5.23 – Seizure Care/Reporting

Definitions

Seizure

A discrete event characterized by a sudden, excessive, and disorderly (abnormal) discharge of electrons in the brain that may be accompanied by an abrupt alteration in motor and sensory function and level of consciousness.

Rationale

• Seizure disorders are chronic health conditions experienced by many people with
  developmental disabilities.
• The primary goal of care is to minimize the impact of seizure disorders on the lives of
  individuals with developmental disabilities.
• The cooperation of all team members, including the individual, is required to establish
  optimal levels of seizure control.
• The primary care prescriber or medical consultant is the only team member who can
  medically diagnose a seizure, classify the seizure type, and order treatment.
• Seizures are classified according to the International Classification System of Epileptic
  Seizures, permitting selection of an appropriate anticonvulsant and optimal seizure
  management by the primary care prescriber.
• The proper diagnosis and classification of seizure disorders may be difficult to determine
  because of communication deficits, confusing clinical presentation, and absent or
  insufficient history.
• The primary care prescriber must rely on the description of seizures by observers to make
  a reliable diagnosis.
• Accurate descriptions of seizure activity and a system for recording and reporting the
  activity is essential to seizure management.
• Because seizures frequently occur during the absence of professional staff, all staff
  involved with individuals who may have seizures must be trained in observing and
  recording seizure activity, and managing and protecting the individual during and after a
  seizure.

Management of Seizures

Proper interventions should take place at the time of seizure activity.

1. Staff observing the seizure activity should notify the nurse and provide an accurate
   description of the clinical presentation. The nurse should document the reported
   observations in the nursing notes.
2. Staff should notify the nurse immediately.
   a. The nurse should assess the condition of the individual immediately after receiving
   the call for assistance. The assessment should include the individual’s level of
   cardio-pulmonary risk, by a physician if warranted. Any action taken, including a request for medical
   consultation, should be documented in the nursing notes.
   b. The nurse should continue to follow the procedures outlined in the guideline for
   Prolonged Seizure Activity, documenting reported observations, personal
   observations, actions taken, and the individual’s response to treatment in the
   nursing notes.

Nursing assessment of seizure activity should occur and be documented in the nursing notes.

1. Appropriate information about what occurred during the ictal (active seizure) phase
   should be documented.
2. If the nurse does not actually witness the seizure, persons present should be consulted to obtain the information.
3. The individual should be monitored during the postictal phase of the seizure. The
   individual’s postictal condition and activity should be documented.
4. Any action taken, including a request for medical consultation, should be documented in
   the nursing notes.
5. Any observer must document and call Incident Hotline.

Diagnostic Reasoning

Significant or unusual findings should be reported immediately to the primary care
prescriber. The decision of what to report is based on review of the seizure characteristics as well
as the seizure history which includes:

1. current seizure medications and past history,
2. current frequency of seizures, date of last seizure, and type and characteristics of
   seizures,
3. any complications or injuries related to the seizures,
4. neurological consultation reports including results of specified follow-up,
5. EEG reports and results, and
6. recent serum anticonvulsant levels.

Planning strategies related to seizure management should occur and be documented.

1. The individual’s risk factors and actual or potential health problems should be included
   in the health assessment report and in individual’s plan.
2. If the individual receives psychotropic medication, information about the individual’s
   seizure status and anticonvulsant medications should be discussed and documented as part
   of the individual’s Psychotropic Drug Review Plan.
3. Information regarding the type, frequency, and pattern of seizure activity; precipitating
   and associated factors; and trends in seizure activity should be included in the health
   plan.
4. Information about the potential and actual side effects of the prescribed anticonvulsant
   medications should be included in the health plan.
5. Training sessions for direct care staff as well as other team members should occur. These
   sessions should include specific issues related to the individual’s seizures as well as
   overall observation, management, documentation, and safety issues related to seizure
   activity.

Plans should be implemented and nursing interventions documented.

1. All orders for medication, treatment, and diagnostic procedures should be carried out as
   prescribed by the primary care prescriber.
2. The nursing notes should reflect that diagnostic procedures were completed as ordered.
3. Appropriate injury protective practices should be initiated as prescribed by the primary
   care prescriber or recommended by the Interdisciplinary Team. Team recommendations
   should be included in the Plan.
4. The individual’s seizure activity should be accurately documented in the individual’s
   record. Periodic review to identify trends and changes should be documented in the
   UI Review.

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 developmental disabilities may have altered
   bowel habits, slowed activity, and /or decreased motor skills before a seizure

During a seizure: (Ictal stage)

• When a seizure occurs, observe and document the following:
• Date, time of onset, duration
• Activity at time of onset
• Level of consciousness (confused, dazed, excited, unconscious)
• Presence of aura (if known)
• Movements
• 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
• 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
• Respirations (impaired/absent; rhythm and rate)
• Heart (rate and rhythm)
• Skin changes
  • color/temperature;
  • pale/cyanotic, (also check lips, earlobes, nailbeds)
  • cool/warm;
  • perspiration/clammy)
• Gastrointestinal
  • belching
  • flatulence
  • vomiting
• Pupillary size, symmetry, and reaction to light
• Changes in sensory awareness (auditory, gustatory, olfactory, vertiginous, visual)
• Presence of other unusual and/or inappropriate behaviors
• Ensure adequate ventilation.
  • Loosen clothing, postural support devices and/or restraints.
  • DO NOT try to force an airway or tongue blade through clenched teeth. (Forced
    airway insertion can cause injury.)
  • 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.)
• Protect the person from injury (e.g., help break fall, clear the area of furniture).
• 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.)
• 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.)
• Provide as much privacy as possible for the individual during and after seizure activity.

After the Seizure: (Postictal Stage)

After the seizure activity has ceased, record the presence of the following conditions and their duration in the individual’s record. Continue to assess until the person returns to baseline.

• gag reflex, decreased
• headache (character, duration, location, severity)
• incontinence (bladder and bowel)
• injury (bruises, burns, fractures, lacerations, mouth trauma)
• residual deficit
  • behavior change
  • confusion
  • language disturbance
  • poor coordination
  • weakness/paralysis of body part(s)
• 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.)
• Complete seizure report and notify nurse and incident hotline.

Possible Precipitating Factors for Seizures:

• Physical Overexertion
  • Sleep deprivation
  • Alteration in bowel elimination
  • Fever
  • Recent head trauma
  • Concurrent illness/infections
  • Over-hydration
  • Excesses in caffeine, sugar, and other foods
• Psychosocial/emotional Stress
  • Depression
  • Anxiety
  • Psychosis
  • Anger
• Metabolic and Electrolyte Imbalance
  • Low blood glucose
  • Low sodium
  • Low calcium
  • Low magnesium
  • Dehydration
  • Hyperventilation
• Medication or chemical
  • Reduction or inadequate treatment of AEDs
  • Withdrawal of alcohol or other sedative
  • agents
  • Administration of drugs with pro-convulsant
  • properties (e.g., central nervous system
  • stimulants and anticholinergics including
  • over the counter antihistamines)
  • Most dopamine blocking agents
  • Newer antipsychotics, particularly clozapine
  • Antidepressants, especially buproprion
  • Immune suppressants such as cyclosporine
  • Antibiotics such as quinolones or imipenem/cilastatin
  • Toxins
  • Hormonal Variations
  • Menstruation
  • Ovulation
  • Pregnancy
  • Environmental • Particular odors
  • Flashing lights
  • Certain types of music

Individual Plan Considerations for Seizures:

General Health

• Avoid constipation, excessive fatigue, hyperventilation and stress because they may trigger seizures.
• Seizures may increase around the time of menses.
• Fever may trigger seizures, therefore, the fever and underlying cause must be treated. If
  antibiotics are ordered, interactions with AEDs should be evaluated.
• Environmental and recreational risk factors that should be avoided or minimized:
  • Electric shocks
  • Noisy environments
  • Bright, flashing lights
  • Poorly adjusted televisions or computer screens
• Showers, rather than tubs baths, should be taken, when possible.
• Good oral hygiene and regular visits to the dentist are important to minimize effects of
  gingival hyperplasia that can occur from some AEDs.

Diet

• A well balanced diet should be eaten at regular times.
• Coffee and other caffeinated beverages should be limited to a moderate amount.
• Fluid intake should be between 1,000 to 1,500 ml per day (depending on the weather).
• Alcoholic beverages should be avoided

Physical Activity

• Regular activity and exercise should be encouraged. Activity tends to inhibit rather than increase seizures. However, over-fatigue and hyperventilation should be avoided. When possible, exercise should take place in climate-controlled settings.
• Activities that could harm the patient should be avoided. The person may swim if
  accompanied by someone who knows what to do if a seizure occurs. The person
  should wear a life jacket and stay in relatively shallow water to facilitate seizure
  management should a seizure occur.
• Regular sleep patterns are important.

Last Revised: 6/6/22