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Anticonvulsants and Management of Seizures
Study Questions
Introduction:
A nurse is caring for a client who has a history of epilepsy and is taking phenytoin. The nurse notes that the client has swollen and bleeding gums. What is the most appropriate action for the nurse to take?
Explanation
The correct answer is choice:
B. Instruct the client to use a soft toothbrush and floss gently. This is because phenytoin can cause gingival hyperplasia, which is an enlargement of the gums due to an increase in the number of cells or the size of the gingiva³. This condition can be prevented or minimized by maintaining good oral hygiene and avoiding trauma to the gums².
Choice A is wrong because advising the client to stop taking phenytoin and report to the doctor is not appropriate. Phenytoin is an anticonvulsant medication that is used to treat epileptic seizures, and stopping it abruptly can cause withdrawal symptoms or seizure recurrence¹. The client should not stop taking phenytoin without consulting their doctor, who may adjust the dose or switch to another medication if needed.
Choice C is wrong because administering an oral antiseptic rinse to the client is not effective for treating gingival hyperplasia. Oral antiseptic rinses are used to reduce plaque and bacteria in the mouth, but they do not address the underlying cause of gingival hyperplasia, which is a defect in collagen metabolism³. Oral antiseptic rinses may also have adverse effects such as staining the teeth, altering the taste, or causing mouth irritation².
Choice D is wrong because referring the client to a dentist for evaluation and treatment is not the most appropriate action for the nurse to take. Although a dentist can help diagnose and manage gingival hyperplasia, the nurse should first educate the client about the importance of oral hygiene and instruct them on how to care for their gums. The nurse should also monitor the client's condition and report any changes or complications to the doctor. A dentist referral may be indicated if the gingival hyperplasia is severe or does not respond to oral hygiene measures².
A nurse is teaching a group of clients who have different types of seizures about the appropriate use of anticonvulsants. Which of the following statements by the clients indicate a need for further teaching? (Select all that apply)
Explanation
This statement indicates a need for further teaching because phenytoin and phenobarbital are not effective for treating absence seizures, which are a type of generalized onset seizure that cause brief lapses in awareness, such as blank staring¹. Phenytoin and phenobarbital are narrow-spectrum anticonvulsants that are mainly used for focal seizures, which begin in one area of the brain². Taking these medications for absence seizures may worsen the condition or cause adverse effects.
The other statements are correct and do not indicate a need for further teaching.
Choice A is correct because carbamazepine and valproic acid are both effective for treating partial seizures, which are a type of focal seizure that may or may not affect awareness².
Choice B is correct because phenobarbital and lamotrigine are both effective for treating generalized tonic-clonic seizures, which are a type of generalized onset seizure that cause muscle stiffness and jerking movements².
Choice D is correct because valproic acid and levetiracetam are both effective for treating myoclonic seizures, which are a type of generalized onset seizure that cause brief jerking movements². Choice E is correct because lamotrigine and topiramate are both effective for treating atonic seizures, which are a type of generalized onset seizure that cause sudden loss of muscle tone².
A nurse is administering intravenous phenytoin to a client who is experiencing status epilepticus. The nurse observes that the client's hand becomes swollen and purple after the injection. What is the most likely explanation for this finding?
Explanation
This means that the drug has leaked out of the vein and into the surrounding tissue, causing inflammation, pain, and tissue damage⁵⁶. Phenytoin is a known vesicant, which means it can cause severe skin reactions when extravasated⁵. The clinical manifestation of phenytoin extravasation is called purple glove syndrome (PGS), which is characterized by a purplish to black discoloration of the extremity followed by peripheral edema and pain distal to the site of infusion¹².
Choice A is wrong because the client is not having an allergic reaction to phenytoin. An allergic reaction would cause symptoms such as rash, itching, hives, swelling of the face or throat, difficulty breathing, or anaphylaxis⁷. The client's symptoms are localized to the hand and are consistent with extravasation, not allergy.
Choice B is wrong because the client is not developing purple glove syndrome. Purple glove syndrome is the name of the condition caused by phenytoin extravasation, not a separate entity¹². The client already has purple glove syndrome as a result of the extravasation.
Choice D is wrong because the client is not developing thrombophlebitis. Thrombophlebitis is inflammation of a vein caused by a blood clot, usually in the legs⁸⁹. Thrombophlebitis can cause symptoms such as
A nurse is reviewing the medication history of a client who has epilepsy and is taking valproic acid. The nurse notes that the client is also taking warfarin for atrial fibrillation. What is the most appropriate action for the nurse to take?
No explanation
A nurse is educating a client who has epilepsy and is planning to become pregnant about the risks of anticonvulsant therapy during pregnancy. Which of the following statements by the nurse is correct?
Explanation
This is because anticonvulsants are essential for preventing seizures, which can be harmful for both the mother and the baby¹. Stopping or changing anticonvulsants without medical supervision can increase the risk of seizure recurrence or withdrawal symptoms¹. The doctor can monitor the blood levels of anticonvulsants and adjust the dose if needed, as well as prescribe folic acid supplements to reduce the risk of neural tube defects¹².
Choice A is wrong because advising the client to stop taking their anticonvulsants as soon as they find out that they are pregnant is not appropriate. As mentioned above, stopping anticonvulsants abruptly can cause seizures or withdrawal symptoms, which can be dangerous for both the mother and the baby¹. The client should not stop taking their anticonvulsants without consulting their doctor, who can weigh the benefits and risks of continuing or discontinuing the medication¹.
Choice C is wrong because advising the client to switch to a different type of anticonvulsant that is safer for their baby is not appropriate. There is no single anticonvulsant that is safe for all types of seizures and all stages of pregnancy². Some anticonvulsants may have a lower risk of teratogenicity than others, but they may also have different efficacy and side effects². The choice of anticonvulsant depends on several factors, such as the type and frequency of seizures, the previous response to medication, the presence of comorbidities, and the potential interactions with other drugs². The client should not switch to a different anticonvulsant without consulting their doctor, who can determine the best option for their individual case².
Choice D is wrong because advising the client to reduce their dose of anticonvulsants gradually until they deliver their baby is not appropriate. Reducing the dose of anticonvulsants can increase the risk of seizure recurrence, which can be harmful for both the mother and the baby¹. The dose of anticonvulsants should be based on the blood levels and clinical response of the client, not on a fixed schedule¹. The client should not reduce their dose of anticonvulsants without consulting their doctor, who can monitor their condition and adjust the dose if needed¹.
Seizure Pathophysiology and Types of Seizures
A nurse is caring for a client who has a history of simple focal seizures. Which of the following interventions should the nurse implement during a seizure episode?
Explanation
This is because documenting the seizure activity is important for assessing the type, frequency, and severity of seizures, as well as the response to treatment¹. The nurse should note the time of onset and termination of the seizure, the body parts involved, the level of consciousness, the presence of aura or prodrome, the type and pattern of movements, the eye deviation or blinking, the vocalization or breathing changes, the incontinence or salivation, and any postictal symptoms¹².
Choice A is wrong because administering oxygen via nasal cannula is not necessary for a client who has a simple focal seizure. A simple focal seizure is a type of seizure that affects only one part of the brain and does not impair awareness or consciousness³. The client may experience sensory, motor, autonomic, or psychic symptoms, but they do not have generalized convulsions or respiratory compromise³. Oxygen therapy is indicated for clients who have generalized tonic-clonic seizures or status epilepticus, which can cause hypoxia or apnea¹².
Choice C is wrong because inserting an oral airway to prevent tongue biting is not appropriate for a client who has a simple focal seizure. An oral airway is a device that is inserted into the mouth to keep the tongue from blocking the airway and to facilitate ventilation⁴. An oral airway should not be used for clients who are conscious or have a gag reflex, as it can cause injury, vomiting, or aspiration⁴. A client who has a simple focal seizure is fully alert and conscious and does not need an oral airway³. Tongue biting is rare in simple focal seizures and more common in generalized tonic-clonic seizures.
Choice D is wrong because restraining the client's limbs to prevent injury is not appropriate for a client who has a simple focal seizure. Restraining a client during a seizure can cause more harm than good, as it can increase agitation, prolong the seizure, or cause fractures or dislocations¹². A client who has a simple focal seizure may have involuntary movements of one part of the body, such as twitching or jerking of an arm or leg³. The nurse should not restrain these movements but rather protect the client from hitting any hard or sharp objects¹².
A nurse is assessing a client who has been taking phenytoin for seizure control. The nurse suspects phenytoin toxicity based on which of the following findings?
Explanation
Nystagmus is a sign of phenytoin toxicity, which is caused by overdose, dosage changes, drug interactions, or physiological alterations. Nystagmus is a rapid, involuntary movement of the eyes, which can impair vision and balance. Nystagmus can occur at phenytoin levels above 20 mcg/mL¹².
Choice B is wrong because bradycardia, or slow heart rate, is not a common sign of phenytoin toxicity. Bradycardia can occur in rare cases of phenytoin overdose, especially if the drug is given intravenously too fast¹⁵. However, it is not a reliable indicator of phenytoin toxicity.
Choice C is wrong because hypertension, or high blood pressure, is not a sign of phenytoin toxicity. Hypertension can occur in some patients with seizures, but it is not related to phenytoin levels. Normal blood pressure ranges are less than 120/80 mm Hg for adults⁷⁹.
Choice D is wrong because hyperreflexia, or increased reflexes, is not a sign of phenytoin toxicity. Hyperreflexia can occur in some neurological disorders, such as multiple sclerosis or spinal cord injury, but it is not associated with phenytoin levels. Normal reflexes are graded from 0 to 4+, with 2+ being the average.
A nurse is planning care for a client who is scheduled to undergo a corpus callosotomy for the treatment of refractory seizures. Which of the following interventions should the nurse include in the plan?
Explanation
Corpus callosotomy is a surgical procedure that involves cutting the corpus callosum, the band of nerve fibers that connects the two hemispheres of the brain. This surgery aims to reduce the frequency and severity of generalized seizures, especially drop attacks, by preventing the spread of epileptic activity from one side of the brain to the other²³. After surgery, it is important to monitor the patient's neurologic status, including level of consciousness, pupillary response, motor function, and sensory function, to detect any complications or changes in seizure activity¹².
Choice B is wrong because prophylactic antibiotics are not routinely given before corpus callosotomy. Antibiotics may be used to treat infections that occur after surgery, such as meningitis or wound infection, but they are not indicated for prevention¹².
Choice C is wrong because instructing the patient to avoid coughing or sneezing after surgery is not a specific intervention for corpus callosotomy. Coughing or sneezing may increase intracranial pressure and cause discomfort, but they are not likely to affect the outcome of the surgery or cause complications¹².
Choice D is wrong because elevating the head of the bed to 45 degrees after surgery is not recommended for corpus callosotomy. Elevating the head of the bed may help reduce cerebral edema and improve venous drainage, but it may also increase the risk of bleeding or air embolism¹². The optimal position for the patient after corpus callosotomy is supine with the head in a neutral position¹².
Diagnostic Tests for Seizures
A nurse is caring for a patient who is scheduled for an electroencephalogram (EEG). Which of the following instructions should the nurse provide to the patient?
Explanation
An EEG is a test that records the electrical activity of your brain using electrodes attached to your scalp¹². The test is usually done while you are awake, but relaxed and still, for about 30 to 60 minutes¹. You may be asked to close your eyes, breathe deeply, or look at a flashing light during the test to see how your brain responds to different stimuli¹².
Choice A is wrong because the test will not be done while you are asleep. An EEG can be done while you are asleep in some cases, such as when you have sleep disorders or nocturnal seizures, but this is not the standard procedure¹². You may be asked to stay awake the night before the test if you need to have an EEG while you are asleep¹.
Choice C is wrong because the test will not be done while you are under general anesthesia. General anesthesia is not needed for an EEG, as it is a non-invasive and painless test¹². General anesthesia may interfere with the brain activity that the EEG is trying to measure³.
Choice D is wrong because the test will not be done while you are sedated. Sedation is not usually required for an EEG, as it is a simple and safe test¹². Sedation may also affect the brain activity that the EEG is trying to record³. Sedation may be used in some cases, such as when children are unable to stay still or cooperate during the test⁴.
A nurse is caring for a patient who is scheduled for an electroencephalogram (EEG). Which of the following statements should the nurse include in the teaching? (Select all that apply)
Explanation
Provocation refers to methods that may trigger or enhance epileptic activity in the brain, such as hyperventilation, photic stimulation, sleep deprivation, or cognitive tasks¹². Provocation can help diagnose photosensitive epilepsy, absence seizures, or other types of seizures that may not occur spontaneously during the EEG¹². However, provocation is not always necessary or feasible, depending on the patient's condition and the purpose of the EEG¹².
Video recording refers to capturing the patient's behavior and movements during the EEG, which can help correlate the clinical manifestations with the electrical activity of the brain³⁴. Video recording can help differentiate epileptic seizures from nonepileptic events, identify the type and onset of seizures, and evaluate the response to treatment³⁴. However, video recording is not always available or required, depending on the setting and the indication of the EEG³⁴.
Choice B is wrong because the EEG cannot be done with different electrode arrangements. The EEG electrode placement follows the International 10-20 system, which is a standardized method to describe and apply the location of scalp electrodes based on anatomical landmarks and proportional distances⁵⁶. The 10-20 system ensures consistency and reproducibility of EEG recordings across different centers and studies⁵⁶.
Choice C is wrong because the EEG cannot be done with contrast. Contrast is a substance that enhances the visibility of structures or fluids within the body in imaging tests, such as CT scan or MRI scan⁷⁸. Contrast is not used in EEG, as it is a non-invasive and painless test that measures electrical activity in the brain using electrodes attached to the scalp⁷⁸.
Choice D is wrong because the EEG is usually done without sedation. Sedation is not routinely required for EEG, as it is a simple and safe test that does not cause pain or discomfort⁷⁸. Sedation may also affect the electrical activity of the brain that the EEG is trying to measure⁹. Sedation may be used in some cases, such as when children are unable to stay still or cooperate during the test, or when sleep-deprived EEG is needed
A nurse is caring for a patient who is scheduled for an electroencephalogram (EEG). Which of the following statements by the patient indicates a need for further teaching?
Explanation
This statement by the patient indicates a need for further teaching, as it is incorrect and shows a misunderstanding of the EEG procedure.
An EEG is a test that records the electrical activity of your brain using electrodes attached to your scalp . The test does not involve any injection of dye or contrast, as it is not an imaging test that requires enhancing the visibility of structures or fluids within the body . The test is non-invasive and painless, and does not expose you to any radiation or harmful substances .
Choice A is wrong because "I may need to hyperventilate during the test." This statement by the patient is correct and does not indicate a need for further teaching. Hyperventilation is a method of provocation that may be used during the EEG to trigger or enhance epileptic activity in the brain . Hyperventilation involves breathing deeply and rapidly for a few minutes, which can lower the carbon dioxide level in the blood and cause changes in the brain's electrical activity .
Choice B is wrong because "I may need to have flashing lights during the test." This statement by the patient is correct and does not indicate a need for further teaching. Photic stimulation is another method of provocation that may be used during the EEG to trigger or enhance epileptic activity in the brain . Photic stimulation involves exposing the patient to a flashing light of varying frequency and intensity, which can stimulate the visual cortex and cause changes in the brain's electrical activity .
Choice D is wrong because "I may need to have sleep deprivation before the test." This statement by the patient is correct and does not indicate a need for further teaching. Sleep deprivation is a condition that may be required before the EEG to increase the likelihood of detecting abnormal brain activity or seizures . Sleep deprivation involves staying awake for most or all of the night before the test, which can alter the brain's electrical activity and make it more sensitive to provocation methods .
A nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI) scan of the brain. Which of the following statements by the patient indicates a need for further teaching?
Explanation
This statement indicates a need for further teaching because sleep deprivation is not required for an MRI scan of the brain. Sleep deprivation is sometimes used for an electroencephalogram (EEG) test, which measures the electrical activity of the brain, but not for an MRI, which uses magnetic fields and radio waves to produce images of the brain.
Choice A is wrong because the patient may need to have an injection of dye or contrast during the test. This can help enhance the visibility of certain structures or abnormalities in the brain¹².
Choice B is wrong because the patient may need to have flashing lights during the test. This is part of a functional MRI (fMRI) of the brain, which can measure the metabolic changes in the brain when the patient performs certain tasks¹.
Choice D is wrong because it is similar to choice A. Contrast and dye are different terms for the same substance that can be injected during an MRI scan².
To prepare for an MRI scan of the brain, the patient should not eat or drink anything for four hours prior to the exam, and should not wear any metal objects, such as jewelry, hairpins, or eye makeup³⁴⁵. The patient should also inform the medical staff if they have any metal implants or devices in their body, such as pacemakers, artificial joints, or aneurysm clips¹⁴.
A nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI) scan of the brain. Which of the following instructions should the nurse provide to the patient?
Explanation
This instruction is incorrect and should not be provided to the patient, because an MRI scan of the brain does not measure the electrical activity of the brain or use electrodes. This is a description of an electroencephalogram (EEG) test, which is a different procedure¹².
Choice A is wrong because it is a correct instruction that the nurse can provide to the patient. The MRI can reveal structural abnormalities or lesions that may cause seizures, such as tumors, strokes, infections, or malformations¹².
Choice B is wrong because it is also a correct instruction that the nurse can provide to the patient. The MRI can detect abnormal patterns or discharges that indicate seizure activity, especially if it is a functional MRI (fMRI) that can measure the metabolic changes in the brain when the patient performs certain tasks¹².
Choice D is wrong because it is partly correct and partly incorrect. The MRI can be done in a clinic or hospital, depending on the purpose and duration of the test, but not at home¹³. MRI machines are large and expensive devices that require special facilities and trained staff to operate them¹.
Anticonvulsant Medications
A nurse is caring for a client who has been prescribed phenytoin for seizure prevention. The nurse should monitor the client for which of the following adverse effects of phenytoin?
Explanation
The nurse should monitor the client for gingival hyperplasia, which is an overgrowth of the gums that can occur as an adverse effect of phenytoin¹². Gingival hyperplasia can cause bleeding, inflammation, and infection of the gums, and may interfere with chewing and oral hygiene¹². The nurse should advise the client to brush and floss their teeth regularly, and to see a dentist for regular check-ups and cleaning¹².
Choice B is wrong because hypertension, or high blood pressure, is not a common or serious adverse effect of phenytoin¹³. Phenytoin may actually lower blood pressure in some cases, especially when given intravenously¹⁴. The nurse should monitor the client's blood pressure before and during phenytoin therapy, and report any significant changes to the prescriber¹⁴.
Choice C is wrong because diarrhea is not a common or serious adverse effect of phenytoin¹³. Phenytoin may cause constipation in some people, which can be relieved by increasing fluid and fiber intake, and using laxatives if needed¹⁵. The nurse should ask the client about their bowel habits and provide appropriate interventions as needed¹⁵.
Choice D is wrong because tachycardia, or fast heart rate, is not a common or serious adverse effect of phenytoin¹³. Phenytoin may cause bradycardia, or slow heart rate, in some cases, especially when given intravenously or in high doses¹⁴. The nurse should monitor the client's heart rate and rhythm before and during phenytoin therapy, and report any significant changes to the prescriber¹⁴.
A nurse is teaching a client who has been newly diagnosed with epilepsy about the use of anticonvulsant medications. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)
Explanation
- **"I should stop taking these medications if I have a rash or fever."** This statement is incorrect and indicates a need for further teaching because the client should not stop taking anticonvulsant medications abruptly, as this can cause withdrawal symptoms and increase the risk of seizures¹². The client should contact their healthcare provider if they have a rash or fever, as these could be signs of an allergic reaction or infection, but they should not stop the medication without medical advice¹².
- **"I should have my blood levels checked regularly to make sure I am taking the right dose."** This statement is correct for some anticonvulsant medications, such as phenytoin, carbamazepine, and valproate, but not for others, such as levetiracetam, lamotrigine, and gabapentin¹³. The client should ask their healthcare provider which medications require blood level monitoring and how often they need to have it done¹³.
The other statements by the client are correct and do not indicate a need for further teaching:
- **"I should avoid drinking alcohol while taking these medications."** This statement is correct because alcohol can interact with anticonvulsant medications and increase their side effects, such as drowsiness, dizziness, and impaired coordination¹². Alcohol can also lower the seizure threshold and trigger seizures in some people¹².
- **"I should take these medications at the same time every day."** This statement is correct because taking anticonvulsant medications at the same time every day helps maintain a steady level of the drug in the blood and prevent seizures¹². The client should follow the prescribed schedule and dosage of their medication and not miss or skip any doses¹².
- **"I should not drive or operate heavy machinery until I know how these medications affect me."** This statement is correct because anticonvulsant medications can cause side effects that impair the client's ability to drive or operate heavy machinery, such as blurred vision, confusion, fatigue, and poor
A nurse is administering carbamazepine to a client who has partial seizures. The client asks the nurse how this medication works. What should the nurse say?
Explanation
The correct answer is choice
A. "It blocks sodium channels in your brain cells, which reduces their excitability and prevents seizures."
The nurse should say: "Carbamazepine works by blocking sodium channels in your brain cells, which reduces their excitability and prevents seizures." This is the most accurate and simple explanation of the mechanism of action of carbamazepine⁴.
The other choices are incorrect and should not be said by the nurse:
- **"It enhances the activity of GABA in your brain, which inhibits the transmission of nerve impulses and prevents seizures."** This is not how carbamazepine works. This is a description of the mechanism of action of some other anticonvulsants, such as benzodiazepines and barbiturates¹².
- **"It modulates the activity of NMDA receptors in your brain, which reduces the influx of calcium and prevents seizures."** This is not how carbamazepine works. This is a description of the mechanism of action of some other anticonvulsants, such as felbamate and topiramate¹².
- **"It facilitates the opening of potassium channels in your brain cells, which stabilizes their membrane potential and prevents seizures."** This is not how carbamazepine works. This is a description of the mechanism of action of some other anticonvulsants, such as ezogabine and retigabine¹².
A nurse is reviewing the medication history of a client who is taking valproic acid for generalized tonic-clonic seizures. The nurse should recognize that valproic acid can interact with which of the following medications?
Explanation
Valproic acid can interact with warfarin and increase the risk of bleeding by inhibiting the metabolism of warfarin and displacing it from plasma protein binding sites¹. The nurse should monitor the client's international normalized ratio (INR) and prothrombin time (PT) and adjust the warfarin dose accordingly.
Choice B. Metformin is wrong because valproic acid does not have a significant interaction with metformin. Metformin is an oral antidiabetic drug that lowers blood glucose levels by decreasing hepatic glucose production and increasing insulin sensitivity².
Choice C. Ibuprofen is wrong because valproic acid does not have a significant interaction with ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that reduces inflammation, pain, and fever by inhibiting cyclooxygenase enzymes².
Choice D. Levothyroxine is wrong because valproic acid does not have a significant interaction with levothyroxine. Levothyroxine is a synthetic thyroid hormone that replaces the deficient endogenous hormone in hypothyroidism².
A nurse is preparing to administer phenobarbital to a client who has status epilepticus. The nurse should be aware that phenobarbital has which of the following mechanisms of action?
No explanation
A nurse is administering an intravenous dose of diazepam (Valium) to a client who is having a status epilepticus episode.
What are some important nursing considerations when giving this medication? (Select all that apply.)
Explanation
Choice A is correct because diazepam is a benzodiazepine that can cause respiratory depression, especially when given intravenously. The nurse should monitor the client's respiratory rate and oxygen saturation and be prepared to provide respiratory support if needed²⁴.
- Choice B is correct because diazepam should be diluted with normal saline or dextrose 5% in water before administration to prevent venous irritation and thrombophlebitis. The concentration of diazepam should not exceed 5 mg/mL²⁴.
- Choice C is correct because diazepam should be injected slowly over at least 3 minutes to avoid adverse effects such as hypotension, bradycardia, cardiac arrest, or apnea. The maximum rate of injection is 5 mg/min²⁴.
- Choice D is correct because diazepam is incompatible with many other drugs and solutions, and can precipitate or adsorb to plastic tubing. The nurse should flush the IV line with normal saline before and after administration to prevent drug interactions and ensure complete delivery of the medication²⁴.
- Choice E is wrong because repeating the dose of diazepam every 15 minutes until seizure activity stops is not recommended. Diazepam has a short duration of action and can accumulate in the body with repeated doses, increasing the risk of toxicity and respiratory depression. If seizures persist after the initial dose of diazepam, the nurse should start emergency IV antiepileptic drug therapy with levetiracetam, sodium valproate, or phenytoin³⁶.
Advantages of different anticonvulsant medications for different types of seizures
A nurse is caring for a client who has been taking phenytoin (Dilantin) for partial seizures. The nurse notes that the client has a serum phenytoin level of 25 mcg/mL. What is the appropriate action by the nurse?
Explanation
Phenytoin is an anticonvulsant that works by stabilizing the neuronal membrane and preventing the spread of seizure activity¹. The therapeutic range of phenytoin is **10-20 mcg/mL**²³⁴⁵. A serum phenytoin level of **25 mcg/mL** is above the therapeutic range and indicates toxicity. The nurse should hold the next dose and notify the provider to prevent further adverse effects, such as nystagmus, ataxia, confusion, and coma¹.
Choice A. Administer the next dose as scheduled is wrong because it would increase the risk of phenytoin toxicity and worsen the client's condition.
Choice C. Increase the next dose by 25% is wrong because it would also increase the risk of phenytoin toxicity and worsen the client's condition.
Choice D. Decrease the next dose by 25% is wrong because it may not be enough to lower the phenytoin level to the therapeutic range. The nurse should consult with the provider before making any dose adjustments.
A nurse is teaching a client who has been prescribed carbamazepine (Tegretol) for tonic-clonic seizures. Which of the following statements should the nurse include in the teaching? (Select all that apply.)
Explanation
Carbamazepine is an anticonvulsant that works by stabilizing the neuronal membrane and preventing the spread of seizure activity¹. One of the common side effects of carbamazepine is drowsiness or dizziness, which may affect your ability to drive or operate machinery. You should avoid alcohol and other sedatives while taking this medication, and be careful when getting up from a lying or sitting position².
Choice B. You should avoid grapefruit juice while taking this medication is also correct. Grapefruit juice can interact with carbamazepine and increase its blood levels, which may increase the risk of toxicity and adverse effects. You should avoid drinking grapefruit juice or eating grapefruit while taking this medication, unless your doctor tells you otherwise³⁴.
Choice C. You should have your blood pressure checked regularly while taking this medication is wrong because carbamazepine does not affect blood pressure significantly. However, you should have your blood counts checked regularly while taking this medication, as carbamazepine can cause serious blood disorders such as aplastic anemia and agranulocytosis. You should also have your liver function tests and thyroid function tests monitored periodically, as carbamazepine can cause liver damage and thyroid abnormalities².
Choice D. You should report any signs of bleeding or bruising to your provider is also correct. Carbamazepine can interact with warfarin and other anticoagulants and increase the risk of bleeding by inhibiting the metabolism of warfarin and displacing it from plasma protein binding sites⁵. You should report any signs of bleeding or bruising to your provider, and have your INR and PT checked regularly if you are taking warfarin or other anticoagulants with carbamazepine.
Choice E. You should use a reliable form of contraception while taking this medication is also correct. Carbamazepine can reduce the effectiveness of hormonal contraceptives such as the pill, the implant, the patch, the vaginal ring, and the emergency contraceptive pill by inducing the liver enzyme CYP450, which breaks down estrogen and progesterone faster. This could put you at risk of an unplanned pregnancy. You should use a reliable form of non-hormonal contraception such as condoms or an intrauterine device (IUD) while taking this medication, unless your doctor advises you otherwise²⁶.
A nurse is preparing to administer valproic acid (Depakote) to a client who has absence seizures. The client asks the nurse why this medication is prescribed. What is an appropriate response by the nurse?
Explanation
Valproic acid is an anticonvulsant that is used to treat absence seizures, which are brief episodes of staring or blanking out. Valproic acid is believed to increase the concentration of gamma-aminobutyric acid (GABA) in the brain, which is a neurotransmitter that reduces the excitability of neurons and prevents seizures¹².
Choice A is wrong because valproic acid does not inhibit the breakdown of a neurotransmitter, but rather increases its availability. The neurotransmitter that is inhibited by valproic acid is not known to prevent seizures, but rather to cause them. This neurotransmitter is glutamate, which is the main excitatory neurotransmitter in the brain³.
Choice C is wrong because valproic acid does not block sodium channels that trigger seizures, but rather calcium channels that are involved in neuronal signaling. Blocking sodium channels is the mechanism of action of another class of anticonvulsants, such as phenytoin and carbamazepine⁴.
Choice D is wrong because valproic acid does not suppress calcium influx that causes seizures, but rather inhibits calcium channels that regulate calcium influx. Suppressing calcium influx is the mechanism of action of another anticonvulsant, ethosuximide, which is also used to treat absence seizures⁵.
A nurse is reviewing the medication history of a client who has been taking phenobarbital (Luminal) for generalized seizures. The client reports feeling tired and depressed most of the time. What is an appropriate response by the nurse?
Explanation
Phenobarbital is a barbiturate that can cause physical and psychological dependence with chronic use, meaning that the body and the mind become accustomed to the drug and need it to function normally. Dependence can lead to withdrawal symptoms when the drug is stopped or reduced, such as insomnia, nausea, tremors, and dizziness⁹. Dependence can also increase the risk of overdose, tolerance, and addiction¹³.
Choice A is wrong because these are not common side effects of phenobarbital, but signs of dependence. Common side effects of phenobarbital may include drowsiness, lack of energy, dizziness, or spinning sensation².
Choice B is wrong because these are not signs of toxicity, but signs of dependence. Toxicity occurs when the drug reaches a level in the body that causes harmful effects, such as respiratory depression, hypotension, coma, or death⁵. Signs of toxicity may include slow or shallow breathing, weak pulse, cold or clammy skin, little or no urination, pinpoint pupils, feeling cold, or fainting².
Choice C is wrong because these are not symptoms of withdrawal, but signs of dependence. Withdrawal occurs when the drug is stopped or reduced after a period of regular use, causing the body and the mind to react to the absence of the drug. Withdrawal symptoms may include anxiety, restlessness, irritability, agitation, confusion, hallucinations, seizures, or delirium⁹. Increasing the dose of phenobarbital can worsen the dependence and increase the risk of adverse effects.
The Principles of Anticonvulsant Therapy.
A nurse is caring for a client who has been prescribed phenytoin (Dilantin) for seizure control. The nurse should monitor the client for which adverse effect of this drug?
Explanation
The nurse should monitor the client for gingival hyperplasia, which is an overgrowth of the gums, as an adverse effect of phenytoin. Gingival hyperplasia can cause bleeding, inflammation, and infection of the gums, and may interfere with chewing and oral hygiene¹². The nurse should advise the client to brush and floss their teeth regularly, use a soft toothbrush, and visit a dentist every 3 to 4 months²³.
Choice A is wrong because hypertension is not an adverse effect of phenytoin. Phenytoin can cause hypotension, especially when given intravenously at a high rate or in large doses⁴⁵. The nurse should monitor the client's blood pressure and heart rate and inject the medication slowly over at least 3 minutes⁵.
Choice C is wrong because diarrhea is not an adverse effect of phenytoin. Phenytoin can cause constipation, especially in elderly clients or those with reduced mobility . The nurse should encourage the client to drink plenty of fluids, eat high-fiber foods, and exercise regularly to prevent constipation.
Choice D is wrong because tachycardia is not an adverse effect of phenytoin. Phenytoin can cause bradycardia, especially when given intravenously at a high rate or in large doses⁴⁵. The nurse should monitor the client's heart rate and rhythm and inject the medication slowly over at least 3 minutes⁵.
A nurse is teaching a client who has been newly diagnosed with epilepsy about the principles of anticonvulsant therapy. Which statements by the client indicate understanding of the teaching? (Select all that apply.)
No explanation
A nurse is preparing to administer carbamazepine (Tegretol) to a client who has partial seizures. The nurse should inform the client that this drug may cause which adverse effect?
Explanation
You may develop a rash or itching. The nurse should inform the client that this drug may cause a rash or itching, which can be a sign of a serious allergic reaction or a rare but life-threatening skin condition called Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN)¹². The nurse should instruct the client to stop taking the drug and seek medical attention immediately if they develop a rash, hives, blisters, peeling skin, fever, or swollen lymph nodes²³.
Choice A is wrong because blurred vision or drowsiness are not adverse effects of carbamazepine, but rather common side effects that usually go away with time or dose adjustment¹². The nurse should advise the client to avoid driving or operating machinery until they know how the drug affects them, and to report any persistent or severe vision problems to their doctor²³.
Choice C is wrong because difficulty urinating or constipation are not adverse effects of carbamazepine, but rather rare side effects that may indicate urinary retention or bowel obstruction¹⁴. The nurse should encourage the client to drink plenty of fluids, eat high-fiber foods, and exercise regularly to prevent these problems, and to report any difficulty passing urine or stool to their doctor³⁴.
Choice D is wrong because nausea or vomiting are not adverse effects of carbamazepine, but rather common side effects that can be minimized by taking the drug with food or milk¹². The nurse should advise the client to eat small, frequent meals and avoid spicy or fatty foo
A nurse is evaluating the response of a client who is receiving gabapentin (Neurontin) for neuropathic pain. The nurse should assess the client for which outcome?
Explanation
The nurse should evaluate the response of the client who is receiving gabapentin (Neurontin) for neuropathic pain by measuring the frequency and intensity of pain using a valid and reliable pain scale, such as the numeric rating scale or the visual analog scale¹². The nurse should also ask the client about their satisfaction with pain relief and their functional status²³. The main goal of gabapentin therapy is to reduce pain by at least 50% or to a tolerable level⁴⁵.
Choice B is wrong because increased range of motion and mobility are not outcomes that the nurse should assess the client for when receiving gabapentin for neuropathic pain. Gabapentin is not indicated for musculoskeletal pain or inflammatory pain, and does not have anti-inflammatory or muscle relaxant properties⁶. Gabapentin may improve mobility indirectly by reducing pain, but this is not a direct outcome of the drug.
Choice C is wrong because improved mood and sleep quality are not outcomes that the nurse should assess the client for when receiving gabapentin for neuropathic pain. Gabapentin is not indicated for depression or insomnia, and does not have antidepressant or sedative properties⁶. Gabapentin may improve mood and sleep indirectly by reducing pain, but this is not a direct outcome of the drug.
Choice D is wrong because decreased inflammation and swelling are not outcomes that the nurse should assess the client for when receiving gabapentin for neuropathic pain. Gabapentin is not indicated for inflammatory pain or edema, and does not have anti-inflammatory or diuretic properties⁶. Gabapentin may reduce swelling indirectly by reducing pain, but this is not a direct outcome of the drug.
Nursing Implications of Anticonvulsant Therapy
A nurse is reviewing the medication list of a patient who is taking carbamazepine (Tegretol) for seizures. Which of the following drugs may interact with carbamazepine and require dosage adjustments? (Select all that apply.)
Explanation
- Choice A is correct because warfarin (Coumadin) may interact with carbamazepine and require dosage adjustments. Carbamazepine can increase the metabolism of warfarin and decrease its anticoagulant effect, which can increase the risk of blood clots or stroke¹⁴. The nurse should monitor the patient's international normalized ratio (INR) and prothrombin time (PT) and adjust the warfarin dose accordingly¹⁵.
- Choice B is correct because erythromycin (Erythrocin) may interact with carbamazepine and require dosage adjustments. Erythromycin can inhibit the metabolism of carbamazepine and increase its blood levels, which can increase the risk of toxicity or adverse effects, such as drowsiness, dizziness, nausea, or rash¹⁴. The nurse should monitor the patient's carbamazepine levels and signs of toxicity and adjust the carbamazepine dose accordingly¹⁵.
- Choice E is correct because metformin (Glucophage) may interact with carbamazepine and require dosage adjustments. Carbamazepine can decrease the absorption of metformin and reduce its blood glucose-lowering effect, which can increase the risk of hyperglycemia or diabetes complications¹⁴. The nurse should monitor the patient's blood glucose levels and adjust the metformin dose accordingly¹⁵.
- Choice C is wrong because ibuprofen (Advil) does not interact with carbamazepine and does not require dosage adjustments. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that does not affect the metabolism or blood levels of carbamazepine or be affected by it²³. The nurse should advise the patient to use ibuprofen as needed for pain or inflammation, but to avoid taking it with other NSAIDs or aspirin to prevent bleeding or stomach ulcers²³.
- Choice D is wrong because levothyroxine (Synthroid) does not interact with carbamazepine and does not require dosage adjustments. Levothyroxine is a thyroid hormone replacement that does not affect the metabolism or blood levels of carbamazepine or be affected by it²³. The nurse should advise the patient to take levothyroxine on an empty stomach, at least 30 minutes before or 4 hours after any other medications, to ensure optimal absorption²³.
A nurse is monitoring a patient who is receiving valproic acid (Depakote) for seizures. The patient reports nausea, vomiting, and abdominal pain.
What is the nurse's best action?
Explanation
This statement is incorrect because grapefruit juice does not interact with phenytoin and has no effect on its metabolism or blood levels¹. The patient does not need to avoid grapefruit juice while taking phenytoin, unless they are also taking another drug that is affected by grapefruit juice, such as some statins, calcium channel blockers, or cyclosporine²³.
The other statements by the patient are correct and indicate an understanding of the teaching.
- Choice A is correct because the patient should brush their teeth gently with a soft toothbrush to prevent gingival hyperplasia, which is an overgrowth of the gums that can occur with phenytoin use. The patient should also floss regularly and visit a dentist every 3 to 4 months.
- Choice B is correct because the patient should wear a medical alert bracelet that says they have epilepsy and are taking phenytoin. This can help emergency personnel to provide appropriate care and avoid drug interactions if the patient has a seizure or another medical problem.
- Choice C is correct because the patient should check their blood pressure regularly while taking phenytoin, as this drug can cause hypotension, especially when given intravenously or in high doses. The patient should also monitor their heart rate and rhythm, as phenytoin can cause bradycardia or arrhythmias.
A nurse is caring for a patient who has been taking gabapentin (Neurontin) for neuropathic pain. The patient says, "I don't think this drug is working. I still have pain and now I feel dizzy and tired all the time." How should the nurse respond?
Explanation
The nurse should respond by saying, "You should report these symptoms to your doctor as they may indicate toxicity." This is the correct answer because dizziness and tiredness are common side effects of gabapentin, but they may also be signs of toxicity if they are severe or persistent¹². The nurse should also ask the patient about their dose and frequency of gabapentin, and check their blood levels if possible³. The nurse should advise the patient not to stop or change their dose of gabapentin without consulting their doctor, as this can cause withdrawal symptoms or seizures¹².
The other statements by the nurse are incorrect and indicate a need for further education.
- Saying, "You should stop taking the drug and ask your doctor for something else." is wrong because the nurse should not advise the patient to stop taking gabapentin abruptly, as this can cause withdrawal symptoms or seizures. The nurse should also not suggest alternative drugs without knowing the patient's medical history, allergies, or other medications¹².
- Saying, "You should increase your dose until you get relief from your pain." is wrong because the nurse should not advise the patient to increase their dose of gabapentin without consulting their doctor, as this can cause toxicity or adverse effects. The nurse should also not imply that gabapentin is ineffective for neuropathic pain, as it is one of the first-line drugs for this condition⁴.
- Saying, "You should continue taking the drug as prescribed and avoid driving or operating machinery." is partially correct, but not the best response. The nurse should advise the patient to continue taking gabapentin as prescribed and avoid driving or operating machinery until they know how the drug affects them, but they should also report their symptoms to their doctor as they may indicate toxicity¹².
A nurse is preparing to administer intravenous (IV) phenobarbital (Luminal) to a patient who has status epilepticus. Which of the following actions should the nurse take?
Explanation
D. Monitor the patient's respiratory rate and oxygen saturation during and after the drug administration.
The action that the nurse should take is choice D. Monitor the patient's respiratory rate and oxygen saturation during and after the drug administration. This is an important action because phenobarbital is a barbiturate that can cause respiratory depression, especially when given intravenously²³. The nurse should monitor the patient's respiratory rate and oxygen saturation and be prepared to provide respiratory support if needed²³.
The other actions by the nurse are incorrect and indicate a need for further education.
- Choice A is wrong because the nurse should not dilute the drug in normal saline solution, but rather in water for injection. Normal saline is not compatible with phenobarbital and can cause precipitation or crystallization of the drug¹². The nurse should dilute each 1 mL injection solution to 10 mL with water for injection before administration¹.
- Choice B is wrong because the nurse should not flush the IV line with dextrose solution before and after the drug administration, but rather with water for injection. Dextrose is not compatible with phenobarbital and can cause precipitation or crystallization of the drug¹². The nurse should flush the IV line with water for injection before and after administration to prevent drug interactions and ensure complete delivery of the medication¹.
- Choice C is wrong because the nurse should not give the drug by rapid IV push over 10 to 20 seconds, but rather slowly over at least 3 minutes. Rapid IV administration of phenobarbital can cause severe respiratory depression, apnea, laryngospasm, hypertension or vasodilation with hypotension²³. The maximum rate of injection is 30 mg/minute in children and 60 mg/minute in adults³.
Outcomes of Anticonvulsant Therapy and Seizure Management
A nurse is evaluating the outcomes of anticonvulsant therapy and seizure management for a patient with epilepsy. Which of the following tools can the nurse use to measure the impact and burden of seizures on the patient and the caregiver?
Explanation
The nurse can use seizure scales or questionnaires to measure the impact and burden of seizures on the patient and the caregiver. Seizure scales or questionnaires are tools that assess the frequency, duration, severity, and type of seizures, as well as the quality of life, mood, cognition, and functioning of the patient and the caregiver¹². Some examples of seizure scales or questionnaires are the National Hospital Seizure Severity Scale, the Liverpool Seizure Severity Scale, the Quality of Life in Epilepsy Inventory, and the Epilepsy and Learning Disabilities Quality of Life Scale¹².
Choice B is wrong because EEG is not a tool to measure the impact and burden of seizures on the patient and the caregiver. EEG is a diagnostic test that records the electrical activity of the brain and can detect abnormal patterns that indicate seizures or epilepsy³. EEG can help confirm the diagnosis, classify the type of seizures, identify the seizure focus, and guide the treatment of epilepsy³. However, EEG cannot measure the subjective aspects of seizure burden, such as quality of life, mood, cognition, or functioning.
Choice C is wrong because serum drug levels are not a tool to measure the impact and burden of seizures on the patient and the caregiver. Serum drug levels are laboratory tests that measure the concentration of anticonvulsant drugs in the blood and can help monitor the effectiveness and toxicity of these drugs. Serum drug levels can help adjust the dose, avoid drug interactions, and prevent breakthrough seizures or adverse effects. However, serum drug levels cannot measure the subjective aspects of seizure burden, such as quality of life, mood, cognition, or functioning.
Choice D is wrong because the quality of life scales or questionnaires is not a tool to measure the impact and burden of seizures on the patient and the caregiver. Quality of life scales or questionnaires are tools that assess the physical, psychological, social, and spiritual aspects of well-being and satisfaction with life. Quality of life scales or questionnaires can help evaluate the outcomes and effectiveness of epilepsy treatment. However, quality-of-life scales or questionnaires cannot measure the objective aspects of seizure burden, such as frequency, duration, severity, or type of seizures.
A nurse is teaching a patient who has been prescribed lamotrigine (Lamictal) for partial seizures. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Explanation
- Choice A is correct because the patient should report any rash, fever, or swollen lymph nodes to the prescriber immediately. These can be signs of a serious allergic reaction or a rare but life-threatening skin condition called Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN)¹². The patient should stop taking the drug and seek medical attention immediately if they develop these symptoms²³.
- Choice C is correct because the patient should use a reliable form of contraception while taking this medication. Lamotrigine can reduce the effectiveness of oral contraceptives and increase the risk of pregnancy¹². Lamotrigine can also cause birth defects or fetal harm if taken during pregnancy¹². The patient should consult their prescriber about the best method of contraception for them and inform them if they become pregnant or plan to become pregnant while taking lamotrigine²³.
- Choice D is correct because the patient should avoid exposure to sunlight and use sunscreen and protective clothing. Lamotrigine can increase the sensitivity of the skin to sunlight and cause sunburn or rash¹². The patient should limit their time in the sun and protect their skin from sun damage²³.
- Choice B is wrong because the patient does not need to take the medication with food to prevent gastrointestinal upset. Lamotrigine can be taken with or without food, depending on the patient's preference¹². Taking the medication with food may delay its absorption, but does not affect its bioavailability or efficacy⁴. The patient may experience some mild gastrointestinal side effects, such as nausea, vomiting, or diarrhea, but these usually go away with time or dose adjustment¹².
- Choice E is wrong because the patient does not need to avoid drinking alcohol or using illicit drugs while taking this medication. Lamotrigine does not have a significant interaction with alcohol or illicit drugs and does not affect the central nervous system as much as other anticonvulsants. However, the patient should still drink alcohol moderately and avoid using illicit drugs for their general health and well-being.
A nurse is caring for a patient who has a history of absence seizures. The patient suddenly stops talking and stares blankly into space for a few seconds. What is the nurse's best action?
Explanation
This is an appropriate action because absence seizures involve brief, sudden lapses of consciousness that last for a few seconds¹²³. The patient may stare blankly into space, stop talking, or stop moving during the seizure¹²³. The nurse should protect the patient from injury by guiding them to a safe place, such as a chair or a bed, and staying with them until they regain awareness¹²³. The nurse should also observe and document the time, duration, and type of seizure¹²³.
The other actions by the nurse are incorrect and indicate a need for further education.
- Choice A is wrong because calling for help and preparing to administer rescue medication is not necessary for absence seizures. Absence seizures are usually harmless and do not cause physical injury or complications¹²³. They do not require emergency treatment or rescue medication, unless they occur in clusters or last longer than 15 seconds¹²³.
- Choice C is wrong because shaking the patient and asking them if they are okay is not helpful for absence seizures. Shaking the patient may startle them or cause injury, and asking them questions may confuse them or increase their anxiety¹²³. The patient is not aware of their surroundings or able to respond during the seizure¹²³. The nurse should avoid touching or talking to the patient unnecessarily during the seizure¹²³.
- Choice D is wrong because documenting the time, duration, and type of seizure in the patient's chart is not the best action. Documenting the seizure is important, but it should not be done before ensuring the patient's safety and comfort¹²³. The nurse should document the seizure after it ends and after checking the patient's vital signs and level of consciousness¹²³.
A nurse is administering intramuscular (IM) phenytoin (Dilantin) to a patient who has status epilepticus that is unresponsive to IV therapy. Which of the following actions should the nurse take?
Explanation
large muscle mass. This is the correct action because phenytoin (Dilantin) is a poorly soluble drug that can cause tissue irritation, necrosis, and abscess formation when given intramuscularly¹³. The nurse should use a large-bore needle (at least 21 gauge) and inject the drug slowly into a large muscle mass, such as the gluteus maximus or the vastus lateralis, to minimize these complications¹³. The nurse should also avoid injecting more than 5 mL of solution per site and rotate the injection sites¹³.
The other actions by the nurse are incorrect and indicate a need for further education.
- Choice B is wrong because the nurse should not use a small-bore needle and inject the drug rapidly into a small muscle mass. This can increase the risk of tissue damage, pain, and infection due to the high pH and low solubility of phenytoin¹³. The nurse should use a large-bore needle and inject the drug slowly into a large muscle mass to reduce these risks¹³.
- Choice C is wrong because the nurse should not mix the drug with lidocaine or procaine to reduce pain and tissue irritation. These are local anesthetics that can interfere with the absorption and efficacy of phenytoin¹². The nurse should not mix phenytoin with any other drugs or solutions, as it is incompatible with many of them and can cause precipitation or crystallization¹².
- Choice D is wrong because the nurse should not massage the injection site after administration to enhance absorption. This can cause tissue damage, pain, and infection due to the high pH and low solubility of phenytoin¹³. The nurse should avoid touching or rubbing the injection site after administration to prevent these complications¹³.
A nurse is caring for a patient who has been diagnosed with epilepsy and has been prescribed carbamazepine (Tegretol). Which of the following statements by the patient indicates understanding of teaching related to this medication?
Explanation
This statement indicates that the patient understands that carbamazepine can cause a serious skin reaction called Stevens-Johnson syndrome, which requires immediate medical attention. The other statements are incorrect for the following reasons:
- A. "I will need to have my blood levels checked every week". This statement is incorrect because carbamazepine levels do not need to be checked every week, but rather every few months or as directed by the doctor.
- B. "I will drink grapefruit juice every morning with my medication". This statement is incorrect because grapefruit juice can increase the blood levels of carbamazepine and cause toxicity. The patient should avoid drinking grapefruit juice while taking this medication.
- D. "I will take my medication with food or milk". This statement is incorrect because carbamazepine should be taken on an empty stomach, at least one hour before or two hours after meals, to ensure optimal absorption. Taking it with food or milk can reduce its effectiveness.
Summary
A nurse is preparing to administer intravenous phenytoin (Dilantin) to a patient who has status epilepticus. Which of the following actions should the nurse take?
Explanation
This action is necessary to prevent the formation of precipitates in the IV line, which can cause thrombophlebitis or embolism. The other actions are incorrect for the following reasons:
- A. "Flush the IV line with normal saline before and after giving phenytoin". This action is correct, but not sufficient to prevent precipitation. Phenytoin is incompatible with many IV solutions and drugs, so it should be given in a separate line or flushed thoroughly with normal saline before and after administration.
- B. "Mix phenytoin with dextrose solution in a syringe". This action is incorrect because phenytoin is incompatible with dextrose solution and will form a precipitate. Phenytoin should only be diluted with normal saline.
- C. "Give phenytoin as a bolus over 1 minute". This action is incorrect because phenytoin should be given slowly, at a rate of no more than 50 mg/min, to avoid hypotension and cardiac arrhythmias.
A nurse is reviewing discharge instructions with a patient who has epilepsy and has been prescribed lamotrigine (Lamictal). Which of the following statements by the patient indicates a need for further teaching?
Explanation
This statement is incorrect because ibuprofen may interact with lamotrigine and increase the risk of side effects such as dizziness, drowsiness, confusion, and difficulty concentrating¹². A clinical study found that common interactions between lamotrigine and ibuprofen include gait disturbance among females and insomnia among males². The patient should avoid taking ibuprofen while on lamotrigine and consult their doctor for alternative pain relief options. The other statements are correct for the following reasons:
- A. "I will wear sunscreen and protective clothing when I go outside". This statement is correct because lamotrigine can make the skin more sensitive to sunlight and increase the risk of sunburns and rashes. The patient should protect their skin from sun exposure while taking this medication.
- C. "I will report any changes in my vision or mood to my doctor". This statement is correct because lamotrigine can cause vision problems such as blurred vision, double vision, or eye irritation, as well as mood changes such as depression, anxiety, or suicidal thoughts. The patient should monitor their vision and mood and report any changes to their doctor promptly.
- D. "I will not stop taking my medication abruptly". This statement is correct because stopping lamotrigine suddenly can cause withdrawal symptoms such as seizures, headaches, nausea, or insomnia. The patient should follow their doctor's instructions on how to taper off the medication gradually if they need to stop taking it.
A nurse is providing discharge teaching to a client who has a new prescription for valproic acid to treat seizures. Which of the following instructions should the nurse include in the teaching?¹
Explanation
This instruction is important because valproic acid can cause nausea, vomiting, stomach pain, and diarrhea as common side effects³⁴. Taking the medication with food can help reduce these gastrointestinal symptoms and improve the patient's tolerance and adherence to the treatment. The other choices are incorrect for the following reasons:
- B. "Avoid driving until the medication level is therapeutic". This instruction is unnecessary because valproic acid does not impair driving performance or increase the risk of accidents¹. The patient can drive safely as long as they do not experience drowsiness, dizziness, or blurred vision from the medication.
- C. "Drink at least 3 L of fluid per day". This instruction is excessive because valproic acid does not cause dehydration or fluid loss¹. The patient should drink enough fluids to stay hydrated, but not more than their normal intake.
- D. "Report any bruising or bleeding to the provider". This instruction is irrelevant because valproic acid does not affect blood clotting or increase the risk of bleeding¹. The patient should report any bruising or bleeding to the provider only if they have other conditions or medications that may cause these problems.
A nurse is caring for a patient who experiences seizure activity while in bed. What action by the nurse takes priority?
Explanation
This action takes priority because the patient's head is at risk of hitting the bed, the side rails, or other objects during a seizure, which can cause trauma, bleeding, or brain damage . The nurse should place a soft pad or pillow under the patient's head and move any sharp or hard objects away from the bed. The other choices are incorrect for the following reasons:
- A. "Loosening restrictive clothing". This action is helpful but not urgent because restrictive clothing can interfere with breathing or circulation during a seizure, but it is not a life-threatening issue . The nurse can loosen the patient's clothing after protecting their head and ensuring their airway is clear.
- B. "Restraining the client's limbs". This action is harmful and contraindicated because restraining the patient's limbs can cause injury, pain, or fractures during a seizure, as well as increase their anxiety and agitation . The nurse should never restrain a patient who is having a seizure, but rather let them move freely and safely.
- C. "Removing pillows and raising side rails". This action is unnecessary and potentially dangerous because removing pillows can expose the patient's head to injury, and raising side rails can trap the patient's limbs or body between them during a seizure . The nurse should keep pillows under the patient's head and lower the side rails if possible.
A client with mild parkinsonism is started on oral amantadine (Symmetrel). What statement accurately describes the action of this medication?
Explanation
This statement accurately describes the action of amantadine, which is a medication that has both antiviral and antiparkinsonian effects. The mechanism of action of amantadine in the treatment of parkinsonism is not fully understood, but it may involve increasing dopamine release in the brain, stimulating norepinephrine response, or activating dopaminergic receptors¹². The other choices are incorrect for the following reasons:
- B. "Dopamine in the central nervous system is decreased". This statement is incorrect because amantadine does not decrease dopamine levels, but rather enhances them. Decreasing dopamine levels would worsen the symptoms of parkinsonism, which are caused by a deficiency of dopamine in the basal ganglia.
- C. "Acetylcholine in the central nervous system is increased". This statement is incorrect because amantadine does not affect acetylcholine levels or activity. Acetylcholine is another neurotransmitter that is involved in the regulation of movement and cognition. Increasing acetylcholine levels would have anticholinergic effects, such as dry mouth, blurred vision, constipation, and confusion.
- D. "Acetylcholine in the central nervous system is decreased". This statement is incorrect because amantadine does not affect acetylcholine levels or activity. Decreasing acetylcholine levels would have cholinergic effects, such as salivation, lacrimation, urination, and diarrhea.
The healthcare provider prescribes captopril (Capoten) 37.5 mg. The medication is available in 25 mg tablets. What should the nurse administer?
No explanation
A nurse is caring for a client who is taking lamotrigine for partial seizures. The nurse should instruct the client to report which of the following signs of a serious adverse reaction to lamotrigine?¹
Explanation
This statement indicates that the client understands that lamotrigine can cause a serious adverse reaction called aseptic meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. Aseptic meningitis can cause symptoms such as fever, headache, stiff neck, sore throat, nausea, vomiting, and sensitivity to light¹². The client should report any signs of aseptic meningitis to their provider immediately, as it may require discontinuation of lamotrigine and medical attention¹². The other statements are incorrect for the following reasons:
- A. "Blurred vision". This statement is incorrect because blurred vision is a common and usually mild side effect of lamotrigine that does not require reporting to the provider unless it is severe or persistent¹². Blurred vision may improve over time as the client adjusts to the medication¹².
- B. "Headache". This statement is incorrect because headache is a common and usually mild side effect of lamotrigine that does not require reporting to the provider unless it is severe or persistent¹². Headache may improve over time as the client adjusts to the medication¹².
- D. "Nausea". This statement is incorrect because nausea is a common and usually mild side effect of lamotrigine that does not require reporting to the provider unless it is severe or persistent¹². Nausea may improve over time as the client adjusts to the medication¹².
A nurse is teaching a client who has a new prescription for gabapentin for partial seizures. Which of the following instructions should the nurse include in the teaching?
Explanation
This instruction is important because gabapentin can cause drowsiness, dizziness, or blurred vision as common side effects¹². These effects can impair the client's ability to drive safely and increase the risk of accidents or injuries. The client should avoid driving or operating machinery until they know how gabapentin affects them and their doctor says it is safe to do so¹². The other instructions are incorrect for the following reasons:
- A. "Take this medication with food or milk to prevent gastric irritation". This instruction is unnecessary because gabapentin does not cause gastric irritation or ulcers as a side effect¹². The client can take gabapentin with or without food, depending on their preference and tolerance¹².
- C. "Increase your intake of fluids and fiber to prevent constipation". This instruction is irrelevant because gabapentin does not cause constipation as a side effect¹². The client should maintain a normal intake of fluids and fiber to promote bowel health, but not specifically because of gabapentin use¹².
- D. "Discontinue this medication gradually to prevent withdrawal symptoms". This instruction is incorrect because gabapentin does not cause withdrawal symptoms or physical dependence as a side effect¹². However, the client should not stop taking gabapentin suddenly or without their doctor's advice, as this can increase the risk of seizures or other complications¹².
A patient who has been taking phenytoin for several years comes to the clinic for a follow-up visit and tells the nurse that he has been experiencing gum tenderness and bleeding when he brushes his teeth. The nurse will perform which action?
Explanation
This is because phenytoin, a medication used to control seizures, may cause gingival hyperplasia or overgrowth of the gums¹. This can lead to tenderness, swelling, or bleeding of the gums. The condition is more common in patients taking phenytoin, cyclosporine, or calcium channel blockers¹. The etiology of phenytoin-induced gingival enlargement is likely due to the direct effects of the drug and its metabolites on the gingival fibroblasts¹. Patients can benefit from controlling the inflammatory component through an appropriate oral hygiene program¹. Referral to a general dentist or periodontist is appropriate for management¹.
Choice A is wrong because flossing his teeth regularly may not prevent or reduce the gingival overgrowth caused by phenytoin. Flossing may also aggravate the bleeding of the gums.
Choice B is wrong because serum drug levels may not correlate with the extent of gingival overgrowth. Some studies do not support the concept that the dose, duration, and plasma levels of phenytoin affect the severity of gingival enlargement².
Choice C is wrong because this is not a harmless side effect of phenytoin. Gingival overgrowth may interfere with speech, mastication, tooth eruption and aesthetics². It may also increase the risk of periodontal disease and infection³.
The nurse is caring for a patient who has been receiving intravenous phenytoin (Dilantin). The patient complains of pain and burning at the IV site, and the nurse notes redness and swelling at the site. What will the nurse do?
Explanation
This is because phenytoin, a medication used to treat seizures, can cause a rare but serious side effect called “purple glove syndrome” when administered intravenously². This condition is characterized by worsening limb edema and discoloration that may result from the crystallization of phenytoin within the blood². It can lead to skin necrosis and limb ischemia, requiring amputation in severe cases². Therefore, the nurse should stop the infusion immediately, remove the IV line, and report the adverse reaction to the provider. The patient may need surgical intervention or other treatments to prevent further complications².
Choice A is wrong because applying warm compresses and slowing the infusion rate may not prevent or reverse the damage caused by phenytoin infiltration. In fact, it may worsen the condition by increasing the blood flow to the affected area and prolonging the exposure to the drug².
Choice C is wrong because requesting an order for intravenous fosphenytoin instead of phenytoin may not be appropriate or necessary at this point. Fosphenytoin is a prodrug of phenytoin that has some advantages over phenytoin, such as better solubility, faster infusion rate, and fewer cardiovascular complications⁷. However, it is not indicated for the treatment of purple glove syndrome or phenytoin infiltration. Moreover, fosphenytoin may still cause some adverse effects, such as hypotension, pruritus, rash, and paresthesia⁶. Therefore, the nurse should focus on managing the current situation rather than switching to another drug.
Choice D is wrong because stopping the infusion temporarily and administering an antihistamine may not be effective or sufficient for treating phenytoin infiltration. Purple glove syndrome is not an allergic reaction, but a local tissue injury caused by phenytoin crystallization². Therefore, an antihistamine may not have any benefit for this condition. Stopping the infusion temporarily may not prevent further damage to the tissue or blood vessels. The nurse should discontinue the IV line completely and notify the provider as soon as possible.
A nurse is caring for a client who has been prescribed phenobarbital (Luminal) for status epilepticus. The nurse should monitor the client for which adverse effect of this drug?¹
Explanation
This is because phenobarbital, a medication used to treat seizures, can cause serious side effects on the respiratory system, such as weak or shallow breathing, apnea, respiratory arrest, and death². Respiratory depression is more likely to occur in patients who are elderly, debilitated, or have underlying lung disease². The nurse should monitor the patient's respiratory rate, oxygen saturation, and level of consciousness, and be prepared to administer oxygen or mechanical ventilation if needed³.
Choice B is wrong because hyperglycemia is not a common or serious adverse effect of phenobarbital. Phenobarbital does not affect blood glucose levels directly, but it may interfere with the metabolism of some oral antidiabetic drugs, such as sulfonylureas. Therefore, patients who take both phenobarbital and antidiabetic drugs may need to adjust their doses or monitor their blood glucose more frequently.
Choice C is wrong because hypertension is not a common or serious adverse effect of phenobarbital. Phenobarbital may cause hypotension or orthostatic hypotension in some patients, especially when given intravenously or in high doses². The nurse should monitor the patient's blood pressure and heart rate, and avoid sudden changes in position³.
Choice D is wrong because insomnia is not a common or serious adverse effect of phenobarbital. Phenobarbital is a barbiturate that has sedative and hypnotic properties. It may cause drowsiness, dizziness, lethargy, and impaired cognition in some patients². The nurse should advise the patient to avoid driving or operating machinery while taking phenobarbital, and to avoid alcohol and other CNS depressants³.
A client is prescribed ethosuximide (Zarontin) for absence seizures. The nurse should instruct the client to report which adverse effect?¹
Explanation
Skin rash is an adverse effect of ethosuximide (Zarontin) that should be reported to the provider¹. Ethosuximide can cause allergic reactions, such as hives, itching, and skin rash, in some people¹. A skin rash may indicate a serious condition, such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which can be life-threatening¹.
Choice A is wrong because blurred vision is not a common side effect of ethosuximide. Ethosuximide is not known to affect vision or eye health¹.
Choice B is wrong because gingival hyperplasia is not a common side effect of ethosuximide. Ethosuximide is not known to cause overgrowth of the gums or dental problems¹. Gingival hyperplasia is more commonly associated with other anticonvulsants, such as phenytoin (Dilantin)².
Choice D is wrong because constipation is not a common side effect of ethosuximide. Ethosuximide may cause gastrointestinal side effects, such as nausea, vomiting, stomach pain, and loss of appetite, but not constipation¹³. Constipation is more commonly associated with other anticonvulsants, such as carbamazepine (Tegretol)⁴.
The nurse is caring for a client who has been taking phenytoin (Dilantin) for several years to control tonic-clonic seizures. The client tells the nurse that he wants to stop taking the medication because it makes his gums swell and bleed. What is the most appropriate response by the nurse?
Explanation
Phenytoin (Dilantin) can cause overgrowth of gum tissue, also known as gingival hyperplasia, in some people¹. This can lead to swelling, bleeding, and infection of the gums¹. Good oral hygiene, such as brushing, flossing, and using mouthwash, can help prevent or reduce gum problems¹. The client should also see the dentist regularly for check-ups and cleaning¹.
Choice A is wrong because the client should not stop taking phenytoin without consulting the provider. Stopping phenytoin suddenly can increase the risk of seizures or status epilepticus, which is a life-threatening condition¹. If the client wants to switch to another anticonvulsant medication, the provider should advise on how to do so safely and gradually¹.
Choice B is wrong because the client should not reduce the dose of phenytoin without consulting the provider. Reducing the dose of phenytoin can lower the blood level of the medication and make it less effective in controlling seizures¹. The provider should monitor the blood level of phenytoin and adjust the dose accordingly¹.
Choice D is wrong because the client should not take ibuprofen (Motrin) or aspirin (Ecotrin) to relieve the inflammation and pain in the gums. These medications are nonsteroidal anti-inflammatory drugs (NSAIDs) that can interact with phenytoin and increase its blood level and side effects². They can also increase the risk of bleeding, especially in people with low platelet count or clotting problems². The client should consult the provider before taking any other medications with phenytoin¹.
The nurse is preparing to give medications to a client who has been receiving long-term therapy with phenytoin (Dilantin). The nurse notes that the client has coarse facial features, hirsutism, and acne. What is the most appropriate nursing diagnosis for this client?
Explanation
Phenytoin (Dilantin) can cause cosmetic side effects, such as coarse facial features, hirsutism, and acne, in some people¹²³. These side effects can affect the client's self-esteem, social interactions, and emotional well-being¹. The nurse should assess the client's perception of his or her appearance and provide support and education to cope with the changes¹.
Choice A is wrong because risk for infection related to immunosuppression is not a relevant nursing diagnosis for this client. Phenytoin can cause blood dyscrasias, such as leukopenia and thrombocytopenia, in some people¹²³. However, these side effects are not related to immunosuppression and do not increase the risk of infection¹. The nurse should monitor the client's blood counts and report any signs of bleeding or anemia to the provider¹.
Choice C is wrong because impaired skin integrity related to hypersensitivity reaction is not a relevant nursing diagnosis for this client. Phenytoin can cause allergic reactions, such as rash, fever, lymphadenopathy, and hepatitis, in some people¹²³. However, these side effects are not related to impaired skin integrity and do not cause skin breakdown or ulceration¹. The nurse should discontinue the medication and report any signs of hypersensitivity reaction to the provider¹.
Choice D is wrong because deficient knowledge related to self-care and medication management is not a relevant nursing diagnosis for this client. Phenytoin requires careful monitoring and education to ensure therapeutic and safe use¹²³. However, this nursing diagnosis does not address the client's specific concern about the cosmetic side effects of phenytoin¹. The nurse should provide information and counseling about the benefits and risks of phenytoin therapy and discuss alternative options with the provider if needed¹.
Exams on Anticonvulsants and Management of Seizures
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- Objectives
- Introduction:
- Seizure Pathophysiology and Types of Seizures
- Diagnostic Tests for Seizures
- Anticonvulsant Medications
- Advantages of different anticonvulsant medications for different types of seizures
- The Principles of Anticonvulsant Therapy.
- Nursing Implications of Anticonvulsant Therapy
- Outcomes of Anticonvulsant Therapy and Seizure Management
- Summary
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Objectives
Objectives
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Define seizure, epilepsy, and status epilepticus and describe their causes and risk factors
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Identify the different types of seizures (partial, generalized, absence, myoclonic, atonic, tonic-clonic) and their clinical features
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Explain the pathophysiology of seizure generation and propagation in the brain
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Describe the diagnostic tests used to evaluate seizures, such as EEG, MRI, CT, and blood tests
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List the common anticonvulsant medications and their mechanisms of action, pharmacokinetics, adverse effects, interactions, and contraindications
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Compare and contrast the advantages and disadvantages of different anticonvulsant medications for different types of seizures and patients
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Discuss the principles of anticonvulsant therapy, such as monotherapy versus polytherapy, titration, therapeutic drug monitoring, and withdrawal
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Explain the nursing implications of anticonvulsant therapy, such as patient education, compliance, side effect management, and drug administration
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Demonstrate the skills of seizure management and safety precautions, such as seizure observation and documentation, first aid measures, rescue medications, and postictal care
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Evaluate the outcomes of anticonvulsant therapy and seizure management, such as seizure frequency and severity, quality of life, and complications
Introduction:
Introduction:
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A seizure is a sudden alteration in behavior due to transient pathology.
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Symptoms include loss of consciousness, abnormal motor activity,and abnormal sensation.
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Single event seizures are often PROVOKED by fever(in children), lack of sleep, drugs, alcohol, hypoglycemia, tumors, and stroke.
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Epilepsy is multiple, unprovoked seizures.
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Status epilepticus is a state in which seizures rapidly recur with no recovery between seizures. It is potentially the most dangerous of seizures.
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Seizures are classified as generalized or partial.
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Generalized seizures involve the entire cortex of both hemispheres from the onset.
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Partial seizures involve one discrete part of the brain.
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Anticonvulsants are drugs used to manage epilepsy by preventing or reducing the occurrence of seizures.
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Anticonvulsants have different mechanisms of action, pharmacokinetics, adverse effects, interactions, and contraindications.
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Anticonvulsants are selected based on the type of epilepsy, age of the patient, patient tolerance, and specific patient characteristics.
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Anticonvulsant therapy requires careful adjustment of doses, monitoring of drug levels, and patient education.
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Seizure management involves observing and documenting seizures, providing first aid measures, administering rescue medications if needed, and caring for the patient after the seizure.
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Seizure management aims to prevent injury, maintain airway patency, support vital signs, and prevent complications.
Seizure Pathophysiology and Types of Seizures
Seizure Pathophysiology and Types of Seizures
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Seizures are paroxysmal manifestations of the electrical properties of the cerebral cortex.
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A seizure results when a sudden imbalance occurs between the excitatory and inhibitory forces within the network of cortical neurons in favor of a sudden onset net excitation.
Seizure Types:
Type |
Description |
Clinical Features |
Partial |
|
|
Generalized |
|
|
Diagnostic Tests for Seizures
Diagnostic Tests for Seizures:
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Diagnostic tests for seizures are procedures that help to confirm the diagnosis of seizures, determine the type and cause of seizures, and guide the treatment and management of seizures.
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Diagnostic tests for seizures include the following types:
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Electroencephalogram (EEG):
This is the most common test used to diagnose seizures. It measures the electrical activity of the brain using electrodes attached to the scalp. It can detect abnormal patterns or discharges that indicate seizure activity. EEG can be done in a clinic, hospital, or at home, depending on the purpose and duration of the test.
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EEG can be done while the patient is awake or asleep, and may be combined with video recording to capture any clinical signs of seizures.
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EEG can be done with or without provocation, which means stimulating the brain with certain triggers such as flashing lights, hyperventilation, or sleep deprivation to induce seizures.
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EEG can be done with different electrode arrangements, such as standard (1020 system), high density (more electrodes), or sphenoidal (near the temporal lobes) to increase the sensitivity and specificity of the test.
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Magnetic resonance imaging (MRI):
This is a test that uses powerful magnets and radio waves to create detailed images of the brain. It can reveal structural abnormalities or lesions that may cause seizures, such as tumors, bleeding, cysts, scars, or malformations.
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MRI can be done with or without contrast, which means injecting a dye into a vein to enhance the visibility of certain structures or blood vessels in the brain.
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MRI can be done with different sequences or techniques, such as T1weighted (shows anatomy), T2weighted (shows fluid), FLAIR (suppresses fluid), diffusion-weighted (shows movement of water molecules), or spectroscopy (shows chemical composition) to provide more information about the brain tissue.
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MRI can be done with functional MRI (fMRI), which measures changes in blood flow that occur when specific parts of the brain are working. This can help to identify the location of critical functions such as speech and movement before surgery.
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Computerized tomography (CT):
This is a test that uses X-rays to obtain cross-sectional images of the brain. It can show structural abnormalities or lesions that may cause seizures, such as tumours, bleeding, cysts, scars, or malformations.
Anticonvulsant Medications
Anticonvulsant Medications:
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Anticonvulsants are drugs that prevent or reduce the occurrence of seizures by stabilizing the electrical activity of the brain.
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Anticonvulsants have different mechacontinuenisms of action, such as:
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Blocking sodium channels or calcium channels, which reduces the excitability of neurons and the release of glutamate, an excitatory neurotransmitter⁶.
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Enhancing the activity of GABA, an inhibitory neurotransmitter, by increasing its synthesis, release, or binding to receptors⁶.
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Modulating other receptors or channels, such as AMPA, NMDA, SV2A, and α2δ⁶.
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Anticonvulsants have different pharmacokinetics, which refers to how they are absorbed, distributed, metabolized, and excreted in the body⁶.
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Some anticonvulsants have a narrow therapeutic range, which means that there is a small difference between the effective dose and the toxic dose. These drugs require regular monitoring of blood levels to ensure safety and efficacy⁶.
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Some anticonvulsants are inducers or inhibitors of liver enzymes, which means that they can affect the metabolism of other drugs. This can lead to drug interactions that may increase or decrease the effects of either drug⁶.
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Anticonvulsants have different adverse effects, which may vary depending on the dose, duration, and individual response⁶.
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Common adverse effects include drowsiness, dizziness, nausea, vomiting, rash, weight gain or loss, and cognitive impairment⁶.
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Serious adverse effects include allergic reactions, liver toxicity, blood dyscrasias (abnormal blood cells), StevensJohnson syndrome (a severe skin reaction), teratogenicity (birth defects), and suicidal ideation⁶.
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Anticonvulsants have different contraindications, which are conditions or factors that make their use unsafe or inappropriate⁶.
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Some anticonvulsants are contraindicated in pregnancy or breastfeeding due to the risk of harming the fetus or infant⁶.
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Some anticonvulsants are contraindicated in patients with liver or kidney impairment due to the risk of accumulation and toxicity⁶.
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Some anticonvulsants are contraindicated in patients with certain genetic conditions or allergies that increase their susceptibility to adverse effects⁶.
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The following table summarizes some of the common anticonvulsant medications and their characteristics:
Drug |
Mechanisms of action |
Pharmacokinetics |
Adverse effects |
Interactions |
Contraindications |
Phenytoin |
Blocks sodium channels; stabilizes neuronal membranes; reduces glutamate release |
Oral or IV administration; highly protein bound; hepatic metabolism; narrow therapeutic range (10-20 mcg/mL); induces liver enzymes |
CNS depression, gingival hyperplasia, hirsutism, rash, osteoporosis, blood dyscrasias, teratogenicity, purple glove syndrome (IV) |
Decreases the effects of oral contraceptives, warfarin, and corticosteroids; increases the effects of alcohol and CNS depressants; affected by many drugs that alter protein binding or liver enzymes |
Hypersensitivity, sinus bradycardia, heart block, pregnancy (D) |
Carbamazepine |
Blocks sodium channels; stabilizes neuronal membranes; reduces glutamate release |
Oral administration; hepatic metabolism; induces liver enzymes; autoinduction (decreases its own levels over time); therapeutic range (4-12 mcg/mL) |
CNS depression, diplopia, ataxia, rash, hyponatremia, blood dyscrasias, hepatotoxicity, teratogenicity |
Decreases the effects of oral contraceptives, warfarin, and other drugs metabolized by liver enzymes; increases the effects of alcohol and CNS depressants; affected by grapefruit juice and other drugs that inhibit liver enzymes |
Hypersensitivity, bone marrow suppression, pregnancy (D) |
Valproic Acid |
Enhances GABA activity; blocks sodium and calcium channels; inhibits glutamate receptors |
Oral or IV administration; hepatic metabolism; inhibits liver enzymes; therapeutic range (50-100 mcg/mL) |
CNS depression, GI upset, weight gain, alopecia, tremor, hepatotoxicity, pancreatitis, blood dyscrasias, teratogenicity |
Increases the effects of phenobarbital and phenytoin; decreases the effects of lamotrigine and carbamazepine; affected by aspirin and other drugs that alter protein binding or liver enzymes |
Hypersensitivity, liver disease, urea cycle disorders, pregnancy (D) |
Phenobarbital |
Enhances GABA activity; blocks glutamate receptors; depresses reticular activating system |
Oral or IV administration; hepatic metabolism; induces liver enzymes; long half-life (2-6 days); therapeutic range (15-40 mcg/mL |
CNS depression, sedation, tolerance, dependence, respiratory depression (IV), rash, osteoporosis, blood dyscrasias, teratogenicity |
Decreases the effects of oral contraceptives |
Advantages of different anticonvulsant medications for different types of seizures
Advantages of different anticonvulsant medications for different types of seizures and patients
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The following table summarizes some of the advantages of different anticonvulsant medications for different types of seizures and patients:
Drug |
Advantages |
Phenytoin |
- Effective for partial and tonic-clonic seizures - Available in oral and IV forms - Long half-life allows once-daily dosing - Low cost - Narrow therapeutic range requires frequent monitoring - Many adverse effects and interactions - Induces liver enzymes that affect other drugs - Teratogenic and contraindicated in pregnancy |
Carbamazepine |
- Effective for partial and tonic-clonic seizures - Also used for trigeminal neuralgia and bipolar disorder - Available in extended-release forms - Autoinduction reduces its own levels over time - Many adverse effects and interactions - Induces liver enzymes that affect other drugs - Teratogenic and contraindicated in pregnancy |
Valproic Acid |
- Effective for partial, generalized, and absence seizures - Also used for migraine prophylaxis and bipolar disorder - Available in oral and IV forms - Broad spectrum of action - Inhibits liver enzymes that affect other drugs - Many adverse effects, especially hepatotoxicity and pancreatitis - Teratogenic and contraindicated in pregnancy |
Phenobarbital |
- Effective for partial and generalized seizures, especially in neonates and infants - Also used for sedation and anxiety - Available in oral and IV forms - Long half-life allows once-daily dosing - Low cost - High risk of sedation, tolerance, dependence, and respiratory depression - Many adverse effects and interactions - Induces liver enzymes that affect other drugs - Teratogenic and contraindicated in pregnancy |
The Principles of Anticonvulsant Therapy.
The Principles of Anticonvulsant Therapy.
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The principles of anticonvulsant therapy are the guidelines and strategies that help to optimize the use of anticonvulsants for the management of epilepsy.
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The principles of anticonvulsant therapy include the following aspects:
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Monotherapy versus polytherapy: This involves choosing whether to use one or more anticonvulsants for a given patient.
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Monotherapy is preferred as it reduces the risk of adverse effects, interactions, and noncompliance.
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Polytherapy may be considered if monotherapy fails to control seizures or causes intolerable side effects.
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Polytherapy requires careful selection, combination, and adjustment of drugs to avoid pharmacokinetic or pharmacodynamic interactions.
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Titration: This involves adjusting the dose of anticonvulsants gradually until the desired effect is achieved or the maximum tolerated dose is reached.
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Titration helps to avoid overdosing, underdosing, and abrupt changes in drug levels that may trigger seizures or toxicity.
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Titration should be done according to the individual response, seizure type, and drug characteristics.
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Titration should be done with caution in elderly, pediatric, pregnant, or comorbid patients.
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Therapeutic drug monitoring: This involves measuring the serum levels of anticonvulsants at regular intervals to ensure that they are within the therapeutic range.
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Therapeutic drug monitoring helps to assess the efficacy, safety, and compliance of anticonvulsant therapy.
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Therapeutic drug monitoring is especially important for drugs with a narrow therapeutic range, such as phenytoin, carbamazepine, valproic acid, and phenobarbital.
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Therapeutic drug monitoring should be done at steady state, before the next dose, and after any dose change or addition of another drug.
Outcomes of Anticonvulsant Therapy and Seizure Management
Outcomes of Anticonvulsant Therapy and Seizure Management
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The main outcome of anticonvulsant therapy and seizure management is to achieve seizure freedom or reduction without adverse effects.
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Seizure freedom or reduction can improve the quality of life, psychosocial functioning, cognitive performance, and mood of patients with epilepsy.
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Seizure freedom or reduction can also prevent complications such as status epilepticus, sudden unexpected death in epilepsy (SUDEP), injuries, and comorbidities.
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The outcomes of anticonvulsant therapy and seizure management can be evaluated by using various tools, such as:
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Seizure diaries or calendars, which record the frequency, duration, type, and triggers of seizures.
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Seizure scales or questionnaires, which measure the severity, impact, and burden of seizures on the patient and the caregiver.
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EEG, which monitors the electrical activity of the brain and detects any epileptiform discharges or patterns.
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Serum drug levels, which measure the concentration of anticonvulsants in the blood and assess their efficacy and toxicity.
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Quality of life scales or questionnaires, which evaluate the physical, mental, emotional, and social wellbeing of the patient and the caregiver.
Seizure Management Skills
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Seizure management skills are the abilities and knowledge that enable a person to respond appropriately and effectively to a seizure event.
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Seizure management skills include the following aspects:
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Seizure observation and documentation: This involves recognizing the signs and symptoms of a seizure, noting the time and duration of the seizure, and recording the details of the seizure in a diary or calendar. This helps to monitor the seizure pattern, identify possible triggers, and evaluate the response to treatment.
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Seizure first aid measures: This involves protecting the person from injury, maintaining a clear airway, loosening tight clothing, turning the person on their side if possible, and staying with the person until they recover. This helps to prevent complications such as aspiration, hypoxia, and trauma.
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Seizure rescue medications: This involves administering emergency medications such as buccal midazolam or rectal diazepam to stop prolonged or recurrent seizures that may lead to status epilepticus. This requires a prescription from a doctor and an individualized protocol for when and how to use them.
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Seizure postictal care: This involves checking the person's vital signs, assessing for injuries or complications, providing reassurance and comfort, and allowing them to rest or sleep if needed. This helps to facilitate recovery and prevent further seizures.
Summary
Nursing Implications of Anticonvulsant Therapy
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Nursing implications of anticonvulsant therapy are the actions and responsibilities that nurses have to perform and consider when caring for patients who are taking anticonvulsants.
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Nursing implications of anticonvulsant therapy include the following aspects:
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Patient education: This involves providing information and instructions to patients and caregivers about anticonvulsant therapy, such as:
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The name, dose, frequency, and route of administration of each anticonvulsant
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The expected benefits and possible side effects of each anticonvulsant
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The importance of taking anticonvulsants as prescribed and not missing or changing doses without consulting a doctor
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The need for regular blood tests and followup visits to monitor the response and safety of anticonvulsant therapy
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The signs and symptoms of toxicity or adverse reactions that require immediate medical attention
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The potential interactions of anticonvulsants with other drugs, foods, or supplements
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The precautions and contraindications of anticonvulsants, such as pregnancy, breastfeeding, liver or kidney impairment, or allergies
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The lifestyle modifications that can help prevent or reduce seizures, such as avoiding triggers, managing stress, getting enough sleep, and avoiding alcohol or drugs
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Compliance: This involves ensuring that patients adhere to their prescribed anticonvulsant regimen and do not stop or alter their therapy without medical advice. Compliance can be enhanced by using reminder devices, pill organizers, calendars, or alarms; involving caregivers or family members; simplifying the regimen; addressing barriers or concerns; and providing positive reinforcement.
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Side effect management: This involves monitoring for and managing the common and serious adverse effects of anticonvulsants. Side effect management can include:
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Assessing for signs and symptoms of drowsiness, dizziness, nausea, vomiting, rash, weight gain or loss, and cognitive impairment; providing supportive measures; adjusting doses; or switching drugs as needed
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Assessing for signs and symptoms of allergic reactions, liver toxicity, blood dyscrasias, StevensJohnson syndrome (a severe skin reaction), teratogenicity (birth defects), and suicidal ideation; reporting them promptly; discontinuing drugs; or administering antidotes as indicated
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Educating patients about the prevention and recognition of side effects; advising them to report any new or worsening symptoms; and encouraging them to seek medical help if needed
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Drug administration: This involves administering anticonvulsants safely and correctly according to the prescribed regimen. Drug administration can include:
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Checking the drug name, dose, route, frequency, expiration date, and contraindications before giving each anticonvulsant
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Following the specific instructions for each anticonvulsant, such as shaking suspensions well; swallowing tablets whole; not crushing or chewing extendedrelease forms; giving with or without food; avoiding grapefruit juice; using calibrated syringes or droppers for liquid forms; applying transdermal patches properly; inserting rectal suppositories gently; or administering intravenous injections slowly and with compatible fluids
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Monitoring the patient's vital signs, seizure activity, and serum drug levels before and after giving each anticonvulsant
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Documenting the administration, response, and any adverse effects of each anticonvulsant
Summary
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Seizures are sudden alterations in behavior due to transient pathology in the brain
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Epilepsy is multiple, unprovoked seizures
-
Status epilepticus is a state of continuous or recurrent seizures without recovery
-
Seizures are classified as partial or generalized based on the brain area involved
-
Anticonvulsants are drugs that prevent or reduce seizures by stabilizing the electrical activity of the brain
-
Anticonvulsants have different mechanisms of action, pharmacokinetics, adverse effects, interactions, and contraindications
-
Anticonvulsant therapy requires careful selection, titration, monitoring, and withdrawal of drugs
-
Nursing implications of anticonvulsant therapy include patient education, compliance, side effect management, and drug administration
-
Seizure management skills include seizure observation and documentation, first aid measures, rescue medications, and postictal care
-
Outcomes of anticonvulsant therapy and seizure management include seizure freedom or reduction, quality of life improvement, and complication prevention
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