MARKING KEY

EPILEPSY

A. State four (4) stages of an epileptic attack (20%)

In grand mal, fits usually occur in well -defined stages:-

1. The warning -this takes different forms in different patients e.g. a

peculiar sensation, an odd taste or smell, a sense of nausea etc.

2. Tonic stage-the patient falls often with an epileptic cry.

- Characteristically, the arms flex and the legs extend.

- There is loss of consciousness, muscles become rigid and
breathing ceases for a time.
- The tongue is frequently bitten

3. Clonic stage-spasms of the muscles occur followed by sudden repeated

jerking movements of one or more limbs.

- Fits can occur repeatedly over a number of hours (status epilepticus) and
most frequently seen within 1 hour of waking up from sleep.
4. Coma stage-after clonic spasms,the patient remains in a coma which quickly
passes into a deep ordinary sleep if not awakened.

- The fit, may last up to two minutes or less.

(5 marks each)

B. EXPLAIN FIVE (5) TYPES OF EPILEPTIC SEIZURES 20%

1. Simple partial seizures.

i. A focus within a particular part of the brain, usually the motor strip
is irritated resulting in a disturbance in function of the affected area.
Typically, a focal seizure comprises of a twitching of the thumbs or
side of the face.
ii. The patient does not lose consciousness.
iii. The twitching may start in the thumb and then spread to affect the
hand and arm and possibly include the affected side of the body.
(Jacksonian seizure)

2. COMPLEX PARTIAL SEIZURES.

i. Normally originate in the temporal lobe usually preceded by an aura

or warning.
ii. Followed by an episode of altered behaviour in which the patient
Performs a series of repeated movements a patient may
continually rub his or her hands or pluck at the clothes.(automatism)
iii. Patient may describe a sensory experience e.g. a particular smell.

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3. MYOCLONIC SEIZURES

i. Sudden repeated jerking movements of one or more limbs.

ii. There is a momentary loss of consciousness
iii. Can occur repeatedly over a number of hours and most frequently
seen within 1 hour of waking from sleep.
iv. If standing the person would fall to the ground.

4. TONIC SEIZURES

I Starts with a sudden loss of body posture

ii. Characteristically the arms flex and the legs extend.
iii. Loss of consciousness usually occurs and respiration may cease for
a time.
iv. May be seen as part of a (Tonic clonic) seizure.

5. TONIC ATONIC SEIZER

I. The patient experiences a tonic phase as outlined in ( 4 above).

II. Then experiences atony (Loss of tone)
III. It can be repeated several times during which there is loss of
consciousness.

6. TONIC CLONIC SEIZURES

i. Occurs in several distinct stages

-First the patient may experience a warning sign (aura).eg strange
taste in the mouth or a feeling (does not occur in every one).
-Can occur as warning sign once recognised by the patient-can allow
them to move to a safe place.
ii. Loss of consciousness -if a patient is standing will fall to the ground
iii. The tonic stage is signalled by the stiffening of the body-jaw closes
tight shut and patient may utter a cry as the thoracic muscles
contract and air is forcefully ejected via the vocal cords.
iv. As apnea occurs the patient becomes cyanosed and is often
incontinent of urine and faeces
v. After a period of time the patient will start to breathe stertorously
accompanied by rhythemic jerking of the limbs.
vi. Frothing of the mouth occurs as a result of excessive production of
saliva.
vii. Patient has tachycardia and sweating.
- Once the jecking movements begin to subside coma supervenes
viii. Most patients will fall into a deep sleep for a number of hours and
usually amnesic once they awaken and display episodes of
drowsiness and confusion.

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7. STATUS EPILEPTICUS

I. A serious form of epilepsy. Seizures occur in such rapid succession that

recovery of consciousness between the episodes does not occur.
II. Hyperpyrexia develops, coma deepens and permanent brain damage occurs
due to anoxia. Complete exhaustion and death occur if the patient is not
treated.
III. May be due to abrupt discontinuation of an anticonvulsant drug. Untreated
or inadequately treated seizure may also lead to this emergency.
IV. Seizures must be controlled first with use of IV diazepam. If drug fails the
patient is given muscle Relaxants, intubated and ventilated.

ABSENCE SEIZURE

I. A brief alteration of consciousness which on lookers often do not

notice.
II. Typically occurs in Childhood and is often only noticed as the child
falls further behind with school work.
III. In complex absences, automatism as previously described
accompanies the brief alteration in consciousness.
(4% each for 5 seizures)

C. Describe management during epileptic attack and subsequent care. 35%

MANAGEMENT DURING EPILEPTIC ATTACK

OBJECTIVES.

1. To prevent the patient from suffering harm as a result of the seizure

2. To maintain airway
3. To control fits.

PREVENTION OF INJURY

A seizure cannot be stopped once it has started. It is self-limiting and no immediate

treatment will shorten it.

- The patient is protected as much as possible from exposure to others.

To avoid Fanny from injuring himself, the following are done:-

- Nurse him in a low bed with rails

- Pad sides of the bed
- Insert Padded spatula between teeth before teeth are clenched.
- Not to restrain the jerking limbs forcefully to avoid fractures or dislocations
- Not placing a heater near his bed to avoid burns or electric fan or lamp.
- The nurse stays with the patient for safety, makes observations and records
the events.
- If the patient is up and has not already fallen, he is eased to semiprone
position and a folded blanket or towel placed under the head to prevent
injury during clonic phase.
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MAINTAINING THE AIRWAY

- No attempt is made to insert anything between clenched teeth for fear of

risk of pushing tongue unto the oropharynx obstructing the airway and
injury to the teeth
and soft tissue may occur. In such an injury a broken tooth or aspiration of
blood may occur.
- Restrictive clothing at the neck is loosened
- Any froth at the mouth is wiped out, suction if necessary.
- Mr ngoma is turned on the side to promote drainage of secretions and
prevent aspiration as soon as the clonic stage begins to subside.

OBSERVATIONS

-
If Fanny is in bed, the pillow is removed and the top bedding turned down so
that the patient's responses can be observed.
THE FOLLOWING OBSERVATIONS ARE MADE:-
 The mode of onset-did the patient indicate an aura? Was there a cry? In what
part of the body did the initial phase start? Did the head and eyes deviate to one
side?
 Are the seizure movements localised or generalized? If generalized are they
symmetrical or asymmetrical?
 Is the patient cyanosed?
 Are the teeth clenched and is there frothing at the mouth
 Is there incontinence of urine and faeces.
 How long did the seizure last?

SUBSEQUENT CARE
OBJECTIVES

1.To prevent further fits

2.To give adequate information about long term self care in avoiding further fits
- Following the seizure, the patient will be drowsy and disoriented for sometime.
PREVENTION OF FURTHER FITS
- Administer prescribed medication and ensure compliance to medication.
- Maintain a quiet environment and carry out similar Nursing procedures at same
time to allow for rest.

MAINTENANCE OF SELF ESTEEM

- Any soiled clothing is removed
- Any stool or urine should be cleaned
- Any soiled linen should be changed and Mr Ngoma left comfortable.
- Involve the caretaker so that the same care is continued at home.

OBSERVATIONS

- Temperature, Pulse, respirations and Blood pressure should be checked frequently

according to the patient's condition.
- Observe the level of drowsiness and disorientation and allow the caretaker at bedside.

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 MEDICATION

- Administer prescribed drugs and observe for effects and side effects.e.g phenytoin
300mg B.D. Orally, Side effects depression, drowsiness, headache, hypoglycaemia,
Phenobarbitone 120mg B.D Orally, Side effects depression, insomnia, tiredness,
Hypoglycaemia.
PSYCHOLOGICAL CARE:

- An explanation of the event is given.

- Fears and anxieties which are unexpressed and unrelieved may result in
ineffective copying. Occupational therapist should be involved to allay any
anxieties about loss of the job.
- The patient may express anxiety and embarrassment and see themselves as
being different and inferior, having to adjust to potentially disruptive seizures
and dependency on medication. Necessary information is given and issues that
cannot be handled are referred to appropriate people. Important to avoid
alteration in the self image of Mr Ngoma so that he is encouraged to live a
normal life as much as possible.
D. State five (5) IEC points (25%)

- Information about prescribed anticonvulsant drugs is provided.

- The client and family should be alerted to the potential side-effects and are
advised to get in touch with the doctor if they occur.
- They should know that if a drug is not tolerated that there are others that will be
prescribed until optimal control of fits with minimal side effects is achieved.
- The drug must be taken at the prescribed frequency even though there are no
seizures:- effective blood levels of the drug must be maintained by compliance
with the prescribed dosage and frequency.
- Mr Ngoma will be advised not to consume alcohol
- Drug doses must not be altered except with the doctor's approval: the drug is
prescribed on individual basis according to the type, severity and frequency of
the seizure's and the individual's response.
- The patient is cautioned against the taking of any non- prescription drugs.
- The patient should visit the doctor regularly:- Blood serum levels of the
anticonvulsant drug are determined and dosage adjusted if indicated.
- Since a blood dyscrasia is a potential side effect of many of the drugs used
blood cell counts, haematocrit and bleeding time are evaluated regularly and
patient and family informed.
- The patient and family are requested to keep a record of seizures which
includes antecedent events or any known or suspected precipitating factors (S).
- Information about the Epilepsy Association may be very useful. The mutual
support offered to the patient and family by such groups such as this can be
invaluable.
- A medic a lert identification bracelet or pendant should be worn so that
appropriate care can be given during a fit or an emergency.
- The patient should always carry the names, addresses and telephone numbers of
persons' to be contacted.
- To ensure safety to self and others, Mr ngoma should be advised against
driving, cycling or operating at heights or where there is loud noise or flashing
lights.
- Any Sport engaged in should not stimulate seizures or dangerous. He should be
advised against swimming.
(2% each point, 1% for good outlay)

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6
C. THE NURSING INTERVENTIONS
The goal
To prevent the patient from suffering harm as a result of the seizure to be aware of the
needs for long term self care in avoiding further fits.
I POTENTIAL FOR INJURY
When the patient has a seizure, the most important function is to protect the patient from
injury

- The patient is nursed near the nursing statian where he can be readily observed.
- The bed is keep low
- Taking temperature by axilla.
- Having padded sides in place on the bed-or bed rails.
- Staying with the patient during a bath or a shower.
- No heater near by
- In the interest of safety and prevention of injury for self and others the person
With.
- epilepsy may not be allowed to drive a motor vehicle, operate certain machines or
work at.
- heights or where there is loud noise or flashing lights.
- The patient may be advices against swimming, claim being, riding or cycling and
- participating in contact sports.

NEED FOR SPECIAL CARE DURING AND AFTER A SEIZURE

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 - During a seizure the nurse stays with the patient for safety and observations and
recording of events are done.
- A seizers cannot be stopped once it has started it is self-limiting and no immediate
treatment will shorten it.
- If the patient is in bed, the pillow is removed and the top bedding turned down so that
the patient's responses can be observed.
- If the patient is up, and has not already fallen, he is eased to a semiprone position and a
folded blanked or towel placed under the head to prevent injury during the clonic
phase.
- Restrictive clothing at the neck is loosened and the immediate area cleared of anything
that
mighty contribute to injury (eg) furniture, electric fan, lamp).
- No attempt is made to insert anything between the teeth as the teeth are clenched and
there would be a risk of pushing the tongue into the oropharynx obstructing the airway
and injury to the teeth and soft tissue may occur.
- Aspiration of blood or a broken tooth may become a possibility.
- As soon as the clonic stage begins to subside, the patient is turned on the side to
promote drainage of secretions and prevent aspiration.
- A suction may be necessary
- The patient is protected as much as possible from exposure to others.
- During the seizure the following observations are made
- The mode of onset: did the patient indicate an aura? Was there a cry. Is there deviation
of the head and eyes if so to what side. In what part of the body did the initial phase
start.
- Are the seizure movements localized or generalized? If generalized are they
synimetrical or asymmetrical?
- Is the patient cyanosed?
- Are the teeth clenched and is there frothing at the mouth?
- Is there incontinence of urine and faeces
How long did the seizure last.
- Following the seizure, the patient will be drowsy and disoriented for sometime:- close
- observation may be necessary as well as an explanation of the event.

iii. ALTERATION IN SELF IMAGE

- Patients express anxiety and embarrassment and see themselves as being different and
inferior, having to adjust to potentially disruptive seizures and dependency on
medication.
- Acceptance of the diagnosis is difficult for the patient who may respond with denial,
anger,
resentment and despair before acceptance and adaptation.
- Fears and anxieties which are unexpressed and unrelieved may result in ineffective
copying.
- A thorough evaluation of the patient's attitude towards epilepsy and expectations
concerning
Health maintenance is essential.
- The attitudes and expectations of family members should also be evaluated since their
understanding and support is crucial to the patients ability to adjust to his condition.

IEC TO PATIENT AND RELATIVES ABOUT THE DRUGS AND

CONDITION IN GENERAL

- Information about prescribed anticonvert sant drug is provided.

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- The client and family should be alerted to the potential side-effects and are advised to
get in touch with the doctor if they occur.
- They should know that if a drug is not tolerated that there are others that will be
prescribed until optinal control of fits with minimal side effects is achieved.
- The drug must be taken at the prescribed frequency even though there are no seizures:-
effective blood levels of the drug must be maintained by compliance with the
prescribed dosage and frequency and alcohol should not be consumed.
- Drug doses must not be altered except with the doctor's approval: the drug is prescribed
on individual basis according to the type, severity and frequency of the seizure's and
the individual's response.
- The patient is cautioned against the taking of any non- prescription drugs.
- The patient should visit the doctor regularly:- Blood serum levels of the anticonvulsant
drug are determined and dosage adjusted if indicated.
- Since a blood dyscrasia is a potential side effect of many of the drugs used blood cell
counts, haematocrit and bleeding time are evaluated regularly
- The patient and family are requested to keep a record of seizures which includes
antecedent events or any known or suspected precipitating factors (S).
- Information about the Epilepsy Association may be very useful. The mutual support
offered
- To the patient and family by such groups such as this can be invaluable.
- A medic a lert identification bracelet or pendant should be worn so that appropriate
care can be given during a fit or an emergency.
- The patient should always carry the names, addresses and telephone numbers of
persons' to be contacted.