1523.
Wu, Y. P., Follansbee-Junger, K., Rausch, J., & Modi, A. (2014). Parent and family stress factors predict health-related quality in pediatric patients with new-onset epilepsy. Epilepsia, 55(6), 866-877.
