NURSING EPILEPSY

A. DEFINITIONS
Epilepsy is a symptom or manifestation of excessive loss of electrical charge on the central nervous system neuronal cells that can lead to loss of awareness, involuntary movements, abnormal sensory phenomena, increased autonomic activity and other physical disorders.

B. ETIOLOGY 

1. Idiopathic.

2. Acquerit: brain damage, drug toxicity, metabolic bacteria.

- Birth trauma

- Trauma to the head

- A brain tumor

- stroke

- cerebral edema

- hypoxia

- poisoning

- metabolic disorders

- infections.

C. PATHOPHYSIOLOGY

According to the investigators that most of the rise of epilepsy comes from a collection of abnormal neuronal cells in the brain, which releases excessive charge and hypersinkron. Groups of abnormal neuronal cells, which is also known as epileptic focus underpins all types of epilepsy, both the public and the focal (partial). Remove the electrical charge can then be spread through physiological pathways involving anatomical and surrounding suburbs or more distant regions of the brain. Not all neurons in the central nervous system arousal can trigger epilepsy clinic, although he pulled off excess electric charge. Diserebellum neurons in the lower brain stem and spinal cord, although they can release excess electrical charge, but their positions are not able to trigger arousal causes epilepsy. It is not yet revealed exactly what triggers the mechanisms of neuronal cells to release both sync and charge excessive (mechanism of epilepsy).

Generally Pathology:

nerve cell biochemical phenomenon that marks epilepsy:

1. The instability of the nerve cell membrane.

2. Neurons hypersensitif the threshold decreases.

3.Polarization abnormal.

4. Ion imbalance.

D. CLASSIFICATION AND CLINICAL

1. Common epilepsy.

    - Grand mal.

    - Petit mal.

    - Infantile spasm.

2. Epilepsy Type Focal / Partial.

    - Focal motor.

    - Focal sensory.

    - Psychomotor.

Symptoms:

1. General resurrection:

    - Tonic: 20-60 sec. à muscle contractions, leg and elbow flexion, neck and back arched,  

       screaming epilepsy (aura).

    - clonic: spasmus 40 sec. à flexi alternate relaxation, hypertension, midriasis, tachycardia,  

        hyperhidrosis , hypersalivasi.

     - Post-Attack: muscle activity stalled client senses weakness, muscle pain and

        headache clients sleep 1-2 hours.

2. Partial Type:

     - Simple: there is no disturbance of consciousness.

     - Komplex: impaired consciousness.

Ad:

1. Grand mal (tonic clonic):

     - Characterized by aura: the sensation of hearing or sight.

     - Lost consciousness.

     - epileptic cry.

     - increased muscle tone stance flexion / extension. À

     - Jolt, clonic seizures.

     - The tongue may bite, hypertension, tachicardi, sweating, dilated pupils and hypersalivasi.

     - After the attack patient to sleep 1-2 hours.

     - Patient forgotten, sleepy and confused.

2. Petit mal:

     - Missing consciousness briefly.

     - Clients look bemused.

     - What he did stop.

     - Client staggered but did not fall.

3. Infantile spasm:

     - There was aged 3 months - 2 years.

     - Seizures flexor on ektremitas and head.

     - just a few fetik recurrent seizures.

     - Most of the clients are mentally retarded.

4. Focal motor:

     Lesions in the frontal lobe.

5. Focal Sensory:

     lesion in the parietal lobe.

6. Focal Psychomotor:

     temporal lobe dysfunction 

E. DIAGNOSTIC EXAMINATION

Laboratory tests: § routine blood examination, blood banks and other appropriate indications such as blood sugar, electrolytes. Examination of cerebrospinal fluid (if necessary) to determine the pressure, color, clarity, bleeding, number of cells, cell counts, protein content, sugar and other tests NaCl on the indication.

EEG:

An EEG is useful for the diagnosis of epilepsy. There are abnormalities in the form epilepsiform epileptiform discharges or activity), such as spike sharp wave, spike and wave, and so on. EEG recordings can determine the focus and the type of epilepsy is focal, multifocal, cortical or subcortical, and so on. Should be performed at regular intervals (approximately 8-12% of patients with epilepsy have a normal EEG recordings).

Radiological Examination:

Photos skull to skull abnormalities, bone destruction, abnormal calcification intrakranium, exaltation sign of ICTs such as widening sutures, erosion sidelines tursika and so on. Pneumoensefalografi and ventrikulografi to see a picture of the ventricles, sisterna, sub arachnoid cavity and brain imaging. Arteriography to see the blood vessels in the brain: cerebral vascular anomalies, obstruction, neoplasm / hematome / abscess.

F.COMPLICATIONS

Brain damage and mental retardation due hypoksia may arise from recurrent seizures. May present state of depression and anxiety. 

G. MANAGEMENT:

a. Causal Treatment:

It was investigated whether the patient is still suffering from the active disease, such as cerebral tumor, chronic dural sub hematome. If yes, need to be treated first.

b. Rumat Treatment:

Patients epilepsy are given anticonvulsant drugs rumat. In clinical child neurologist Faculty of medicine-RSCM Jakarta, treatment is usually continued until 3 years free of attack, then the medicine is gradually reduced and terminated within 6 months. In general, duration of treatment ranged from 2-4 years free of attacks. During the treatment of the symptoms of intoxication should be checked periodically and laboratory examinations. drugs used for epilepsy that can be applied to all forms of seizures:

- Phenobarbital, the dose of 3-8 mg / kg bw / day.

- Diazepam, dose 0.2 -0.5 mg / kg bw / day.

- Diamox (asetazolamid), 10-90 mg / kg bw / day.

- Dilantin (Difenilhidantoin), the dose of 5-10 mg / kg bw / day.

- Mysolin (Primidion), doses of 12-25 mg / kg bw / day.

When suffering from infantile spasms are given:

- Prednisone dose is 2-3 mg / kg bw / day.

- Dexametasone, doses of 0.2 to 0.3 mg / kg bw / day.

- Adrenokortikotropin, a dose of 2 - 4 mg / kg bw / day

 Nursing:

The problem of patients who need to be aware of is the risk of danger due to rise of epilepsy, impaired sense of security and comfort, the risk of psychosocial disorders, lack of parental knowledge about the disease.

H. NURSING CARE CONCEPTS 

1. PATIENT ASSESSMENT DATA BASE.

ACTIVITY / REST 

Symptoms: Fatigue, general weakness. limitations in activities / work caused by self / significant other.

Alerts: Changes in muscle tone / muscle strength. involuntary movement / contraction of muscle or group of muscles.

CIRCULATION

Symptoms : ictal: hypertension, increased pulse, cyanosis.

Postiktal: normal vital signs or depression with decreased pulse and respiration.

EGO INTEGRITY

Symptoms: Stressor external / internal related to the condition and / or treatment. sensitive excitatory; feeling hopeless / no helpless. Change in touch.

Alerts: Widening the range of emotional responses.

ELIMINATION

Symptoms: episodic incontinence.

Alerts: ictal: increased pressure bladder and sphincter tone.

Postiktal: muscle relaxation resulting in incontinence (both urinary / fecal).

FOOD / FLUID

Symptoms: Sensitivity to food, nausea / vomiting associated with seizure activity.

Alerts: soft tissue damage / gear (injury during a seizure). gingival hyperplasia (Dilantin side effects long term use).

NEUROSENSORI

Symptoms: headache history, activity of repeated seizures, fainting , dizziness. History of head trauma, cerebral anoxia and infection. presence of an aura (visual stimulation, auditory, area hallucinogenic).

Postiktal: weakness, muscle pain, area parestese / paralysis.

Alerts: Characteristics of seizures: Generalized seizures. partial seizures (complex). partial seizures ( simple).

PAIN / CONVENIENCE

Symptoms: Headache, muscle aches / back postiktal period. abnormal paroxysmal pain during the ictal phase.

Alerts: attitude / behavior cautious. Changes in muscle tone. restless behavior / distraction.

BREATH

Symptoms: ictal phase: teeth shut, cyanosis, decreased breathing / fast; increased mucous secretion.

Postiktal Phase: apnea.

SECURITY

Symptoms: History of falls / trauma, fractures. presence of allergies.

Alerts: Trauma to the soft tissue / ecchymosis. decrease in strength / overall muscle tone.

SOCIAL INTERACTION

Symptom: Problems in interpersonal relationships within the family or social environment. Restrictions / avoidance of social contact.

AWARENESS / EDUCATION

Symptoms: A history of epilepsy in the family. Usage / drug dependence (including alcohol).

PRIORITY NURSING

1. Prevent / control seizure activity. 

2. Protect the patient from injury. 

3. Maintain airway. 

4. Increasing positive self esteem. 

5. Provide information about disease process, prognosis, and treatment needs.

PURPOSE REPATRIATION

1. Controlled seizures. 

2. Complications / injuries can be prevented. 

3. Able to show the image of the body. 

4. An understanding of the disease process, prognosis and treatment needs. 

2. NURSING DIAGNOSIS THAT MAY ARISE:

High risk of trauma / respiratory cessation associated with changes in consciousness; weakness; losing big or small muscle coordination.

ACTION PLAN / INTERVENTION:

- Dig with clients various stimulation can trigger seizures. 

   Rational: alcohol, various drugs and other stimulation (such as lack of sleep, the lights were too    

   bright, watching TV too long) can increase brain activity, which in turn increase the risk of  

   seizures.
- Maintain soft pads on the bed barrier attached to low bed position. 

  Rational: reducing trauma during seizures (often / common) occurs during the patient is in bed.
- Stay with the patient in a long long time / after a seizure. 

   Rational: improving patient safety. 

- Record the type of seizure activity (such as the location / length of motor activity, loss of  

   consciousness, incontinence, etc.) and how many times occurs (frequency / recurrence).
   Rational: help to localize the brain areas affected.

High risk of airway clearance / ineffective breathing pattern related to neuromuscular damage; obstruction trakeobronkial.

PLAN ACTION / INTERVENTION:

- Encourage clients to clear the mouth of objects / substances specified / dentures or other device  

  if the aura phase occurs and to avoid jaw shut if seizures occur without marked  

  symptoms.

Rational: reducing the risk of aspiration or the entry of foreign objects into the

  pharynx.

- Place the patient on his side, flat surface, tilt the head during a seizure.

Rational: increasing flow (drainage) secretions , to prevent the tongue falling and block the

   airway. 

-  Take your clothes on the neck / chest and abdomen.

Rational: to facilitate efforts to breathe / chest expansion.

- Enter spatel tongue / artificial airway or the rolls soft materials according to  

  indications.

Rational: if put in early to open the jaw, the tool to prevent biting tongue during

  inhalation and facilitate mucus or ante up the breathing if necessary.

- Do exploitation as indicated.

Rational: reducing the risk of aspiration or asphyxia.

- Collaboration in the provision of supplemental oxygen.

Rational: can lower cerebral hypoxia as a result of decreased circulation or oxygen secondary to  

   vascular spasm during a seizure.

Disorders esteem / self-identity related § uncontrolled perceptions; stigma-related condition; characterized by: fear of rejection, changes in perception of self, less follow / did not participate in the therapy.

PLAN ACTION / INTERVENTION:

- Discuss feelings about the patient diagnostics, self-perception of the treatment does. Advise to

  express his feelings.

Rational: reactions have varied between individuals and the knowledge / experience with state of

  the disease early will affect the acceptance of the rules of treatment.

- Identify / anticipate possible reactions on the state of the disease.

Rational: provides an opportunity to respond to the problem-solving process and provide control measures to the situation at hand. 

- Dig with patients about the success that has been obtained or will be achieved next and  

  Strength

Rational: focus on the positive asfek can help to eliminate the feelings of failure or self-

  awareness and establish patient began receiving handling of the disease.

- Discuss referral to psychotherapy with patients or people nearby.

Rational: seizures have a huge effect on self esteem and patient / significant other may feel guilty

  over the acceptance of her limitations and stigma society. Counseling can help overcome the feeling of self-consciousness.

Lack of knowledge (learning needs), on the conditions and rules of treatment is associated with less exposure, incorrect interpretation of the information, less menginat, characterized by: lack of following the rules of medicine, questions, less control seizure activity.

ACTION PLAN / INTERVENTION:

- Explain again about the pathophysiology / prognosis of the disease and the need for treatment /

  handling within a period of time in accordance with procedures.

Rational: provides an opportunity to clarify misperceptions and circumstances existing disease as

  something that can be handled in the normal way of life.

- Review the drugs are obtained, it is important take medication as directed, and do not stop the

  medication without medical supervision. Includes instructions for dose reduction.

Rational: lack of understanding of the drugs obtained is the cause of the seizures were

  continuously without stopping.

- Instruct patient to wear a bracelet / some kind of clue that tells you is that people with epilepsy.

Rational: speed handling and determine diagnosis in an emergency.

- Discuss the benefits of good general health, such as adequate diet, adequate rest, adequate

  exercise and avoid the dangers of alcohol, caffeine and drugs that can stimulate seizures.

Rational: moderate and regular activity can help menuurnkan / controlling the predisposing factors that increase the feeling healthy and good coping skills and self-esteem.

Risk of impaired growth and development related to brain cell damage and secondary to epileptic seizure activity.

PLAN ACTION / INTERVENTION:

- Teach parents about the developmental tasks according to age group.

Rational: provides an overview of patterns of child development according to the development in

  his age group.

- Observation and give children the opportunity to meet age-appropriate developmental tasks.

Rational: determine the extent of the child's development can be achieved and compared with patterns development of appropriate developmental age group.

REFERENCES

Doengoes, Marylin, 1999. Nursing care plan, EGC, Jakarta.

Elizabeth, J.Corwin. , 2001. Pathophysiology Handbook. Matter I. Publisher: EGC, Jakarta.

Mansjoer, Arif. et al, 2000.Capita Selekta Medicine. Media Auskulapius, Jakarta

Ngastiyah, 1997. Child Care Hospital. EGC, Jakarta