Managing Students with Seizures

1
Managing Students with Seizures

• Recognizing Seizure and Their Impact
• Current Treatment Options
• Seizure First Aid
• Seizure Action Plans
• Training Teachers Other School Personnel

2
Role of School Nurse

• Recognize seizure activity and its impact on
  students
• Train teachers and other personnel to recognize
  and manage seizures
• Help create an environment in which the child
  continues to achieve educational goals
• Coordinate with student, parents, the school, and
  the healthcare team.
  
  
• 
  
  
  
  
  

3
Where it all begins

• Recognizing
• Observing
• Documenting
• This can be challenging symptoms are often
• Subtle
• Difficult to detect
• Occur without warning
• Confused with other behavioral or psychological
  problems
• 
  
  

4
What is Epilepsy?

• A disorder characterized by the tendency to have
  recurrent unprovoked seizures
• Recurrent 2 or more
• Epilepsy is also called a
• SEIZURE DISORDER

5
Epilepsy is a Common Problem

• About 2.7 million Americans have epilepsy
• Affects more than 315,000 students in the United
  States
• More than 45,000 new cases are diagnosed annually
  in students
• 1 in 100 people develop epilepsy
• 1 in 10 will have a seizure in their lifetime
• Epilepsy is more common than Cerebral Palsy,
  Multiple Sclerosis and Parkinsons disease
  combined.

6
What Causes Epilepsy?

• For approximately 70 of students who are
  diagnosed with epilepsy the cause is either
• Cryptogenic (of unknown cause) or
• Idiopathic (presumed to be genetic)
• For the remaining 30, the causes are generally
  the same as those for symptomatic seizures

7
Causes of Symptomatic Seizures

• Brain trauma
• Brain lesions (i.e. tubers)
• Poisoning
• Infections of the brain (i.e. meningitis,
  encephalitis, measles)
• High fever
• Brain injury at birth
• Congenital malformations

8
Risk Factors for Childhood Onset Epilepsy

• Seizures at an early age (starting before age 1
  is highest)
• Prior provoked seizures
• Neurodevelopmental delays
• Mental retardation and cerebral palsy

9
Students with Epilepsy

• Students often outgrow epilepsy and are seizure-
  free as adults
• Majority of seizures are not emergencies but a
  part of daily life
• Some students have more than one type of seizure
• Many students have complete or almost complete
  seizure control when they take medication as
  prescribed

10
Seizure Triggers and Precipitants

• Flashing lights and hyperventilation can trigger
  seizures in some
• students with epilepsy
• Factors that might increase the likelihood of a
  seizure in a student with
• epilepsy include
• Missed or late medication (1 reason)
• Stress/anxiety
• Lack of sleep/fatigue
• Hormonal changes
• ETOH or recreational drugs
• Drug interactions
• Overheating/overexertion
• Poor diet/missed meals

11
Seizure Classification

• Generalized Seizures
• Involves whole brain
• Convulsions, staring, muscle spasms,
• and falls
• Most common are absence tonic-clonic
• Partial Seizures (focal)
• Involves only part of brain
• Simple complex forms
• Symptoms relate to the part of the brain
  effected

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Tonic-Clonic Seizure

• A sudden hoarse cry
• Loss of consciousness
• A fall
• Rigidity
• Convulsions (stiffening of arms and legs followed
  by rhythmic jerking)
• Shallow breathing and drooling may occur
• Possible loss of bowel or bladder control
• Occasionally skin, nails, lips may turn blue
• Generally lasts 1 to 3 minutes
• Usually followed by confusion, headache,
  tiredness, soreness, speech difficulty

13
Absence Seizures

• Pause in activity with blank stare
• Brief lapse of awareness
• Possible chewing or blinking motion
• Usually Lasts 1-10 seconds
• May be confused with
• Daydreaming
• Inattentiveness
• ADD

14
Simple Partial Seizures

• Consciousness is not impaired
• Involuntary movements (isolated twitching of
  arms, face, legs)
• Sensory symptoms (tingling, weakness, sounds,
  smells, tastes, visual distortions)
• Psychic symptoms (déjà vu, hallucinations, fear,
  anxiety, a feeling they cant explain)
• Duration is usually less than 1 minute
• May be confused with acting out, mystical
  experience, mental illness or psychosomatic
  illness

15
Complex Partial Seizures

• Altered awareness
• Blank stare/dazed look
• AUTOMATISMS (picking at clothes, lip smacking,
  chewing)
• Nonsensical speech or lip smacking
• Clumsy or disoriented movements
• Aimless walking

• Picking things up
• Often lasts 1 to 3 minutes
• Often followed by tiredness, headache or nausea
• May be confused with
• Drunkenness or drug abuse
• Aggressive behavior

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Secondarily Generalized Seizures

• Partial seizure spreads to involve entire brain
• Begins with simple or complex partial seizure
• May spread rapidly or occur after a typical
  partial seizure
• Generalized seizure may be
• Tonic-Clonic
• Atonic
• Tonic

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Intractability in Epilepsy

• Students with intractable seizures
• Fail to respond to standard antiepileptic drug
  therapy or other treatment modalities
• May have underlying structural brain or
  neurological conditions
• Pose the greatest challenge for the school nurse

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Status Epilepticus

• Medically defined as 30 minutes of uninterrupted
  seizure activity and may include
• one prolonged seizure or
• multiple seizures without recovery to baseline
• Is a medical emergency and requires immediate
  action to stop the seizure activity
• Every students Seizure Action Plan should
  clearly define what constitutes a seizure
  emergency and detail an emergency response plan

19
Non-Epileptic Seizures

• Events that look like epileptic seizures but on
  EEG monitoring have no correlate
• Also called psychogenic seizures or
  pseudoseizures
• Video-EEG monitoring is the most effective way of
  diagnosing
• Can be caused by a variety of psychological
  factors

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Factors that Impact the Student with Seizures

• Affect
• Learning
• Behavior
• Self-concept
• Stigma
• Psychosocial development
• Overall quality of life

• Factors
• Seizures
• Medication side effects
• Underlying brain abnormalities

21
Impact on Learning

• Most students with epilepsy have IQs within the
  normal range
• Risk of learning problems is 3x greater than
  average
• Students with epilepsy may have difficulty with
  memory, attention and concentration
• Students may be eligible for special education
  and related services
• Students who achieve seizure control quickly,
  with few medication side effects, have the best
  chance for normal educational achievement

22
Impact on Psychosocial Development

• There is an association between seizures/epilepsy
  and the following
• Impaired self-image/self-confidence
  (Shame/embarrassment)
• Low self-esteem
• Anxiety
• Delayed social development
• Once seizures are under control, the psychosocial
  impact may outweigh the medical impact.

23
Factors that May Increase the Risk of Learning,
Behavioral and Psychosocial Problems

• Early age of onset
• Multiple lifetime seizures
• High seizure frequency
• Seizures in school
• Memory deficit
• Slowed motor speed

24
Strategies for Reducing Stigma (1)

• Incorporate epilepsy education into health
  curricula for all students include seizure
  first aid
• Appreciate the spectrum of epilepsy hidden
  nature and uniqueness of individual experiences
• Be aware of cultural differences
• Support student involvement in extracurricular
  activities
• Look beyond the seizures assess the impact.
  Coordinate a team approach
• Help the student and family understand any
  limitations that the doctor may put on the
  student

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Strategies for Reducing Stigma (2)

• Educate all school personnel to assist with
  minimizing stigma (myths, first aid, support
  strategies)
• Prevent bullying and teasing when possible
• Teach coping strategies for managing life and
  school
• Help enhance independence address parental
  over-protectiveness if necessary
• Be a resource. Put the family in contact with the
  Epilepsy Foundation affiliate and any other
  resource that may be helpful

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When to Refer to an Epileptologist?

• Uncontrolled seizures and status epilepticus
• When not already under the care of a specialist
• Significant mood and anxiety disturbances
• Major memory and learning deficits
• Sudden change in seizure type
• Signs of medication toxicity or allergy

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Show DVD

• Seizure Disorders and the School

28
Treatment Options

• Antiepileptic Drugs (AEDs)
• PRN medications (acute seizures and seizure
  emergencies)
• Surgery
• Ketogenic Diet
• Vagus Nerve Stimulation (VNS) Therapy

29
Effectiveness of Antiepileptic Drugs (AEDs)

• Before 1993, drug choices for epilepsy were
  limited
• Since 1993, many new products have been
  introduced
• More than 50 of those with newly-diagnosed
  epilepsy become seizure free on medication
• About 75 of those with epilepsy have seizures
  that are well-controlled by medication

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Medications (newer drugs)

• Felbatol (felbamate)
• Gabatril (tiagabine)
• Keppra (levetiracetam)
• Lamictal (lamotrigine)
• Neurontin (gabapentin)
• Trileptal (oxcarbazepine)
• Topamax (topiramate)
• Zonegran (zonisamide)
• Lyrica (pregabalin)

31
Side Effects of AEDs Overview

• AED side effects can be unpredictable. Some are
  dose dependent, while others occur regardless of
  dose
• Newer medications generally have fewer cognitive
  side effects
• Long term effects are unclear, but even mild side
  effects can have a significant impact
• Behavior and mood changes from AEDs are often
  difficult to sort out and are not necessarily
  dose-related

32
Common AED Side Effects

• Dose-related/toxic
• Diplopia, blurry vision
• Dizziness, lightheadedness
• Sedation
• Slowed thinking
• Feels drunk
• Coordination problems
• Unsteady walking

• Drug-related
• Cognitive problems
• Fatigue
• Weight gain or loss
• Cosmetic acne, excessive hairiness or hair loss
• Hyperactivity, slowed movements
• Personality changes
• Mood changes, depression

33
Drug Reaction Warning Signs

• Rash
• Prolonged fever
• Severe sore throat
• Mouth ulcers
• Easy bruising
• Weakness
• Excessive fatigue
• Swollen glands
• Lack of appetite
• Increased seizures
• THESE ARE SERIOUS BUT NOT COMMON!

Contact Childs Healthcare Provider
34
Surgery for Seizures

• Considered after failing AED therapy
• Surgical evaluation includes inpatient video/EEG
  monitoring
• Other tests may include MRI, SPECT scan, PET
  scan, and neuropsychological testing
• Procedures include focal resection, temporal
  lobectomy, lesionectomy, hemispherectomy and
  corpus callosotomy
• Post-surgical seizure-free rates vary
• Patients usually go home after a short stay at
  the hospital and will likely miss several weeks
  or months of school

35
Transient Surgical Side Effects

• Headaches
• Dizziness and unsteadiness
• Aching jaw
• Swelling or bruising of head and face
• Blurred vision
• Depression or mood changes, which are usually
  temporary
• Sensation changes, especially numbness around the
  operation site

36
Ketogenic Diet

• Introduced in the 1920s as a treatment for
  intractable seizures
• Produces ketotic state using diet high in fat and
  low in protein and carbohydrates
• Used mostly with children
• Effective for all seizure types
• May require 2 to 3 days fasting followed by
  strict diet
• Compliance may be problematic
• Side effects can include renal calculi, weight
  loss, cardiomyeopathy and blood abnormalities
• Researchers still dont know exactly how it works

37
Vagus Nerve Stimulation (VNS) Therapy

• A programmable pulse generator implanted
  subcutaneously in upper left chest
• Electrode wrapped around the left vagus nerve
• Exact mechanism of action not known
• Side effects may include hoarseness, coughing and
  shortness of breath and occur during stimulation
  only

38
VNS Magnet Use

• Typically worn on wrist or belt
• If the student has a seizure warning sign (aura)
  he/she or a trained observer may swipe the
  magnet over the VNS device to activate it and
  help abort a seizure
• Magnet may be swiped during an actual seizure to
  shorten seizure length
• Magnet may be used as often as needed with at
  least a minute between swipes
• For a free video and more information visit
  www.vnstherapy.com

39
PRN Medications for Seizures

• Sometimes AEDs are prescribed for students who
  tend to have seizure clusters or status
  epilepticus. Two of these include
• Lorazepam
• Diazepam rectal gel

40
Diazepam Rectal Gel Administration in Schools

• Approved by the FDA for treatment of prolonged
  and clustered seizures
• Approved by the FDA for use by family members and
  other non-medical caregivers
• Often referred to as a seizure rescue
  medication
• Primary concerns expressed by other school nurses
  include privacy, ability to assess when to
  administer, and respiratory depression
• Despite concerns, respiratory depression is NOT a
  common side effect!

41
Diazepam Rectal Gel Administration in Schools
(continued)

• State nurse practice acts and local school
  districts may have specific regulations regarding
  administration
• If prescribed by a physician, regulations and
  impact on the student must be discussed with
  parents to come to a workable solution
• For more information and a free video on the
  administration of diazepam rectal gel, visit
  www.diastat.com

42
Delegation Issues Laws and Mandates

• Applicable Federal laws or mandates that may
  impact
• delegation include
• Section 504 of the Rehabilitation Act of 1973
• Americans with Disabilities Act (ADA)
• Individuals with Disabilities in Education Act
  (IDEA)
• Local and state laws, such as nurse practice acts
  and
• school district policies, generally govern
  the administration
• of medications in schools
• What do the regulations in your state or school
  district say
• about the delegation of medication
  administration?

43
Tips for Effectively Managing Delegation

• Know state nurse practice act and school district
  policies
• Bring parents and school personnel together to
  attempt to find a workable solution
• Explain to all parties that you are obligated to
  put the health, safety and welfare of the student
  first
• Know applicable state and federal mandates and
  laws

44
More Tips for Effectively Managing Delegation

• When a school nurse delegates a task under
  his/her nursing license the nurse is responsible
  for the following
• Insuring that the delegate is appropriate
• Providing training and ongoing assessment and
  documentation of the competence of a delegate
• Ongoing assessment of the student's health
  outcome

45
Routine First Aid Care and Comfort

• Most seizures are not medical emergencies
• Basic first aid has many common elements, but
  varies depending whether there is
• No change in consciousness
• Altered awareness
• Loss of consciousness

46
No change in Consciousness (Simple Partial
Seizure)

• Stay calm
• Time seizure
• Reassure student that he or she is safe
• Explain to others if necessary
• Protect students privacy

47
Altered Awareness (Complex Partial Seizure)

• Speak softly and calmly
• Guide away from potentially harmful objects such
  as tables, chairs and doors
• Allow for wandering in a contained area
• If lasts 5 minutes beyond what is routine for
  that student or another seizure begins before
  full awareness is regained, follow emergency
  protocol
• DO NOT restrain or grab (may result in
  combativeness)
• DO NOT shout or expect verbal instructions to be
  obeyed

48
Loss of Consciousness (Generalized Tonic-Clonic
Seizure)

• Protect from potentially harmful objects
• Observe and time events
• Ensure airway is unobstructed
• Cushion and protect head
• Turn student on one side
• Remain with student until fully conscious
• Follow the students Seizure Action Plan

• DO NOT put anything in mouth
• DO NOT restrain

49
When is a Seizure an Emergency?

• First time seizure
• Convulsive seizure lasting more than 5 minutes
• Repeated seizures without regaining consciousness
• More seizures than usual or change in type
• Student has diabetes or is pregnant
• Seizure occurs in water
• Student is injured
• Parents request emergency evaluation
• Follow the seizure emergency definition and
  protocol as defined by healthcare provider and
  included in the Seizure Action Plan

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Use of PRN Medications

• Prescribed for seizure clusters and prolonged
  seizures
• Emergency protocol should include
• Medication name
• Details about exactly when it should be given
• Specific administration instructions
• Monitor responses and side effects
• Follow Seizure Action Plan emergency response
  protocol

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Tonic-Clonic Seizure in a Wheelchair

• Do not remove from wheelchair unless absolutely
  necessary
• Secure wheelchair to prevent movement
• Fasten seatbelt (loosely) to prevent student from
  falling from wheelchair
• Protect and support head
• Ensure breathing is unobstructed and allow
  secretions to flow from mouth
• Pad wheelchair to prevent injuries to limbs
• Follow relevant seizure first aid protocol

52
Tonic-Clonic Seizure on a School Bus

• Safely pull over and stop bus
• Place the student on one side across seat facing
  away from the seat back (or in the aisle if
  necessary)
• Follow standard seizure first aid protocol until
  the seizure abates and child regains
  consciousness
• Continue to the destination or follow school
  policy

53
Tonic-Clonic Seizure in Water

• Support head so that both the mouth and nose are
  always above the water
• Remove the student from the water as soon as it
  can be done safely
• If the student is not breathing, begin rescue
  breathing
• Always transport the child to the emergency room
  even if he/she appears fully recovered

54
Seizure Action Planning

• Assess student needs and gather information
• Customize a Seizure Action Plan
• Teach school personnel and tailor interventions
  as needed

55
Questionnaire for Parent of a Student with
Seizures

• Can be difficult to get parent(s) to complete
  this form and may take persistence
• May require you to interview the parent(s) to
  clarify information
• Update annually or when any changes occur
• Seizure Observation Record
• To be completed by school personnel when
  reporting a seizure(s)
• Helps to identify seizure triggers, patterns
  precautions

56
Seizure Observation Record

• To be completed by school personnel when
  reporting a seizure(s)
• Helps to identify seizure triggers, patterns and
  precautions

57
Seizure Action Plan

• To be completed by the school nurse
• Provides basic information about students
  seizures, seizure first aid and emergency
  response
• Distribute to relevant school personnel at the
  beginning of a school year, when a diagnosis is
  made or when a change in health status occurs
• Should generally be signed and approved by the
  treating physician

58
Assessment Information Gathering

• Have parent or guardian complete and sign a
  Parent Questionnaire
• Gather seizure history and treatment information
• Speak with the students medical team to clarify
  treatment and emergency response protocol
• Observe and document any in-school seizures
• Speak with teachers and other school personnel
  about
• Possible seizure precipitants (triggers)
• Observed or perceived impact on learning and
  behavior

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Assessment Information Gathering contd

• Consider transportation issues
• Complete a school safety assessment
• Identify activities that may need to be modified
  or necessitate special precautions
• Some students may need a safety helmet
• Determine best method to communicate with parents
  and medical team

60
Communication Tips

• Set up a log for communicating with
  parents/guardians on a daily or weekly basis
• Be a liaison for parents and teachers regarding
  any status changes
• Have teachers regularly note physical, emotional
  or cognitive changes
• Create a substitute teacher folder with the
  Seizure Action Plan and other relevant
  information and keep this folder in a secure
  location

61
Training School Personnel is Important

• Helps enlist the full cooperation of school
  personnel
• Optimizes ability to manage seizures and
  consequences
• Helps insure full integration of the student in
  school activities
• Minimizes stigma

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Goal of Training for School Personnel

• School personnel should be able to
• Recognize seizures and consequences
• Provide appropriate first aid
• Recognize when a seizure is a medical emergency
• Provide appropriate social and academic support
• Understand the Seizure Action Plan

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Essential Training Topics

• What is a seizure? What is epilepsy?
• Who has epilepsy?
• What do seizures look like?
• What are common myths about epilepsy?
• What is appropriate first aid for seizures?
• When is a seizure an emergency?
• What causes seizures?

64
More Essential Training Topics

• What are common seizure triggers?
• What can be done to prevent stigma?
• What is a Seizure Action Plan? How is it best
  used?

65
Optional Topics to Consider as Appropriate

• Seizures outside the classroom (playground, field
  trips, etc.)
• Seizures in a wheelchair
• Seizures on a school bus
• Seizures in the water
• Special issues in treatment
• Use of the Ketogenic diet
• Use of the vagus nerve stimulator magnet
• Use of rescue medication, including rectal
  diazepam

66
Resources

• Seizure Training for School Personnel Toolkit
• Brochures, videos, pamphlets, fact sheets,
  posters
• Seizures and You Take Charge of the Facts. (An
  Epilepsy Awareness Program for Teens)
• Managing Students with Seizures A Quick
  Reference Guide for School Nurses
• To review the product catalogue online, go to
  www.epilepsyfoundation.org and visit the Epilepsy
  Foundations Marketplace
• Materials may be ordered through the local
  Epilepsy Foundation affiliate sponsoring this
  program or by calling 1 [phone]

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www.epilepsyfoundation.org/schoolnurse

• Seizure Action Planning forms (customizable)
• Downloadable fact sheets on key subjects of
  interest to school nurses
• Links to other useful Websites