Nursing Process: The Patient With Epilepsy

NURSING PROCESS: THE PATIENT WITH EPILEPSY

Assessment

The nurse elicits information about the seizure history. The pa-tient is asked about the factors or events that may precipitate the seizures. Alcohol intake is documented. The nurse determines if the patient has an aura (a premonitory or warning sensation) be-fore an epileptic seizure, which may indicate the origin of the seizure (eg, seeing a flashing light may indicate the seizure origi-nated in the occipital lobe). Observation and assessment during and after a seizure assist in identifying the type of seizure and its management.

The effects of epilepsy on the patient’s lifestyle are assessed (Buelow, 2001). What limitations are imposed by the seizure dis-order? Does the patient have a recreational program? Social con-tacts? Is the patient working, and is it a positive or stressful experience? What coping mechanisms are used?

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, the patient’s major nursing diag-noses may include the following:

·      Risk for injury related to seizure activity

·       Fear related to the possibility of seizures

·      Ineffective individual coping related to stresses imposed by epilepsy

·      Deficient knowledge related to epilepsy and its control

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS

The major potential complication of patients with epilepsy is as follows:

Status epilepticus

Planning and Goals

The major goals for the patient may include prevention of injury, control of seizures, achievement of a satisfactory psychosocial ad-justment, acquisition of knowledge and understanding about the condition, and absence of complications.

Nursing Interventions

PREVENTING INJURY

Injury prevention for the patient with seizures is a priority. If at risk for injury (depending on the seizure type), the patient should be placed on the floor and any obstructive items should be re-moved. The patient should never be forced into a position, nor should anyone attempt to insert anything into the patient’s mouth once a seizure has begun. Patients on seizure precautions should have pads applied to side rails while in bed.

REDUCING FEAR OF SEIZURES

Fear that a seizure may occur unexpectedly can be reduced by the patient’s adherence to the prescribed treatment regimen. Coop-eration of the patient and family and their trust in the prescribed regimen are essential for control of seizures (Schachter, 2001). It should be emphasized that the prescribed antiseizure medication must be taken on a continuing basis without fear of drug depen-dence or addiction. Periodic monitoring is necessary to ensure the adequacy of the treatment regimen and to prevent side effects.

In an effort to control seizures, factors that may precipitate them are identified: emotional disturbances, new environmen-tal stressors, onset of menstruation in female patients, or fever (Greenberg, 2001). The patient is encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimu-lants), exercise, and rest (sleep deprivation may lower the seizure threshold). Moderate activity is therapeutic, but excessive exer-cise should be avoided.

Photic stimulation (bright flickering lights, television viewing) may precipitate seizures; wearing dark glasses or covering one eye may be preventive. Tension states (anxiety, frustration) induce seizures in some patients. Classes in stress management may be of value. Because seizures are known to occur with alcohol intake, alcoholic beverages should be avoided.

IMPROVING COPING MECHANISMS

It has been noted that the social, psychological, and behavioral problems frequently accompanying epilepsy can be more of a handicap than the actual seizures. Epilepsy may be accompanied by feelings of stigmatization, alienation, depression, and uncertainty. The patient must cope with the constant fear of a seizure and its consequences (Buelow, 2001). Children with epilepsy may be ostracized and excluded from school and peer activities. These problems are compounded during adolescence and add to the challenges of dating, not being able to drive, and feeling different. Adults face these problems in addition to the burden of finding employment, concerns about relationships and childbearing, in-surance problems, and legal barriers. Alcohol abuse may compli-cate matters. Family reactions may vary from outright rejection of the person with epilepsy to overprotection. As a result, many people with epilepsy have psychological and behavioral problems.

Counseling assists the individual and family to understand the condition and the limitations imposed by it. Social and recre-ational opportunities are necessary for good mental health. Nurses can improve the quality of life for patients with epilepsy by edu-cating them and their families about symptoms and their man-agement (Rice, 2000).

PROVIDING PATIENT AND FAMILY EDUCATION

Of all the care contributed by the nurse to the person with epilepsy, perhaps the most valuable facets are education and efforts to modify the attitudes of the patient and family toward the dis-order. The person who experiences seizures may consider every seizure a potential source of humiliation and shame. This may re-sult in anxiety, depression, hostility, and secrecy on the part of the patient and family. Ongoing education and encouragement should be given to patients to enable them to overcome these feel-ings. The patient with epilepsy should carry an emergency med-ical identification card or wear a medical information bracelet. The patient and family need to be educated about medications as well as care during a seizure.

MONITORING AND MANAGINGPOTENTIAL COMPLICATIONS

Status epilepticus, the major complication, is described below. An-other complication is the toxicity of medications. The patient and family are instructed about side effects and are given specific guide-lines to assess and report signs and symptoms indicating medication overdose. Many antiseizure medications require careful monitoring for therapeutic levels. Patients should plan to have serum drug lev-els drawn at regular intervals. There are also many known drug in-teractions with antiseizure medications. A complete pharmacologic profile should be reviewed with the patient to avoid interactions ei-ther potentiating or inhibiting the effectiveness of the medications.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

Thorough oral hygiene after each meal, gum massage, daily floss-ing, and regular dental care are essential to prevent or control gin-gival hyperplasia in patients receiving phenytoin (Dilantin). The patient is also instructed to inform all health care providers of the medication being taken because of the possibility of drug inter-actions. An individualized comprehensive teaching plan is needed to assist the patient and family to adjust to this chronic disorder (Shafer, 1999). Written patient education materials must be ap-propriate for the patient’s reading level (Murphy, Chesson, Berman et al., 2001). See Chart 61-5 for home care instruction points.

Continuing Care

Because epilepsy is a long-term disorder, the use of costly med-ications may create a significant financial burden. The Epilepsy Foundation of America offers a mail-order program to provide medications at minimal cost and access to life insurance. This or-ganization serves as a referral source for special services for people with epilepsy.

For many, overcoming employment problems is a challenge. State vocational rehabilitation agencies can provide information about job training. The Epilepsy Foundation of America has a training and placement service. If seizures are not well controlled, information about sheltered workshops or home employment programs may also be obtained. Federal and state agencies and federal legislation may be of assistance to people with epilepsy who experience job discrimination. As a result of the Americans With Disabilities Act, the number of employers who knowingly hire people with epilepsy may be increasing, but barriers to em-ployment still exist (Buelow, 2001).

People who have uncontrollable seizures accompanied by psy-chological and social difficulties can be referred to comprehensive epilepsy centers where continuous audio-video and EEG moni-toring, specialized treatment, and rehabilitation services are avail-able (Schachter, 2001). Patients and their families need to be reminded of the importance of following the prescribed treat-ment regimen and keeping follow-up appointments. In addition, they are reminded of the importance of participating in health promotion activities and recommended health screenings to pro-mote a healthy lifestyle. Genetic and preconception counseling is advised.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1.     Sustains no injury during seizure activity

a.     Complies with treatment regimen and identifies the hazards of stopping the medication

b.     Patient and family can identify appropriate care during seizure

c.      Exhibits decreased fear

d.     Displays effective individual coping

e.      Exhibits knowledge and understanding of epilepsy

a.     Identifies the side effects of medications

b.     Avoids factors or situations that may precipitate seizures (flickering lights, hyperventilation, alcohol)

c.      Follows a healthy lifestyle by getting adequate sleep and eating meals at regular times to avoid hypoglycemia

f.       Absence of complications