Seizure Disorders and Status Epilepticus: Nursing Review

Seizures are a high-yield neurologic topic for nursing exams because management decisions are time-sensitive and many drugs carry serious black-box warnings. This guide reviews seizure types, the phases of a generalized seizure, emergency care for status epilepticus, antiepileptic medications, and the bedside nursing actions you must know.

What Is a Seizure?

• A seizure is a sudden, uncontrolled electrical disturbance in the brain.
• It causes changes in behavior, movement, sensation, or consciousness.
• Epilepsy is diagnosed after two or more unprovoked seizures.

Types of Seizures

• Focal seizure — starts in one area of the brain; the client may remain aware or have impaired awareness.
• Generalized tonic-clonic — tonic stiffening followed by clonic jerking; loss of consciousness with postictal confusion.
• Absence seizure — brief loss of awareness with staring; common in children; no postictal confusion.
• Myoclonic seizure — sudden brief muscle jerks, usually bilateral.
• Atonic seizure — sudden loss of muscle tone causing drop attacks.

Phases of a Generalized Seizure

• Prodromal phase — hours to days before; mood changes, irritability, anxiety, poor concentration, sleep disturbance, or headache.
• Aura phase — seconds to minutes before; unusual smells or tastes, flashing lights, dizziness, numbness, déjà vu, or a rising abdominal sensation.
• Ictal phase — the active seizure: loss of consciousness, muscle stiffening, and tonic-clonic jerking.
• Postictal phase — after the seizure: confusion, fatigue, drowsiness, headache, muscle soreness, and temporary disorientation.

Status Epilepticus (Emergency)

• Status epilepticus is a continuous seizure lasting longer than 5 minutes, OR two or more seizures without full recovery between them.
• It is a life-threatening medical emergency.
• Prolonged seizures cause hypoxia, acidosis, and brain damage.

Immediate Management

1. Assess ABCs and secure the airway.
2. Give oxygen and maintain SpO₂ > 94%.
3. Establish IV access.
4. Give a benzodiazepine as first-line treatment.
   • Lorazepam 4 mg IV is preferred.
   • If no IV access: midazolam IM or diazepam rectal gel.
5. If seizures continue after 5–10 minutes, give fosphenytoin or phenytoin.
   • Fosphenytoin is preferred because it can be given IM.
   • Phenytoin requires cardiac monitoring during IV infusion.
6. If seizures persist after two medications, the patient requires intubation.
7. Propofol or midazolam infusion is used for refractory status epilepticus.

Seizure Precautions and Nursing Actions

Precautions at the Bedside

• Pad the side rails and keep the bed in the lowest position.
• Keep suction and oxygen at the bedside at all times.
• Do not place a tongue blade or any object in the patient's mouth (risk of aspiration and dental injury).
• Do not restrain the patient.

Actions During a Seizure

• Turn the patient onto their side to prevent aspiration.
• Loosen tight clothing around the neck.
• Remove eyeglasses and move nearby objects away.
• Time the seizure.

Diagnostic Tests

• EEG — primary test for diagnosing seizure disorders.
• MRI or CT — identifies structural causes such as tumors or scar tissue.
• Blood tests — rule out metabolic causes such as hypoglycemia or electrolyte imbalances.

Antiepileptic Medications

• Phenytoin (Dilantin) — tonic-clonic and focal seizures. Therapeutic level 10–20 mcg/mL; causes gingival hyperplasia. Monitor serum level, LFTs, CBC.
• Valproate (Depakote) — broad-spectrum. Black box for hepatotoxicity; teratogenic — avoid in pregnancy. Monitor LFTs, ammonia, CBC.
• Levetiracetam (Keppra) — broad-spectrum. Renal elimination; can cause behavioral and mood changes. Monitor renal function and behavior.
• Carbamazepine (Tegretol) — focal and tonic-clonic. Black box for Stevens-Johnson syndrome; can cause SIADH with hyponatremia. Monitor CBC, sodium, LFTs.
• Lamotrigine (Lamictal) — broad-spectrum. Black box for serious rashes — stop at first sign of rash. Requires slow titration.
• Ethosuximide — used only for absence seizures. Monitor CBC and LFTs.

Patient Teaching

• Take antiepileptic medications exactly as prescribed.
• Never stop medications abruptly — withdrawal can trigger seizures.
• Avoid alcohol — it lowers the seizure threshold.
• Get adequate sleep; sleep deprivation triggers seizures.
• Wear medical alert identification.
• Do not drive until cleared by a provider.
• Report rash, fever, or bruising immediately.

Common Exam Traps

• Do not put anything in the mouth during a seizure.
• Turn the patient to the side to prevent aspiration.
• Status epilepticus = seizure > 5 minutes = emergency.
• Lorazepam IV is first-line for status epilepticus.
• Phenytoin requires cardiac monitoring during IV infusion.
• Lamotrigine — any rash means stop the drug.
• Valproate is teratogenic — avoid in pregnancy.
• Carbamazepine causes SIADH with hyponatremia.
• Absence seizures are treated with ethosuximide only.

Key takeaways

• Status epilepticus = seizure lasting > 5 minutes or repeated seizures without recovery; treat as an emergency with ABCs, O₂, IV access, and IV lorazepam first-line.
• During a seizure: turn to the side, loosen clothing, time the event, and never put anything in the mouth or restrain the patient.
• Maintain seizure precautions: padded rails, low bed, suction and oxygen at bedside.
• Know the key drug warnings: phenytoin level 10–20, valproate hepatotoxicity/teratogenicity, lamotrigine rash, carbamazepine SIADH/SJS, ethosuximide for absence only.
• Teach patients to never stop antiepileptics abruptly, avoid alcohol, get adequate sleep, and wear medical alert ID.