Angeles University Foundation

Angeles City

College of Nursing

In Partial Fulfillment of the requirements in NCM 106 RLE

Head injury, Seizures, Spinal Cord Injury and Cerebrovascular Accident

Submitted by: Bondoc, Catherine Jane Del Rosario, Jovella BSN 4-10 Group 39

Submitted to: Kristine Ann S. Fernandez, RN,MN Clinical Instructor Date Submitted: September 26, 2011

HEAD TRAUMA

I. DEFINITION Acute Head Injury is an

insult to the head, which may or may not include damage to the brain; it may be capable of producing emotional, physical, intellectual,

social, and vocational changes to the patient experiencing such condition. It is often used interchangeably with the term traumatic brain injury.

Mechanisms of Head Injury: 1. Acceleration it pertains to an injury that occurs when the immobile head is struck by a moving object. A falling hollow block while in a construction site hits the head, for example. 2. Deceleration this results if the head is moving and hits an immobile object. One example is when the head hits the steering wheel during a car accident. 3. Deformation this refers to injuries in which the force results in deformation and disruption of the integrity of the impacted body part, an example of which is a skull fracture.

Classifications of Head Injuries 1. Scalp Injuries these can cause lacerations, hematomas, and contusions or abrasions to the skin. These injuries might be unattractive and may bleed a lot. Clients with minor scalp injuries not accompanied by damage to other areas, such as the brain, do not require hospitalization.

2. Skull Fractures. Skull fractures are breaks in the integrity of the skull, which are often caused by a force enough to allow a breakage to the skull to occur and cause brain injury. The fracture themselves do not signal that brain injury is also present; however, skull fractures often cause serious brain damage.

Subtypes of skull fractures: a. Linear fractures- these are breaks in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone. They are important only if there is significant underlying brain damage. b. b. Depressed skull fractures may be palpated and may be seen radiographically. They injure the brain by bruising it (resulting in a contusion) or by driving bone fragments into it (causing lacerations).

c. Basilar skull fractures occur on bones over the base of frontal and temporal lobes. These are not observable in plain radiographs but may be manifested as ecchymosis around the eyes or behind the ears or by blood or CSF leakage from the ears or nose. 3. Brain injuries

a. Concussion. A concussion is head trauma that causes jarring or shaking of the brain within the skull. There is no break in the skull or dura and no visible damage on CT/MRI scans. b. Contusions. Contusions are associated with more extensive damage than that from concussions. With contusion, the brain itself is damaged, often with multiple areas of small hemorrhage and bruised areas in brain tissue. Abnormalities may be located primarily in one area of the brain, but other areas may also be injured. 4. Focal injuries a. Epidural Hematoma forms between the skull and dura mater and is usually associated with a skull fracture. It is the most serious type of hematoma and is a surgical emergency since arteries are located in the epidural area. b. Subdural Hematoma is a collection of blood in the subdural space (between the dura mater and arachnoid mater) due to trauma that forms slowly. It is venous in origin and has greater prognosis than epidural hematoma.

II. RISK FACTORS Modifiable: Ingestion of alcohol or influence of other depressants. They slow the reflexes and alter cognitive processes and perception. They also cause sedation or decrease in the LOC. These physiologic changes increase the chances of being involved in an accident that may lead to traumatic head injuries.

Faulty Driving Habits. Seat belts are necessary in order to maintain safety during driving. Failure to use them may cause severe head injuries in cases of car crash. Also, using texting and fast-paced driving increases the chances of being involved in vehicular accidents.

Falls. Falling out of bed, slipping in the bath, falling down steps, falling from ladders. They can cause head injuries especially if they fall head first or if the head bumps into the floor.

Violence. Abuse also leads to traumatic head injury once the head hits something hard.

Sports Injuries.

Sports such as boxing, skateboarding and parkour

predisposes a person to traumatic head injuries (THI) since there is a large chance that the head will be hit by something that may cause it to be damaged. Workplace. those who are working in construction sites are subject to the danger of falling from the building or having hit of a hard debris in the head.

Non-Modifiable: Age. Children are predisposed to (THI) since their fontanels are not yet closed and their cranial bones are still soft and easily traumatized. Old people have slowed reflexes due to deteriorating and degenerating bodies caused by aging. Males. This is based on statistics.

III. SIGNS AND SYMPTOMS Signs and symptoms may vary depending on the area of brain damage and the extent of damage. Major head injuries cause direct damage to the parenchyma of the brain. Kinetic energy is transmitted to the brain, and bruising analogous to

that seen in soft tissue injuries result. A blow to the surface of the brain results in rapid brain tissue displacement and disruption of blood vessels, leading to bleeding, tissue injury, edema and inflammation. The affected area may be stretched, twisted, or rotated, and their functions disrupted.

1. Scalp Injuries Lacerations, hematomas, contusions or abrasions depending on the extent of damage due to the impact force to the head.

2. Skull Fractures. Other than a history of skull fracture, clients may not have clear manifestations of the injury. Therefore, they need careful ongoing assessment. They may develop the following: Evidence of various cranial nerve injuries. Indications of cranial nerve and inner ear damage may be noted at the time of the initial injury or may not appear until later. o o o o Vision changes from optic nerve damage Hearing loss from auditory nerve damage Loss of the sense of smell from olfactory nerve damage Squint or fixed, dilated pupil and loss of some eye movements from oculomotor nerve damage o o o Facial paresis or paralysis (unilateral) from facial nerve damage Vertigo caused by damage from otoliths in the inner ear Nystagmus from damage to the vestibular system

* Basilar Skull Fracture

CSF or other fluid rhinorrhea or otorrhea. The fracture can cause leakage of the cerebrospinal fluid.

Raccoons eyes or the hematoma of the periorbital area and Battles sign or ecchymosis on the ears/mastoid process since the fracture is on the frontal and temporal lobe. This is caused by blood pooling at the base of the skull.

3. Brain Injuries a. Concussion Loss of consciousness for 5 minutes or less; retrograde,

posttraumatic amnesia or both; headache and dizziness; nausea and vomiting due to the jarring of the head. b. Contusions Cerebral contusions Agitation, confusion but still with alertness is due to temporal

lobe contusion Hemiparesis but still with alertness is due to a frontal lobe

contusion Aphasia is caused by the affectation of frontotemporal lobe. May be

classified as Wernickes, Broccas or Global.

Brain Stem contusions Altered level of consciousness for several hours and usually days or weeks and the client may regain partial consciousness within hours or remain in a coma. This is caused by a significant brain stem disruption.

Permanent comatose may happen if the reticular activating system is damaged.

Respirations may be normal, periodic, very rapid, or ataxic if the pons, which is the respiratory center is damaged

Pupils are usually small, equal, and reactive. Damage to the upper brain stem (third cranial nerve) may cause papillary abnormalities.

Loss of normal eye movements may occur because pathways controlling eye movements traverse the midbrain and pons.

4. Focal injuries a. Epidural Hematoma/Extradural Hematoma. An epidural hematoma occurs from injury to the cerebral blood vessels, most often the middle meningeal artery. Bleeding is usually continuous (arterial in nature), and a large clot forms, which separates the dura from the skull. Manifestations are usually acute in onset because the bleeding is often arterial. The following sequence of events may occur: 1. The client is unconscious immediately after head trauma. 2. The client awakens and is quite lucid. 3. Loss of consciousness occurs and pupil dilation response rapidly deteriorates, with onset of eye movement paralysis, on the same side as that of hematoma. 4. The client lapses into a coma. b. Subdural Hematoma. The onset and development of the clinical

manifestations may be somewhat slower because the bleeding is venous rather than arterial. Client may remain unconscious after injury or may have a variable level of consciousness depending on the extent of injury and tearing of the blood vessels.

Headache if the client is conscious due to tissue injury The client may become irritable and confused and lapse into a coma or show a fluctuating level of consciousness due to decreased brain tissue perfusion.

Hemiparesis, papillary dilation, or extraocular eye movement may happen with damage to parts of the brain responsible for these functions.

IV. COMPLICATIONS Cerebral bleeding or hemorrhage. Cerebral edema Brain ischemia from hypoxia and hypotension Hematoma may happen due to ruptured blood vessels either arterially or venous. Increased Intracranial Pressure (ICP). According to the Monro-Kellie hypothesis, a balance between the brain, blood and cerebrospinal fluid (CSF) maintain the pressure within the cranium. In cases of head injury, edema and bleeding can cause an increase in ICP manifested by alteration in level of consciousness, decrease in the Glasgow Coma Scale (GCS) score, changes in speech, pupillary reactivity, motor or sensory ability, or cardiac rate and rhythm, headache, nausea and vomiting. The late response and that which indicates severe increased ICP is the Cushings Triad (systolic hypertension, widened pulse pressure, and bradycardia) Brain Herniation can occur if the increase in ICP is not managed. This represents the bodys last attempt to restore normal brain volume and pressure. It is always considered an emergency.

Infections (e.g., brain abscess and meningitis). Open fractures in the head are break in the bodys first line of defense and allow communication between the external environment and the brain becoming the possible portal of entry fro microorganisms.

Seizures may happen due to meningeal irritation. Death may happen if sever brain injury occurs.

V. DIAGNOSTIC PROCEDURES: 1. Skull X-ray. It will reveal the size and shape of the skull bones and will reveal the presence of fracture. Nursing Responsibilities: Before the Procedure: Orient client about the procedure. Assess for the need for sedation especially for pediatric clients. Assess pregnancy status. Immobilize the neck for suspected spinal fracture prior to the procedure.

During: Accompany clients who are confused, combative, or ventilator-dependent to help in different positions and gain cooperation. Remove accessory, metal objects from the field of X-ray to prevent artifacts.

After:

Support client and family in light of their fears and apprehension about being tested and awaiting results. Obtain counseling or support services for the patient as indicated.

2. Computed Tomography (CT-scan) uses a computer to reconstruct a crosssectional image from measurements of X-ray tissue penetration. It will help detect intracranial bleeding, bleeding in the subarachnoid space, fracture, and shift of brain structures. Nursing Responsibilities for Non-Contrast CT-scan: Before: Obtain a written consent. Assess for claustrophobia. Assess pregnancy status. Fasting is usually not required. Assess the need for sedation especially for pediatric clients. Orient the client about the procedure. Inform the patient that he or she may hear a clicking noise during the procedure. Instruct the patient not to move the head and to lie still throughout the procedure. During: After: Support client and family in light of their fears and apprehension about being tested and awaiting results. Obtain counseling or support services for the patient as indicated. Accompany clients who are confused, combative, or ventilator-dependent.

Nursing Responsibilities for Contrast CT-scan: Before: Obtain a written consent. Assess for claustrophobia. Assess pregnancy status. Obtain a history of renal disease and secure a request for serum creatinine to assess renal function. Obtain history for allergies to iodine or contrast material. Assess the need for sedation especially for pediatric clients. Advise and keep the client on NPO status 4 hours before the procedure. If the test is scheduled at p.m., the client can have minimal amounts of liquid or a light breakfast and can take oral medications before placing the client on NPO status. Orient the client about the procedure. Inform the patient that he or she may hear a clicking noise during the procedure. Also tell the client that a feeling of warmth along the site of IV infusion will be felt and may taste a fishy, salty or metallic taste. Instruct the patient not to move the head and to lie still throughout the procedure. During: After: Observe the client for allergic reactions. Assess for presence of hematoma or signs of IV infiltration along the injection site. Accompany clients who are confused, combative, or ventilator-dependent.

Assess for neurologic function especially if the client was sedated. Instruct the client to increase fluid intake to promote the excretion of contrast medium.

Support client and family in light of their fears and apprehension about being tested and awaiting results. Obtain counseling or support services for the patient as indicated.

3. Magnetic Resonance Imaging combines radiofrequency (RF) waves and magnetic fields to provide more anatomically detailed pictures than are available with CT. Like CT scan, it will also reveal fractures and areas of bleeding or brain shift. Nursing Responsibilities: Before: Obtain a written consent. Assess for claustrophobia. Assess if the client has metallic prosthetic devices such as pacemakers, hearing aides, aneurysm surgical intracranial clips and metal prosthesis. Also assess for pregnancy. These are all contraindicated with the procedure. Orient the client about the procedure. Inform the patient that he or she may hear a drum-like noise during the procedure. Assess the need for sedation especially for pediatric clients. Remove metal objects from the field. Just before the procedure, have the patient urinate.

During: Accompany clients who are confused, combative, or ventilator-dependent.

Instruct the patient not to move the head and to lie still throughout the procedure.

Make sure that the technician maintains verbal contact with the conscious patient.

After: If the test is prolonged with the patient lying flat, monitor for orthostatic hypotension. Support client and family in light of their fears and apprehension about being tested and awaiting results. Obtain counseling or support services for the patient as indicated.

4. Cerebral Angiography/Four-vessel Angiography consists of injection of contrast material into an artery to visualize intracranial circulation. It can reveal vasospasm and bleeding. Nursing Responsibilities: Before: Obtain a written consent. Obtain a history of renal disease and secure a request for serum creatinine to assess renal function. Obtain history for allergies to iodine or contrast material. Assess the need for sedation especially for pediatric clients. Initiate IVF administration to prevent nephrotoxicity. Advise and keep the client on NPO status 4 to 6 hours before the procedure. If the test is scheduled at p.m., the client can have minimal amounts of liquid

or a light breakfast and can take oral medications before placing the client on NPO status. Orient the client about the procedure. Instruct the client to lie still throughout. Also tell the client that a feeling of warmth along the site of IV infusion will be felt and may taste a fishy, salty or metallic taste. Instruct the patient to void.

During: After: Apply direct pressure on the insertion site for 10 minutes. May apply cold compress or sand bag for 1-2 hours. Extend the legs and immobilize. Observe the client for allergic reactions. Observe and monitor for distal pulses and the 6 Ps of neurovascular status. Assess for presence of hematoma or signs of IV infiltration along the injection site. Assess for neurologic function especially if the client was sedated. Instruct the client to increase fluid intake to promote the excretion of contrast medium. Support client and family in light of their fears and apprehension about being tested and awaiting results. Obtain counseling or support services for the patient as indicated. Instruct the client to lie still during the procedure. Assist with the performance of the procedure.

5. Lumbar Puncture/Spinal Tap/Lumbar Tap. In this procedure, a spinal needle is inserted into the subarachnoid space in the lumbar region of the spine below the level of the spinal cord to assess for bleeding within the subarachnoid space. Nursing Responsibilities: Before: Obtain informed consent. Assess for signs of increased intracranial pressure (ICP), infection of skin at the puncture site and certain medical conditions (e.g. space occupying lesions that increase ICP and multiple sclerosis). These are contraindicated for this procedure. Assess if the client needs sedation especially for pediatric clients. Orient the client about the procedure. Instruct the client to lie still throughout. Instruct client to empty the bowels and bladder before the procedure. Prepare all the materials needed.

During: Position the client on lateral recumbency. Assist and instruct the client to draw the knees up to the abdomen and chin onto the chest. Instruct the client to lie still during the test. Stand in front of the client and place one hand behind the clients knees and the other around the neck. Maintain client in this position until the end of the procedure. After:

Record vital signs particularly the blood pressure and heart rate and frequently assess neurologic status to monitor for complications such as CSF leakage, infection and brain herniation.

Maintain client in a supine position with no head support (flat on bed) for 6 to 8 hours to prevent spinal headache.

Instruct client to increase fluid intake to replace CSF volume. Give analgesics as ordered. Support client and family in light of their fears and apprehension about being tested and awaiting results. Obtain counseling or support services for the patient as indicated.

VI. PHARMACOLOGIC AND NON-PHARMACOLOGIC TREATMENT: Pharmacologic Treatment: Diuretics: mannitol (Osmitrol), furosemide (Lasix) to combat cerebral edema Inotropic agents: Dopamine (Intropin) to improve cardiac contractility Glucocorticoids: Dexathemasone (Decadron) to reduce cerebral edema Anticonvulsant: phenytoin (Dilantin) Barbiturate: pentobarbital (Nembutal) if unable to control ICP with diuresis Analgesics: codeine phosphate or morphine Antipyretics to decrease cerebral metabolic rate Anesthetic: lidocaine (Xylocaine) for scalp injuries Histamine receptor antagonists: cimetidine (Tagamet), Ranitidine

(Zantac) to prevent the development of stress ulcer (Cushings ulcer). Non-Pharmacologic Treatment:

Application of cervical collar (until neck injury is ruled out) Covering and application of pressure to open head wounds to control bleeding unless there appears to be underlying depressed or compound skull fracture

Complete bed rest Oxygen Therapy Intubation and mechanical ventilation or bag-valve mask for brain herniation Restricted oral intake 24 to 48 hours Intravenous fluid (isotonic solution) to stabilize the blood pressure to systolic pressures over 90 mmHg

Suctioning oropharynx and trachea every 1 or 2 hours.

VII. SURGICAL PROCEDURES 1. Craniotomy surgical incision into the cranium (may be necessary to evacuate a hematoma, clots or contents to make room for swelling to prevent herniation). 2. Ventriculostomy insertion of a drain into the ventricles (to drain CSF in the presence of hydrocephalus, which may occur as a result of head injury). VIII. NURSING RESPONSIBILITIES Assess the complete history of the presenting problem (taking into consideration the nature and cause of the injury as well as past medical and social history). Assess neurologic and respiratory status Assess clients ability to maintain own airway

Maintain a patent airway, assist with endotracheal intubation or tracheotomy, as necessary

Observe for signs of increasing intracranial pressure (greater than 20mmHg for more than 10 minutes).

Monitor and record vital signs and intake and output (insert an indwelling catheter, as ordered).

Monitor oxygenation using pulse oximetry. Protect patient from injury secondary to the condition. Raise side rails and assist unsteady patients.

Assess for CSF leak as evidenced by otorrhea or rhinorrhea. CSF leak could leave the patient at risk for infection. Elevate the head of bed.

Provide suctioning as necessary. If patient is able, assist with turning, coughing and deep breathing exercises to prevent pooling of secretions.

Position patient with head of bed elevated 30 degress Institute seizure precautions but dont restrain the patient. To decrease the patients anxiety, speak calmly and explain every action even if hes unconscious. Do not make any sudden, unexpected moves. Touch the patient gently.

Assist with the patients activities of daily living. Alternate rest with activity.

SEIZURES I. Definition A seizure are sudden, abnormal electrical discharges from the brain that result in changes I sensation, behaviour, movements, perception, or consciousness. A seizure may occur in isolation or with low blood glucose level, drug or alcohol withdrawal, or traumatic brain injury. Epilepsy is a chronic disorder of recurrent seizures. An isolated single seizure does not constitute epilepsy. Epilepsy is a brain disorder in which a person has repeated seizures over time. It can be caused by any process that disrupts the stability of the neuronal cell membrane. A variety of conditions are associated with an extremely high likelihood of onset of a chronic seizure disorder. Generally, seizures are idiopathic, but for ages below 20 years and rarely begins after age 30, Congenital brain defects, Brain injury, High temperatures, Nuerologic problems, and Metabolic problems such as anoxia, hypoglycemia, and hypocalcemia are the common causes associated with the occurrence of seizures. And for age after 20 years of age, generalized seizures usually have an identifiable cause. Primary causes include Traumatic brain injury, Brain tumor, and Infection. There are so many kinds of seizures that neurologists who specialize in epilepsy are still updating their thinking about how to classify them. Usually, they classify seizures into two types, primary generalized seizures and partial seizures. The difference between these types is in how they begin: Partial Seizures: Partial Seizures with No Loss of Consciousness Complex partial seizures

Generalized Seizures:

Absence seizures Atypical absence seizures

Myoclonic seizures Atonic seizures Tonic seizures Clonic seizures Tonic-clonic seizures

Partial Seizures with No Loss of Consciousness Partial Seizures are the most common type of epilepsy. The first clinical and electroencephalographic changes indicate initial activation of neurons in one part of the cerebral hemisphere. There are four types pf simple partial seizures that do not impair consciousness, these include:

Motor manifestations Partial seizures with motor manifestations arise from a focus in
the motor cortex. The resulting motor activity (seizure) occurs in the part of the body innervated by motor neurons originating in the affected region of the cortex. Involuntary movements may spread centrally and involve the entire limb, including one side of the face and lower extremity. This progression or spread is known as the Jacksonian march. The client may also exhibit changes in posture or spoken utterances.

Somatosensory manifestations If the epileptogenic focus is in the parietal region,

the client experiences sensory phenomena such as numbeness and tingling in the affected area. If the focus is occipital region, the client may experience bright, flashing lights in the field of vision opposite the side of the focus.

Autonomic manifestations seizures of the autonomic system produce epigastric

sensations, pallor, sweating, flushing, piloerection, papillary dilation, tachycardia, and tachypnea.

Psych manifestations seizures arising in the anterior temporal lobe can begin with
psychic manifestations. These seizure usually begin with an aura, a subjective sensation that helps localize the focus. An aura may be a strange smell, noise, or sensation preceding a seizure. Visual distortions and feelings such as dj vu are common.

Complex Partial Seizures There are two types of complex partial seizures: complex partial seizure with automatisms and partial seizures evolving into generalized seizures.

Complex partial seizures with Automatisms These automatisms are automatic

behaviours include purposeless repetitive activities such as lip-smacking, chewing, patting a part of the body, or picking at clothes while in a dreamy state. Complex partial seizures with automatisms usually last 2 to 3 minutes butcan last up to 15 minutes. The client is usually unaware of any activity during the seizure and may be confused or drowsy postictally.

Partial seizures evolving to secondary generalized seizures These seizures start

from a particular focus, and then the electrical discharges spread throughout the brain. Clinically, the client first shows focal manifestations, for example, one side of the face moves, and then the whole body discharges spread throughout the brain.

Generalized Seizures Leads to a loss of consciousness, that can be convulsive or nonconvulsive. It can involve both hemispheres. About one third of seizure are generalized. Types of generalized seizures are absence, myoclonic, clonic, tonic, tonic-clonic, and atonic.

Absence seizures are brief episodes of staring. (Although the name looks like a regular English word, your neurologist may pronounce it ab-SAWNTZ.) Another name for them is petit mal (PET-ee mahl). During the seizure, awareness and responsiveness are impaired.

People who have them usually don't realize when they've had one. There is no warning before a seizure, and the person is completely alert immediately afterward. Simple absence seizures are just stares. Many absence seizures are

considered complex absence seizures, which means that they include a change in muscle activity. The most common movements are eye blinks. Other movements include slight tasting movements of the mouth, hand movements such as rubbing the fingers together, and contraction or relaxation of the muscles. Complex absence seizures are often more than 10 seconds long.

Atypical (a-TIP-i-kul) means unusual or not typical. The person will stare (as they would in any absence seizure) but often is somewhat responsive. Eye blinking or slight jerking movements of the lips may occur. This behavior can be hard to distinguish from the person's usual behavior, especially in those with cognitive impairment. Unlike other absence seizures, these seizures usually cannot be produced by rapid breathing. Usually 5 to 30 seconds (commonly more than 10), with a gradual beginning and ending. Atypical absence seizures usually continue into adulthood.

Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles. "Myo" means muscle and "clonus" (KLOH-nus) means rapidly alternating contraction and relaxationjerking or twitchingof a muscle. They're very brief jerks. Usually they don't last more than a second or two. There can be just one, but sometimes many will occur within a short time. Even people without epilepsy can experience myoclonus in hiccups or in a sudden jerk that may wake you up as you're just falling asleep. These things are normal. In epilepsy, myoclonic seizures usually cause abnormal movements on both sides of the body at the same time. They occur in a variety of epilepsy syndromes that have different characteristics:

Juvenile myoclonic epilepsy: The seizures usually involve the neck, shoulders, and upper

arms. In many patients the seizures most often occur soon after waking up. They usually begin around puberty or sometimes in early adulthood in people with a normal range of intelligence. In most cases, these seizures can be well controlled with medication but it must be continued throughout life.

Lennox-Gastaut syndrome: This is an uncommon syndrome that usually includes other

types of seizures as well. It begins in early childhood. The myoclonic seizures usually involve the neck, shoulders, upper arms, and often the face. They may be quite strong and are difficult to control.

Progressive myoclonic epilepsy: The rare syndromes in this category feature a

combination of myoclonic seizures and tonic-clonic seizures. Treatment is usually not successful for very long, as the patient deteriorates over time.

Muscle "tone" is the muscle's normal tension. "Atonic" (a-TON-ik) means "without tone," so in an atonic seizure, muscles suddenly lose strength. Last less than 15 seconds. The eyelids may droop, the head may nod, and the person may drop things and often falls to the ground. These seizures are also called "drop attacks" or "drop seizures." The person usually remains conscious. Another name for this type of seizure is "akinetic" (a-kin-ET-ik), which means "without movement." Atonic seizures often begin in childhood.

Muscle "tone" is the muscle's normal tension at rest. In a "tonic" seizure, the tone is greatly increased and the body, arms, or legs make sudden stiffening movements. Usually last less than 20 seconds. Consciousness is usually preserved. Tonic seizures most often occur during sleep and usually involve all or most of the brain, affecting both sides of the body. If the person is standing when the seizure starts, he or she often will fall. They are particularly common in people who have the epilepsy syndrome called Lennox-Gastaut syndrome, but they can occur in anyone.

"Clonus" (KLOH-nus) means rapidly alternating contraction and relaxation of a muscle -- in other words, repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs. Clonic (KLON-ik) seizures are rare, however. Much more common are tonic-clonic seizures, in which the jerking is preceded by stiffening (the "tonic" part). Sometimes tonic-clonic seizures start with jerking alone. These are called clonic-tonicclonic seizures. The length of this seizure varies. Clonic seizures are not seen very often. They can occur at various ages, including in newborns.

Tonic-Clonic, this type is what most people think of when they hear the word "seizure." An older term for them is "grand mal." As implied by the name, they combine the characteristics of tonic seizures and clonic seizures. The tonic phase comes first: All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. The tongue or cheek may be bitten, so bloody saliva may come from the mouth. The person may turn a bit blue in the face. After the tonic phase comes the clonic phase: The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. After a few minutes, the jerking slows and stops. Bladder or bowel control sometimes is lost as the body relaxes. Consciousness returns slowly, and the person may be drowsy, confused, agitated, or depressed. Generally, 1 to 3 minutes. A tonic-clonic seizure that lasts longer than 5 minutes probably calls for medical help. A seizure that lasts more than 30 minutes, or three seizures without a normal period in between, indicates a dangerous condition called convulsive status epilepticus. This requires emergency treatment. They affect both children and adults.

II. Risk Factors of Seizures With a seizure, it is important to distinguish whether the episode was an epileptic or nonepileptic seizure. Some seizures may result from an acute medical or neurological illness and cease once the illness is treated, e.g. febrile convulsions; electrolyte imbalances such as hypocalcaemia, hypernatremia; hypoglycemia -typically seen in neonates; infections and drugs (Armon 2003) Where as the childs seizures may already have been diagnosed as epilepsy. There can be any number of reasons for a seizure to occur, some examples are: Seizure disorders- epilepsy Family history of epilepsy or seizures that occur with high fevers

Infections: systemic (sepsis), CNS, encephalitis, meningitis, febrile convulsion (Intracranial infections can lead to cerebral edema which can be the focus for seizures.)

Focal infection- abscess Head injury (Especially depressed fractures of the skull and when anoxia has occurred.) Structural lesions- space occupying lesion- tumor (Tumors, for example, can act as a focus for seizures.)

Cerebral infarction, hematoma, intra-ventricular hemorrhage (IVH) (Any incident that interferes with normal blood flow can be a focus for seizures.) Hypoxia Acidosis Metabolic disorders Electrolyte imbalances: hypocalcaemia, hypoglycemia, hyponatremia,

hypernatremia, dehydration (Depolarization is associated with ionic imbalances that alter the chemical environment of the neurons with an intracellular accumulation of sodium, as well as a depletion of intracellular potassium. Depolarization is followed by hyperpolarization; the cell begins to fire repeatedly producing sustained membrane depolarization and seizure activity.) Toxic ingestion

III. Signs & Symptoms A seizure is usually defined as a sudden alteration of behavior due to a temporary change in the electrical functioning of the brain, in particular the outside rim of the brain called the cortex. Below you will find some of the symptoms people with epilepsy may experience before, during and after a seizure. Seizures can take on many different forms and seizures affect different people in different ways. It is not implied that every person with seizures will experience every symptom described below.

Seizures have a beginning, middle, and end When an individual is aware of the beginning, it may be thought of as a warning or aura. On the other hand, an individual may not be aware of the beginning and therefore have no warning.

Sometimes, the warning or aura is not followed by any other symptoms. It may be considered a simple partial seizure by the doctor. The middle of the seizure may take several different forms. For people who have warnings, the aura may simply continue or it may turn into a complex partial seizure or a convulsion. For those who do not have a warning, the seizure may continue as a complex partial seizure or it may evolve into a convulsion. The end to a seizure represents a transition from the seizure back to the individuals normal state. This period is referred to as the post-ictal period (an ictus is a seizure) and signifies the recovery period for the brain. It may last from seconds to minutes to hours, depending on several factors including which part(s) of the brain were affected by the seizure and whether the individual was on anti-seizure medication. If a person has a complex partial seizure or a convulsion, their level of awareness gradually improves during the post-ictal period, much like a person waking up from anesthesia after an operation. There are other symptoms that occur during the post-ictal period and are detailed below. Please note: Below is only a partial list, some people may experience other symptoms not listed below. These lists are meant to help patients communicate with their physicians.

Early seizure symptoms (warnings) Sensory/Thought:

Deja vu Smell Sound Taste Visual loss or blurring Racing thoughts Stomach feelings Strange feelings Tingling feeling

Emotional: Fear/Panic

Pleasant feeling

Physical: Dizziness Headache Lightheadedness Nausea Numbness

No warning: Sometimes seizures come with no warning

Seizure symptoms Sensory/Thought: Black out Confusion Deafness/Sounds Electric Shock Feeling Loss of consciousness Smell Spacing out Out of body experience Visual loss or blurring

Emotional: Fear/Panic

Physical: Chewing movements Convulsion Difficulty talking Drooling Eyelid fluttering Eyes rolling up

Falling down Foot stomping Hand waving Inability to move Incontinence Lip smacking Making sounds Shaking Staring Stiffening Swallowing Sweating Teeth clenching/grinding Tongue biting Tremors Twitching movements Breathing difficulty Heart racing

After-seizure symptoms (post-ictal) Thought: Memory loss Writing difficulty

Emotional: Confusion Depression and sadness Fear Frustration Shame/Embarrassment

Physical: Bruising Difficulty talking

Injuries Sleeping Exhaustion Headache Nausea Pain Thirst Weakness Urge to urinate/defecate

IV. Complications Cognitive and Behavioral Complications Complications affecting your cognitive and behavioral functioning generally stem from complex partial seizures. According to the Neurology Channel, these seizures affect the limbic structure in your brain. This structure is responsible for emotions and motivation. When areas of the brain, such as the hippocampus and hypothalamus, become damaged over time due to seizure activity, cognitive and behavioral complications result. You or others around you may notice a change in your personality. You may lose your sense of humor, be quick to anger or become extremely emotional. You may even experience an increase or decrease in your sex drive. If someone attempts to restrain you during a seizure to prevent you from harming yourself, you may become hostile or violent. Memory loss may also occur. This is typically short term and affects your ability to remember words or names as you are speaking.

Injuries Injuries are common complications of tonic-clonic seizures, also known as grand mal seizures. During these episodes, epileptics lose consciousness and may fall to the floor if not in a safe position when the seizure begins. Their entire body stiffens and shakes uncontrollably until the seizure ends. Because of what occurs during this type of seizure, aspiration is a possible complication. This may occur if you vomit during your episode and the secretions enter your lungs.

You may also bite your tongue, lips or the inside of your cheeks when your jaw clamps together. In addition, you could suffer from a multitude of broken bones, the most severe being a fractured skull from falling during the seizure's onset.

Accidents Epileptics are at an increased risk for accidents versus those who are not diagnosed with this condition. Perhaps the most dangerous are car accidents. If you lose consciousness while driving, the results could be fatal for both you and other drivers on the road. Drowning is another accident, or complication, of seizures. The Mayo Clinic states that epileptics are more than 15 times more likely to drown than those without epilepsy. Again, it all comes down to losing consciousness while in the water, especially if swimming by yourself.

Status Epilepticus Status epilepticus is a condition that describes an epileptic who has a seizure continuously for a period of five minutes or more. It also pertains to those who have recurring seizures without regaining consciousness in between. When either of these situations occurs, the epileptic is at greater risk for brain damage or even death.

Sudden Unexplained Death in Epilepsy Sudden unexplained death in epilepsy (SUDEP) is a complication for which there is no concrete cause. According to the Mayo Clinic in 2009, this complication occurs in less than one out of every 1,000 people with epilepsy and is more prevalent among those whose seizures are not controlled with medication.

The Neurology Channel adds that fluid buildup in the lungs, irregular heartbeats and suffocation may be to blame for the sudden death that occurs among otherwise healthy people with epilepsy. The site also states that patients taking two or more anticonvulsants and those who abuse street drugs appear to be at greater risk

V. Diagnosis The doctor usually orders a variety of tests to help make the diagnosis. These include: A brain wave test, also called an EEG (electroencephalogram), to look for changes in Nursing Responsibilities: Patient Preparation for Electrocardiography (ECG) Explain to the patient the need to lie still, relax, and breathe normally during Note current cardiac drug therapy on the test request form as well as any Explain that the test is painless and takes 5 to 10 minutes.

the brain's electrical patterns that are related to seizures

the procedure. other pertinent clinical information, such as chest pain or pacemaker. Implementation Place the patient in a supine or semi-Fowlers position. Expose the chest, ankles, and wrists. Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs, and on the chest. After all electrodes are in place, connect the lead wires. Press the START button and input any required information. Make sure that all leads are represented in the tracing. If not, determine which electrode has come loose, reattach it, and restart the tracing. All recording and other nearby electrical equipment should be properly grounded. Make sure that the electrodes are firmly attached. Nursing Interventions Disconnect the equipment, remove the electrodes, and remove the gel with a If the patient is having recurrent chest pain or if serial ECGs are ordered,

moist cloth towel. leave the electrode patches in place.

Blood tests, to look for certain medical disorders Nursing Responsibilities:

If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex.

Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Observe standard precautions, and follow the general guidelines. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Perform a venipuncture; collect the specimen in a 5-mL lavender-top (EDTA) tube. An EDTA Microtainer sample may be obtained from infants, children, and adults for whom venipuncture may not be feasible. The specimen should be mixed gently by inverting the tube 10 times. The specimen should be analyzed within 24 hr when stored at room temperature or within 48 hr if stored at refrigerated temperature. If it is anticipated the specimen will not be analyzed within 24 hr, two blood smears should be made immediately after the venipuncture and submitted with the blood sample. Smears made from specimens older than 24 hr may contain an unacceptable number of misleading artifactual abnormalities of the RBCs, such as echinocytes and spherocytes, as well as necrobiotic white blood cells.

Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.

Promptly transport the specimen to the laboratory for processing and analysis. Post-test:

A report of the results will be sent to the requesting HCP, who will discuss the results with the patient. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed.

Either a special x-ray of the brain, a CT scan (sometimes called a CAT scan), or an

MRI scan (magnetic resonance imaging), to look for abnormal areas such as a tumor or infection.

Depending on the urgency of the situation, other tests also might be recommended, such as a lumbar puncture (also called a spinal tap), EKG (electrocardiogram, to check the heart), or a sleep test. The results of these tests often appear completely normal in people with epilepsy. Normal test results do not mean that the seizures are not real or that epilepsy is not present. Nursing Responsibilities: Patient Preparation for Electrocardiography (ECG) Explain to the patient the need to lie still, relax, and breathe normally during Note current cardiac drug therapy on the test request form as well as any Explain that the test is painless and takes 5 to 10 minutes.

the procedure. other pertinent clinical information, such as chest pain or pacemaker. Implementation Place the patient in a supine or semi-Fowlers position. Expose the chest, ankles, and wrists. Place electrodes on the inner aspect of the wrists, on the medical aspect of After all electrodes are in place, connect the lead wires. Press the START button and input any required information. Make sure that all leads are represented in the tracing. If not, determine All recording and other nearby electrical equipment should be properly Make sure that the electrodes are firmly attached.

the lower legs, and on the chest.

which electrode has come loose, reattach it, and restart the tracing. grounded. Nursing Interventions Disconnect the equipment, remove the electrodes, and remove the gel with a If the patient is having recurrent chest pain or if serial ECGs are ordered,

moist cloth towel. leave the electrode patches in place. For CT scan Teach and make sure the patient:

Before the Test Do not eat or drink anything for 4 hours before the scan. Do not consume caffeine after midnight the night before the scan. Take your regular medicines with small sips of water the morning of your If you have diabetes, do not take your insulin or diabetes pills the morning of

scan, unless your doctor tells you otherwise. the scan.

If you have not had a creatinine blood test in the past one month, you will

need one before the scan. This is a test that measures kidney function. Have this blood test at the office of the doctor who ordered the coronary CT angiogram scan. If this has not been drawn, it will be drawn upon arrival for the scan.

If you are a woman of child-bearing age, please tell the nurse or technologist

if you may be pregnant. A nurse will take a brief medical history. For clear images, a heart rate of less than 60 beats per minute is needed. If

your heart rate is more than 60, you will need to take a beta-blocker. If you are already taking a beta-blocker, you may or may not need another dose.

An IV line will be started in your arm. You will need to wait in the CT area before the scan. The nurse or technologist will answer any questions you have.

During the Test

You will be asked to lie still on a narrow table. The table will be circled by a large doughnut-shaped machine. This opening is

much larger than an MRI (magnetic resonance imaging) machine. The technologist will tell you about the scan and answer your questions. You will be asked to hold your breath for a brief time. Lying still during the

scan is important. If your heart rate is more than 60 beats a minute, the nurse may need to give

you more beta-blocker through the IV. The doctor may ask the nurse to give you a nitroglycerin sublingual tablet The contrast dye will be injected through the IV. You may feel a warmth or

right before the images are taken. He or she will explain this to you. flushing right after the contrast is injected. After the test

You will sit in a waiting area for about 15 minutes to make sure you do not

have a reaction to the contrast dye. Your IV will be removed upon discharge. You may return to your regular activity and diet after the scan. Drink four to

six glasses of water. This will help flush the contrast dye from your system. You may drive home. If you take metformin or any medicine that contains metformin

(Glucophage, Glucovance, Metaglip or Avandamet) for diabetes, do not take it for 48 hours after the scan.

VI. TREATMENT Non-pharmacologic: Maintaining an airway Administration of oxygen Head cooling is a novel treatment that uses hypothermia to decrease seizure frequency. The procedure is based on the finding that hyperthermia will increase seizure frequency and lower seizure thresholds, and hypothermia will do the opposite. Bagic and associates from the National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, enlisted 10 normal healthy adult volunteers, each of whom underwent 2 cooling sessions (3 days apart) of 30 and 60 minutes each. The cooling was achieved with a head-neck cooling system allowing the rest of the body to remain warm. At the end of the 30-minute session, mean core temperature was reduced by 0.06C and at the end of the 60-minute session by 0.12C. This change was not significantly different from baseline. However, the reduction in scalp temperature was significant, leading the investigators to conclude that this cooling procedure is safe and feasible. Now this group plans to treat patients.

Pharmacologic: The majority of epileptic seizures are controlled through drug therapy, particularly anticonvulsant drugs. The type of treatment prescribed will depend on several factors including the frequency and severity of the seizures as well as the person's age, overall

health, and medical history. An accurate diagnosis of the type of epilepsy is also critical to choosing the best treatment. Many drugs are available to treat epilepsy, several of which have only recently been released. Older, classic medications used to treat epilepsy include:

Dilantin or Phenytek-Although it has been used in many conditions, phenytoin's only approved use is as an anti-seizure medication (anticonvulsant), especially to prevent tonic-clonic (grand mal) seizures and complex partial seizures (psychomotor seizures). It may be used alone or with phenobarbital or other anticonvulsants.

Phenobarbital- Long-term anticonvulsants for the treatment of generalized tonicclonic and cortical local seizures. And, in the emergency control of certain acute convulsive episodes, e.g., those associated with status epilepticus, cholera, eclampsia, meningitis, tetanus, and toxic reactions to strychnine or local anesthetics.

Tegretol or Carbatrol-Tegretol (carbamazepine) is indicated for use as an anticonvulsant drug. Evidence supporting efficacy of Tegretol (carbamazepine) as an anticonvulsant was derived from active drug-controlled studies that enrolled patients with the following seizure types: Partial, generalized, & mixed seizures.

Mysoline (Primidone)-This medication is used alone or with other medications to control seizures. Controlling and reducing seizures lets you do more of your normal daily activities, reduces your risk of harm when you lose consciousness, and lessens your risk for a possibly life-threatening condition of frequent, repeated seizures. Primidone belongs to a class of drugs known as barbiturate anticonvulsants. It works by controlling the abnormal electrical activity in the brain that occurs during a seizure.

Zarontin-This medication is used alone or with other medications to prevent and control a certain type of seizure (absence or petit mal seizure). It works by controlling the abnormal electrical activity in the brain that occurs during a seizure.

Depakote, Depakote ER- Divalproex sodium is indicated for use as sole and adjunctive therapy in the treatment of simple and absence seizures and adjunctively in patients with multiple seizure types that include absence seizures. It is also indicated for the treatment of manic episodes associated with bipolar disorder (manic-depression).

Valium and similar tranquilizers such as Tranxene and Klonopin- act by enhancing the effects of gamma-aminobutyric acid (GABA) in the brain. GABA is a

neurotransmitter (a chemical that nerve cells use to communicate with each other) that inhibits activity in the brain. Newer drugs to treat epilepsy include:

Felbatol Gabitril Keppra Lamictal Lyrica Neurontin Topamax Trileptal Zonegran

Carbamazepine (CAR-buh-MAZ-uh-peen) is the generic name (non-brand name) of a widely used type of seizure medicine. Common brand names for carbamazepine include Tegretol and Carbatro It is generally available in three forms: Tablets: 200 milligrams (mg). These should be swallowed whole, not chewed. Chewable tablets: 100 milligrams (mg). These can be either swallowed whole Suspension (liquid): 100 milligrams (mg) per 5 milliliters (mL or ml)

or chewed. In general, for a given type of epilepsy there are only minor differences among appropriate drugs. The choice is most often based on other factors specific to each patient, such as which side effects can be tolerated by the patient, other illnesses they may have, and which delivery method is acceptable. Although the different types of epilepsy vary greatly, in general, medications can control seizures in about 70% of patients.

VII. NURSING RESPONSIBILITIES: Administer anticonvulsant therapy as prescribed. Protect the patient from injury during seizures.

Monitor the patient continuously during seizures. If the patient is taking antiseizure medications, constantly monitor for toxic signs and symptoms such as slurred speech, ataxia, lethary, and dizziness. Monitor the patients compliance with anticonvulsant drug therapy. Teach the patient to take exact dose of medication at the times prescribed. Encourage the patient to eat balanced, regular meals. Advise the patient to be alert for odors that may trigger an attack. Limit or avoid alcohol intake. Encourage to have enough sleep to prevent attacks Avoid restraining the patient during a seizure. Loosen any tight clothing, and place something flat and soft, such as pillow, jacket, or hand, under his head. Avoid any forcing anything into the patients mouth if his teeth is clenched. Avoid using tongue blade or spoon during attacks which could lacerate the mouth and lips of displace teeth, precipitating respiratory distress. Protect the patients tongue, if his mouth is open, by placing a soft object between his teeth. Turn the patients head to the side to provide an open airway. Reassure patient after the seizure subsides by telling him that hes all right, orienting him to time and place, and informing that hes had a seizure.

VII. NURSING CARE Before a seizure occurs: 1. Safety measures should be taken if there is an indication that the person is experiencing an aura before the onset of a seizure, (e.g., have the individual lie down). 2. Determine if changes can be made in activities or situations that may trigger seizures. 3. Keep the bed in a low position with siderails up, and use padded siderails as needed. (These precautions help prevent injury from fall or trauma.) 4. Individuals with mental retardation or other developmental disabilities may have altered bowel habits, slowed activity, and /or decreased motor skills before a seizure.

During a seizure: (Ictal stage) 1. When a seizure occurs, observe and document the following: a. Date, time of onset, duration b. Activity at time of onset c. Level of consciousness (confused, dazed, excited, unconscious) d. Presence of aura (if known) e. Movements 1. Body part involved - progression and sequencing of activity (site of onset of first movement is very important as well as pattern, order of progression, or spreading involvement) - symmetry of activity - unilateral or bilateral 2. Type of motor activity - clonic (jerking) - myoclonic (single jerk of muscle or limb) - tonic (stiffening) - abnormal posturing movements, - dystonia, - eyes: eye deviation, open, rolling or closed, eyelids flickering - head turning, - twitching f. Respirations (impaired/absent; rhythm and rate) g. Heart (rate and rhythm)

h. Skin changes - color/temperature; - pale/cyanotic, (also check lips, earlobes, nailbeds) - cool/warm; - perspiration/clammy) i. Gastrointestinal - belching - flatulence - vomiting j. Pupillary size, symmetry, and reaction to light k. Changes in sensory awareness (auditory, gustatory, olfactory, vertiginous, visual) l. Presence of other unusual and/or inappropriate behaviors

2. Ensure adequate ventilation. a. Loosen clothing, postural support devices and/or restraints. b. DO NOT try to force an airway or tongue blade through clenched teeth. (Forced airway insertion can cause injury.) c. Turn the person into a side-lying position as soon as convulsing has stopped. (This will help the tongue return to its normal front-forward position and will also allow accumulated saliva to drain from the mouth.) 3. Protect the person from injury (e.g., help break fall, clear the area of furniture). 4. DO NOT restrain movement. (Trying to hold down the person's arms or legs will not stop the seizure. Restraining movement may result in musculoskeletal injury.)

5. Remain with the person and give verbal reassurance. (The person may not be able to hear you during unconsciousness but verbal assurances help as a person is regaining consciousness.) 6. Provide as much privacy as possible for the individual during and after seizure activity. 7. Provide other supportive therapy as ordered by primary care prescriber or according to facility protocol.

After the Seizure: (Postictal Stage) 1. After the seizure activity has ceased, record the presence of the following conditions and their duration in the individuals record. Continue to assess until person returns to baseline.1 a. gag reflex, decreased b. headache (character, duration, location, severity) c. incontinence (bladder and bowel) d. injury (bruises, burns, fractures, lacerations, mouth trauma) e. residual deficit - behavior change - confusion - language disturbance - poor coordination - weakness/paralysis of body part(s) - sleep pattern disturbance 2. Allow the individual to sleep; reorient upon awakening. (The individual may experience

amnesia; reorientation can help regain a sense of control and help reduce anxiety.) 3. Conduct a post seizure evaluation a. What was the person doing prior to the seizure? b. Was this the first seizure? c. Review current medications including recent changes in medicine and/or dose. d. Other illnesses? e. Possible precipitating factors

BIBLIOGRAPHY Books: Adapated from: Schachter SC, editor. Brainstorms: epilepsy in our words. New York: Raven Press; 1993; and Schachter SC, editor.The brainstorms companion: epilepsy in our view. New York: Raven Press; 1995. Nursing Diagnosis: Application To Clinical Practice" Lynda Juall Carpenito-Moyet; 2007 Appleton R, Chadwick D, Baker G (2001) Epilepsy (4th edition). London, Martin Dunitz Ltd Black, J. M., & Hawks, J. H. (2009). Medical-Surgical Nursing. Singapore: Elsevier.

Internet: http://www.epilepsy.com/101/101_EPILEPSY (Topic Editor: Steven C. Schachter, M.D. Last Reviewed:11/20/06) http://www.livestrong.com/article/74926-complications-seizures/#ixzz1VnaCmpGw http://www.medicinenet.com/epilepsy_treatment/page2.htm