Convulsion Nursing Care Plan & Management

 Description

A convulsion is a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body.Because a convulsion is often a symptom of an epileptic seizure, the term convulsion is sometimes used as a synonym for seizure. However, not all epileptic seizures lead to convulsions, and not all convulsions are caused by epileptic seizures. Convulsions are also consistent with an electric shock.

Epilepsy – Symptom complex characterized by attacks of unconsciousness that may or may not be associated with convulsions, sensory phenomenon or abnormalities in behaviour.

Predisposing Factors
  1. Head injury due to birth trauma
  2. Genetics
  3. Presence of brain tumor
  4. Toxicity from
    • Lead
    • carbon monoxide
  5. Nutritional and Metabolic deficiencies
  6. Physical and emotional stress
  7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice is Diazepam, Valium)
Signs and Symptoms
I. Generalize
Primarily generalized seizures can be sub-classified into a number of categories, depending on their behavioural effects:
  • Petit mal Seizures (Absence seizures) involve an interruption to consciousness where the person experiencing the seizure seems to become vacant and unresponsive for a short period of time (usually up to 30 seconds). Slight muscle twitching may occur.
  • Myoclonic seizures involve an extremely brief (< 0.1 second) muscle contraction and can result in jerky movements of muscles or muscle groups.
  • Clonic seizures are myoclonus that are regularly repeating at a rate typically of 2-3 per second. in some cases, the length varies.
  • Tonic–clonic seizures (Grand Mal Seizures) involve an initial contraction of the muscles (tonic phase) which may involve tongue biting, urinary incontinence and the absence of breathing. This is followed by rhythmic muscle contractions (clonic phase). This type of seizure is usually what is referred to when the term ‘epileptic fit’ is used colloquially.
  • Atonic seizures involve the loss of muscle tone, causing the person to fall to the ground. These are sometimes called ‘drop attacks’ but should be distinguished from similar looking attacks that may occur in cataplexy.
II. Partial or Localized Seizures

Partial seizures (also called focal seizures and localized seizures) are seizures which affect only a part of the brain at onset.The brain is divided into two hemispheres, each consisting of four lobes – the frontal, temporal, parietal and occipital lobes. In partial seizures the seizure is generated in and affects just one part of the brain – the whole hemisphere or part of a lobe. .

Partial seizures can be further characterized as:

  • Simple — not affecting awareness or memory
  • Complex — affecting awareness or memory of events before, during, and immediately after the seizure, and affecting behavior

Jacksonian (focal Seizure)

  • Jacksonian seizure (or Jacksonian march) is a phenomenon where simple partial seizure spread from distal part of limb to face ipsilaterally (on same side of body). They involve a progression of the location of the seizure in the brain, which leads to a “march” of the motor presentation of symptoms.

Complex partial seizures (AKA Psychomotor Seizure and focal motor seizure)

  • A complex partial seizure is an epileptic seizure that is associated with bilateral cerebral hemisphere involvement and causes impairment of awareness or responsiveness, i.e. alteration of consciousness.
  • Complex partial seizures are often preceded by a seizure aura.The seizure aura is a simple partial seizure. The aura may manifest itself as a feeling of déjà vu, jamais vu, fear, euphoria or depersonalization.The seizure aura might also occur as a visual disturbance, such as tunnel vision or a change in the size of objects (macropsia or micropsia).Once consciousness is impaired, the person may display automatisms such as lip smacking, chewing or swallowing.There may also be loss of memory (amnesia) surrounding the seizure event. The person may still be able to perform routine tasks such as walking. Witnesses may not recognize that anything is wrong.
  • Complex partial seizures might arise from any lobe of the brain.Complex partial seizures most commonly arise from the mesial temporal lobe, particularly the amygdala, hippocampus, and neocortical regions. A common associated brain abnormality is mesial temporal sclerosis. Mesial temporal sclerosis is a specific pattern of hippocampal neuronal loss accompanied by hippocampal gliosis and atrophy.Complex partial seizures occur when excessive and synchronous electrical brain activity causes impaired awareness and responsiveness.The abnormal electrical activity might spread to the rest of the brain and cause a secondary generalized tonic–clonic seizure.
III. Status Epilepticus
  • A continuous uninterrupted seizure activity, if left untreated can lead to hyperpyrexia and lead to coma and eventually death.
  • Drug of choice: Diazepam, Valium and Glucose
Diagnostic Procedures
  1. CT Scan – reveals brain lesions
  2. EEG – reveals hyper activity of electrical brain waves
Nursing Management
  1. Maintain patent airway and promote safety before seizure activity
    • clear the site of blunt or sharp objects
    • oosen clothing of client
    • maintain side rails
    • avoid use of restrains
    • turn clients head to side to prevent aspiration
    • place mouth piece of tongue guard to prevent biting or tongue
  2. Avoid precipitating stimulus such as bright/glaring lights and noise
  3. Administer medications as ordered
    • Anti convulsants (Dilantin, Phenytoin)
    • Diazepam, Valium
    • Carbamazepine (Tegretol) – Trigeminal neuralgia
    • Phenobarbital, Luminal
  4. Institute seizure and safety precaution post seizure attack
    • administer O2 inhalation
    • provide suction apparatus
  5. 5. Document and monitor the following
    • onset and duration
    • types of seizures
    • duration of post ictal sleep may lead to status epilepticus
    • assist in surgical procedure cortical resection
References:
  • http://en.wikipedia.org/wiki/Status_epilepticus
  • http://en.wikipedia.org/wiki/Simple_partial_seizure
  • http://en.wikipedia.org/wiki/Complex_partial_seizure
  • http://en.wikipedia.org/wiki/Focal_seizures
  • http://www.scribd.com/doc/5074406/8/CONVULSIVE-DISORDER-CONVULSION
  • http://nursingcrib.com/nursing-notes-reviewer/convulsive-disorders/
  • http://www.nlm.nih.gov/medlineplus/ency/article/000697.htm
  • http://trialx.com/g/Convulsion-1.jpg

Exam

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Nursing Care Plan

Nursing Diagnosis
  • Risk for Trauma
  • Risk for Suffocation

Risk factors may include

  • Weakness, balancing difficulties; reduced muscle, hand or eye coordination
  • Poor vision
  • Reduced sensation
  • Cognitive limitations or altered consciousness
  • Loss of large or small muscle coordination
  • Emotional difficulties

Possibly evidenced by

  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Verbalize understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to correct the situation.
  • Identify actions or measures to take when seizure activity occurs.
  • Identify and correct potential risk factors in the environment.
  • Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
  • Modify environment as indicated to enhance safety.
  • Maintain treatment regimen to control or eliminate seizure activity.
  • Recognize the need for assistance to prevent accidents or injuries.
Nursing Interventions
  • Determine factors related to individual situation, as listed in Risk Factors, and extent of risk.
    • Rationale: Influences scope and intensity of interventions to manage threat to safety.
  • Note client’s age, gender, developmental age, decision-making ability, level of cognition or competence.
    • Rationale: Affects client’s ability to protect self and others, and influences choice of interventions and teaching.
  • Ascertain knowledge of various stimuli that may precipitate seizure activity.
    • Rationale: Alcohol, various drugs, and other stimuli (loss of sleep, flashing lights, prolonged television viewing) may increase brain activity, thereby increasing the potential for seizure activity.
  • Review diagnostic studies or laboratory tests for impairments and imbalances.
    • Rationale: Such may result in or exacerbate conditions, such as confusion, tetany, pathological fractures, etc.
  • Explore and expound seizure warning signs (if appropriate) and usual seizure pattern. Teach SO to determine and familiarize warning signs and how to care for patient during and after seizure attack.
    • Rationale: Enables patient to protect self from injury and recognize changes that require notification of physician and further intervention. Knowing what to do when seizure occurs can prevent injury or complications and decreases SO’s feelings of helplessness.
  • Use and pad side rails with bed in lowest position, or place bed up against wall and pad floor if rails not available or appropriate.
    • Rationale: Prevents or minimizes injury when seizures (frequent or generalized) occur while patient is in bed. Note: Most individuals seize in place and if in the middle of the bed, individual is unlikely to fall out of bed.
  • Educate patient not to smoke except while supervised.
    • Rationale: May cause burns if cigarette is accidentally dropped during aura or seizure activity.
  • Evaluate need for or provide protective headgear.
    • Rationale: Use of helmet may provide added protection for individuals who suffer recurrent or severe seizures.
  • Avoid using thermometers that can cause breakage. Use tympanic thermometer when necessary to take temperature.
    • Rationale: Reduces risk of patient biting and breaking glass thermometer or suffering injury if sudden seizure activity should occur.
  • Uphold strict bedrest if prodromal signs or aura experienced. Explain necessity for these actions.
    • Rationale: Patient may feel restless or need to ambulate or even defecate during aural phase, thereby inadvertently removing self from safe environment and easy observation. Understanding importance of providing for own safety needs may enhance patient cooperation.
  • Do not leave the patient during and after seizure.
    • Rationale: Promotes safety measures.
  • Turn head to side and suction airway as indicated. Insert plastic bite block only if jaw relaxed.
    • Rationale: Helps maintain airway patency and reduces risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Wooden tongue blades should not be used because they may splinter and break in patient’s mouth.
  • Support head, place on soft area, or assist to floor if out of bed. Do not attempt to restrain.
    • Rationale: Supporting the extremities lessens the risk of physical injury when patient lacks voluntary muscle control. Note: If attempt is made to restrain patient during seizure, erratic movements may increase, and patient may injure self or others.
  • Note preseizure activity, presence of aura or unusual behavior, type of seizure activity (location or duration of motor activity, loss of consciousness, incontinence, eye activity, respiratory impairment or cyanosis), and frequency or recurrence. Note whether patient fell, expressed vocalizations, drooled, or had automatisms (lip-smacking, chewing, picking at clothes).
    • Rationale: Helps localize the cerebral area of involvement.
  • Provide neurological or vital sign check after seizure (level of consciousness, orientation, ability to comply with simple commands, ability to speak; memory of incident; weakness or motor deficits; blood pressure (BP), pulse and respiratory rate).
    • Rationale: Documents postictal state and time or completeness of recovery to normal state. May identify additional safety concerns to be addressed.
  • Reorient patient following seizure activity.
    • Rationale: Patient may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety.
  • Allow postictal “automatic” behavior without interfering while providing environmental protection.
    • Rationale: May display behavior (of motor or psychic origin) that seems inappropriate or irrelevant for time and place. Attempts to control or prevent activity may result in patient becoming aggressive or combative.
  • Investigate reports of pain.
    • Rationale: May be result of repetitive muscle contractions or symptom of injury incurred, requiring further evaluation or intervention.
  • Detect status epilepticus (one tonic-clonic seizure after another in rapid succession).
    • Rationale: This is a life-threatening emergency that if left untreated could cause metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased intracranial pressure, airway obstruction, and respiratory arrest. Immediate intervention is required to control seizure activity and prevent permanent injury or death. Note: Although absence seizures may become static, they are not usually life-threatening.

Carry out medications as indicated: Specific drug therapy depends on seizure type, with some patients requiring polytherapy or frequent medication adjustments.

  • Antiepileptic drugs (AEDs): phenytoin (Dilantin), primidone (Mysoline), carbamazepine (Tegretol), clonazepam (Klonopin), valproic acid (Depakene), divalproex (Depakote), acetazolamide (Diamox), ethotoin (Peganone), methsuximide (Celotin), fosphenytoin (Cerebyx);
    • Rationale: AEDs raise the seizure threshold by stabilizing nerve cell membranes, reducing the excitability of the neurons, or through direct action on the limbic system, thalamus, and hypothalamus. Goal is optimal suppression of seizure activity with lowest possible dose of drug and with fewest side effects. Cerebyx reaches therapeutic levels within 24 hr and can be used for nonemergent loading while waiting for other agents to become effective. Note: Some patients require polytherapy or frequent medication adjustments to control seizure activity. This increases the risk of adverse reactions and problems with adherence.
  • Topiramate (Topamax), ethosuximide (Zarontin), lamotrigine (Lamictal), gabapentin (Neurontin);
    • Rationale: Adjunctive therapy for partial seizures or an alternative for patients when seizures are not adequately controlled by other drugs.
  • Phenobarbital (Luminal);
    • Rationale: Potentiates and enhances effects of AEDs and allows for lower dosage to reduce side effects.
  • Lorazepam (Ativan);
    • Rationale: Used to abort status seizure activity because it is shorter acting than Valium and less likely to prolong post seizure sedation.
  • Diazepam (Valium, Diastat rectal gel);
    • Rationale: May be used alone (or in combination with phenobarbital) to suppress status seizure activity. Diastat, a gel, may be administered rectally, even in the home setting, to reduce frequency of seizures and need for additional medical care.
  • Glucose, thiamine.
    • Rationale: May be given to restore metabolic balance if seizure is induced by hypoglycemia or alcohol.
  • Monitor and document AED drug levels, corresponding side effects, and frequency of seizure activity.
    • Rationale: Standard therapeutic level may not be optimal for individual patient if untoward side effects develop or seizures are not controlled.
  • Monitor CBC, electrolytes, glucose levels.
    • Rationale: Identifies factors that aggravate or decrease seizure threshold.
  • Prepare for surgery or electrode implantation as indicated.
    • Rationale: Vagal nerve stimulator, magnetic beam therapy, or other surgical intervention (temporal lobectomy) may be done for intractable seizures or well-localized epileptogenic lesions when patient is disabled and at high risk for serious injury. Success has been reported with gamma ray radio surgery for the treatment of multiple seizure activity that has otherwise been difficult to control.