Ch. 25 Drug Therapy for Seizures

What solution must you use when administering phenytoin Dilantin via the IV route?

0.9 normal saline

Epilepsy

A disorder of the brain that causes recurrent unprovoked seizures.

Generalized seizure

A seizure that involves most or all of the brain caused by electrical discharges originating from both sides of the brain.

Partial seizure

A seizure that starts in one part of the brain. the abnormal electrical activity may remain confined to one area or spread to the entire brain also called a focal or local seizure.

which type of seizure is common in children?

Absence

Second line drugs for seizures

Alternative drugs used for treatment of seizures

Before giving an anti seizure drug

Always get a complete list of drugs patient is taking Check baseline vitals, level of consciousness and gait. ask patient to describe nature of his or her seizures find out if aura occurs before each seizure ask patient to describe it and to notify healthcare providers if they sense one may occur.

Common seizure causing drug

Antidepressant Bupropion alcohol Cocaine and other street drugs Excessive doses of antiseizure drugs Oral contraceptives Phenothiazines Theophylline

Taking Dilantin phenytoin during pregnancy increases the risk of children born with

Cleft palate also Fetal hydantoin syndrome is a rare disorder caused by fetal exposure to phenytoin Dilantan symptoms include facial/skull abnormalties growth deficiencies underdeveloped nails and/or mild developmental delays

Only use normal saline with

Dilantin phenytoin because this drug precipitates forms solid particles due to chemical imcompatibility with dextrose solutions.

Dilantin phenytoin may cause

Diplopia double vision Nystagmus rapid involuntary eye movement Hypotention Gingival hyperplasia excessive growth of gum tissue Hypertrichosis excessive growth of hair in areas no normally hairy Rashes and can also lead to Stevens johnson syndrome a serious life threatening body wide systemic allergic reaction with a rash involving burn like sores on the skin and mucous membranes.

What are 3 common side effects of clonazepam Klonopin

Dizziness sedation, weakness

What are 3 common side effects of gabapentin Neurontin

Drowsiness, fatigue, dizziness, swelling in ankles, weight gain

The nurse is caring for a patient with a diagnosis of idiopathic (no known cause) seizures. What are some factors associated with this type of seizures?

Family history of seizures present

What are the most common causes of seizures in children?

Fever Central nervous system infections Hypoxia Electrolyte imbalances

Common causes for seizures in kids

Fever, head injury CNS infection hypoxia electrolyte imbalances

Depakote Depacon valproic acid & Dilantin phenytoin often cause

GI symptoms such as indigestion nausea and vomiting. prolonged bleeding time*

A newly admitted patient has just been diagnosed with seizures and asks the nurse what can cause them. The nurse tells the patient that during what times is a person with a seizure disorder most at risk for having a seizure?

Going through a divorce During pregnancy After pulling an "all-nighter" While having the flu When a person has a seizure disorder, seizures are more likely to occur during periods of increased emotional or physical stress. Risk factors associated with worsening of a well-controlled seizure disorder include pregnancy and lack of sleep, not sleeping soundly.

For most adults the most common causes of seizures are

Head injury Stroke Tumor

valproic acid Depakote can cause which serious adverse effect

Hepatotoxicity

Serious adverse effects of Depakote Depacon valproic acid include

Hepatotoxicity- liver damage Pancreatitis- inflammation of the pancreas

The nurse is discharging a patient who has been prescribed lamotrigine (Lamictal). What does the nurse tell the patient to do in order to minimize the risk of severe rashes?

Increasing the dose very slowly over 6 to 7 weeks

A seizure patient is being treated with phenobarbital (Luminal). What life-threatening adverse effects are associated with the use of this drug?

Laryngospasm Shock Neutropenia Serum sickness

Life threatening adverse effects of Phenobarbital

Laryngospasm- closure of the larynx which blocks the air to the lungs Shock circulatory collapse Neutropenia decreased number of WBCs additional adverse effects include respiratory depression CNS depression coma & death when high does are prescribed. swelling similar to that seen in urticaria hives can occur beneath the skin instead of on the surface. Angioedema- deep swelling around the eyes lips sometimes hands and feet hypersensitive reaction to the administration of a foreign serum serum sickness which is characterized by fever swelling skin rash and enlargement of lymph nodes.

2nd line alternative drugs for seizures increase the body's threshold against seizure activity by blocking or slowing the spread of abnormal impulses.

Luminal phenobarbital Mysoline primidone Neurontin gabapentin Lamictal lamotrigine Klonopin clonazepam Lyrica pregabalin

which adverse effects must you watch for after giving a patient phenytoin dilantin

Neutropenia Stevens-Johnson syndrome Aplastic anemia

Adverse effects of both Tegretol carbamazepine and Dilantin phenytoin include

Neutropenia a decrease in the number of white blood cells with sore throat fever and chills are at risk for life threatening infections and Aplastic anemia anemia caused by not enough RBCs to carry oxygen to the tissues and cells too few red blood cells produced by bone marrow

Adverse Effects of Zarontin ethosuximide include

Neutropenia-decrease in the number of WBCs Pancytopenia- reduction in the number of erythrocytes all types of WBCs and blood platelets in the circulating blood Aplastic anemia- anemia caused by deficient RBC production in the bone marrow

The nurse is admitting a patient who has been taking phenytoin (Dilantin). What side effects and adverse effects of phenytoin (Dilantin) could be found in a patient on the nurse's physical assessment?

Overgrowth of gum tissues Severe skin rashes Double vision

what 2 drugs may become habit forming

Phenobarbital Luminal and clonazepam Klonopin

A patient was just brought in by ambulance to the emergency department (ED) after having several seizures at home. What actions should be taken if the patient experiences status epilepticus?

Protect the airway and apply oxygen Establish an IV as ordered. Administer diazepam (Valium) as prescribed. Protect the patient from injury.

A patient with a history of seizures has just been admitted. What actions should you take if the patient experiences a tonic-clonic seizure?

Protect the airway. Document the length and time the seizure started. Protect the patient from injury.

Two major partial seizures

Simple partial seizure Complex partial seizures

Epileptic cry

Spasm of the respiratory muscles cause forced exhalation sounding like a scream

A patient has a seizure that lasts longer than 30 minutes this situation is recognized as what kind of seizure?

Status epilepicus

Adverse Effects of Lamictal lamotrigine can lead to

Stevens Johnson syndrome a life threatening body wide or systemic allergic reaction with a rash involving the skin and mucous membranes can also lead to toxic epidermal necrolysis a life threatening skin disorder characterized by blistering and peeling of the top layer of skin

Teachings about anti-seizure drugs

Suddenly stopping an anti-seizure drug may cause seizures to occur. these drugs can cause dizziness or drowsiness alcohol increases it. avoid driving or operating machinery get out of bed slowly suggest that patient wears a medical alert bracelet

A patient who is taking antiseizure medications develops GI symptoms. What would you suggest to the patient?

Take drugs with food

which drug used to treat seizures decreases impulse transmission by affecting sodium channels in neurons

Tegretol carbamazepine

The nurse is obtaining a list of home medications for a patient who will be taking phenytoin Dilantin and an anticoagulant what is the possible interaction between these 2 drugs

The patient is at a higher risk for bleeding

Tegretol Carbamax carbamzepine can cause

Thrombocytopenia- low platelet count risk for severe bleeding passes into breast milk

6 types of generalized seizures

Tonic clonic or grand mal Tonic Atonic Absence Petit mal Myoclonic Clonic

The nurse is caring for a patient admitted with a diagnosis of seizures. The nurse knows that an "epileptic cry" is common with what type of seizure?

Tonic-clonic

primidone Mysoline

Turns into phenobarbital in the body and blocks or slows the spread of abnormal electrical impulses

Seizure

Uncontrolled electrical activity in the brain that may produce a physical convulsion minor physical signs thought disturbances or a combination of symptoms

A patient with a history of seizures has just had abdominal surgery. The nurse knows that what antiseizure medication may affect wound healing?

Valproic acid (Depakote

A patient is taking carbamazepine Tegretol what must you be sure to teach the patient about the drug?

Wear protective clothing and a strong sunscreen

First line drugs for Absence seizures

Zarontin ethosuximide Depakote valproic acid

seizure disorder

a pathologic condition resulting in a sudden episode of uncontrolled electrical activity in the brain.

Status Epilepticus

a prolonged seizure usually defined as lasting longer than 30 minutes or a series of repeated seizures a continuous state of seizure activity that may occur in almost any seizure type. rapid recognition and treatment are essential to prevent brain damage

Assess older adults who have been prescribed first line drugs for partial or generalized seizures for

abnormal heart rhythms and chest pain they are more sensitive to the effects of these drugs

clonazepam klonopin

action not well understood but most likely slows or stops tranmission of abnormal electrical impulses

Postictal phase

after the seizure phase often characterized by confusion headache sore muscles and fatigue

primidone Mysoline decreases the effects of

anticoagulant drugs so higher doses of an anticoagulant may be needed to achieve therapeutic effects

Clonic seizures

are characterized by muscle contraction and relaxation patients may bite their tongue or become incontinent

Adverse Effects of Clonazepam it is a

benzodiazepine CNS drug with the life threatening adverse reaction of respiratory depression.

phenobarbital Luminal

blocks or slows the spread of abnormal electrical impulses

Drugs for partial and generalized seizures Tegretol carbamazepine Depakote Depacon valproic acid Dilantin phenytoin

can increase the effects of anticoagulant watch for abnormal bleeding. can interfere with the effects of birth control have high likelihood of birth defects

Common first line drugs for partial and generalized seizures Tegretol

carbamazepine

A patient with a new diagnosis of seizures asks the nurse what medications are considered first-line drugs for partial and generalized seizures?

carbamazepine (Tegretol) phenytoin (Dilantin) valproic acid (Depakote)

After giving drugs for partial & generalized seizures

check gait remind them about importance of frequent and careful mouth care if GI symptoms develop give these drugs with food. Remind to drink plenty of water these drugs will dry mouth and increase urine excretion watch for signs of abnormal bleeding

common second line drugs for seizures Klonopin

clonazepam

What characterizes the period following a seizure aka postictal phase of a seizure

confusion lethargy decreased responsiveness

gabapentin Neurontin is often used to

control pain from chronic neuropathy and fibromyalgia

Zarontin ethosuximide

depresses the motor cortex and increases the CNS threshold to stimuli

Depakote valproic acid during pregnancy has been associated with

developmental defects, low IQ, birth defects, congenital anomalies and damage to infants liver this drug also passes into breast milk

a health care facility should plan to have which drug immediately available in the event a patient expreiences status epilepticus?

diazepam Valium

A patient taking phenytoin should be instructed to call the prescriber immediately if they develop what condition

difficulty coordinating movements

common side effects of 1st line drugs for generalized and partial seizures

dizziness loss of coordination drowsiness/sedation nausea vomiting hypotension phenytoin also may cause double vision nystagmus rap

diplopia

double vision

First line drugs for Absence Seizures Zarontin

ethosuximide

gingival hyperplasia

excessive growth of gum tissue

A seizure results from

excessive or disordered electrical activity in the brain

Phenobarbital and clonazepam may become habit forming and should only be taken

for the period of time prescribed

common second line drugs for seizures Neurotin

gabapentin

Actions of 2nd line or alternative drugs for seizures

gabapentin Neurontin & lamotrigine Lamictal stabilize the membranes of neurons to decrease seizure activity. the action of clonazepam Klonopin is not well understood but may be related to inhibition slowing or stopping of transmission of abnormal impulses. pregabalin Lyrica is used to decrease the frequency of partial seizures

Before giving 2nd line drugs for seizures be sure to schedule at least 2 hours between

gabapentin Neurontin and antacid drugs because antacids can decrease absorption of this drug

what can the nurse do to reduce nausea and vomiting in patient who is taking carbamazepine Tegretol

give med with food

Remind patients taking ANY anti-seizure drug to avoid

grapefruit and grapefruit because they increase the action of the drug and can lead to more side effects or adverse effects.

Safe use of Zarontin ethosuximide in children under 3 years old

has not been established

What conditions can cause seizures

head injury stroke tumor

which are essential aspects of care for a patient who is experiencing a tonic clonic seizure

help person to the floor loosen clothing around the neck remove any sharp objects

Tonic Seizures

include sudden increase in muscle tone loss of consciousness and autonomic signs such as rapid heart rate sweating pupil dilation flushing and loss of bowel function and bladder control for 30 seconds to several minutes. after patients are usually lethargic for an hr or more.

Sudden withdrawl of pregabalin can

increase the frequency of seizure activity drug should be gradually withdrawn over a week.

When gabapentin Neurontin is prescribed for a patient who is taking Morphine duramorph

increased levels of gabapentin can occur possibly leading to toxicity so lower dose or gabapentin morphine or both may be required

Possible consequences of exposure to phenytoin Dilantin during pregnancy

increased risk for cleft palate growth deficiencies skull abnormalities

nystagmus

involuntary movements of the eyes

Myoclonic Seizure

involves brief jerking or stiffening of the extremities that last a few seconds may involve one or more extremities and the jerking contractions may be asymmetric stronger on one side of the body or symmetric or the same on both sides of the body typically a sudden loss of muscle tone for a few seconds followed by Postictal or after seizure confusion.

A patient tells the nurse that he/she has absence seizure. The nurse knows that what occurrence is normal with this type of seizure?

it only last a few seconds

Common second line drugs for seizures Lamictal

lamotrigine

Children have higher incidence of rashes with

lamotrigine gabapentin may cause fever hyperactivity and hostile or aggressive behavior.

Tonic clonic or grand mal seizures

last 2 to 5 minutes with stiffening or rigidity of the arm and leg muscles and immediate loss of consciousness.

The disadvantage is phenobarbital Luminalis that it can

lead to physical dependence primidone Mysoline is turned into phenobarbital Luminal by the body and acts in the same way.

Children younger than 2 years of age are at increased risk for

liver damage Hepatotoxicity that may lead to death with Depakote valproic acid

Ataxia

loss of coordination clumsiness

thrombocytopenia

low platelet count

neutropenia or leukopenia

low white blood cell count

When seizure drugs are prescribed together

lower doses may be needed

Absence or petit mal seizures

more common in children and tent to occur in families are brief a few seconds with loss of consciousness and blank staring a child may appear to be daydreaming after the child returns to normal immediately.

Complex partial seizures

patients lost consciousness for 1 to 3 minutes may have automatisms automatic unconscious actions such as lip smacking patting or picking at clothes & often experience amnesia after seizure.

Common second line drugs for seizures Luminal

phenobarbital

Common first line drugs for partial & generalized seizures Dilantin

phenytoin

common second line drugs for seizures Mysoline

primidone

Older adults may develop unusual restlessness or excitement with

primidone. lamotrigine and gabapentin are more slowly eliminated from older adults

Tell patients with diabetes that gabapentin Neurontin may affect a dipstick test for

protein in urine or Proteinuria

A patient taking valproic acid Depakote has developed a nosebleed and bruises resulting from very minor injuries this patient may be developing which adverse effect?

reduced platelet count

A person with repeated seizures has a

seizure disorder sometimes called epilepsy. about 2 million people in the U.S have this brain disorder and 10% of american s will experience a seizure sometime during their lives Most of them 60% never experience another seizure.

gabapentin Neurontin

stabilizes the membranes of neurons to decrease seizure activity

Aura

strange sensations such as tingling smell or emotional changes that occur before a seizure.

First line drugs for seizures

the exact action of first line drugs for partial or generalized seizures is not known but these drugs causes a decrease in the voltage frequency and spread of electrical impulses within the motor cortex of the brain which leads to decreased seizure activity.

Simple partial seizures

the patient remains conscious before the seizure the patient may report an aura. One sided movement of an extremity unusual sensations or autonomic changes heart rate, flushing, epigastric discomfort may occur.

If patient develops a rash hold the drug and notify the prescriber immediately

to minimize the risk of sever rashes the dose of Lamictal lamotrigine can be increased very slowly over 6 to 7 weeks. when taking this drug skin rash can be the 1st sign of Stevens Johnson syndrome or toxic epidermal necrolysis

First line drugs for absence seizure and partial & generalized seizures Depakote Depacon

valproic acid

common first line drugs for partial & generalized seizures Depakote,Depacon

valproic acid

What 1st line drug used for partial or generalized seizures increases the availability of the neurotransmitter GABA?

valproic acid Depakote

Drug actions for partial & generalized seizures drugs

valproic acid Depakote, Depacon- The action may be related to increased availability of the neurotransmitter GABA gamma aminobutyric acid. carbamazepine Tegretol- decreases impulse transmission by affecting sodium channels in neurons phenytoin Dilantin- Changes ion transport but exact action is not known

Zarontin ethosuximide can make the eyes more sensitive to light. Instruct patient to protect eyes by

wearing dark glasses in bright light