Epilepsy is a seizure that can be defined as "transient occurrence of neurological signs which occurs due to the abnormal excessive or synchronous neuronal activity in the brain" (Falco-Walter et al., 2018). When these seizures extend beyond the normal and when no recovery is seen, the patient becomes unconscious. This is termed convulsive status epilepticus. This condition is categorized under medical emergencies as it is associated with high morbidity and mortality. It is defined as convulsive status epilepticus when the seizures occur and last for more than 5 minutes or when there are continuous seizures and the patient loses consciousness (Grover et al., 2016). This paper aims to discuss the etiology of both the conditions and the associated nursing management and assessments, and health promotion strategies.
For the proper management of the condition, the physician and pediatrician along with the healthcare team must properly identify the etiology of the condition as this will create an impact on effective management and prognostic counselling. International League against epilepsy has defined six etiologic factors namely- structural, genetic, infection, metabolic, immune and idiopathic. Structural etiology is related to the deformities which can be seen in the electroencephalogram but this cannot define the occurrence of epilepsy (Lapalme-Remis & Cascino, 2016; Scheffer et al., 2017). Epilepsy can have a genetic etiology, a child who might have a family history or genetic predilection for epilepsy also has chances of getting the disease (Falco-Walter et al., 2018). Genetic history is just a chance but it does not necessarily mean the disease will occur (Falco-Walter et al., 2018).
Additionally, infection-seizure can occur in a patient who might have some kind of acute infection but the prevalence of this is seen in people who do not have a history of epilepsy but in patients who have epilepsy it can have exaggerated response (Vezzani et al., 2016). Moreover, transient disturbances in the metabolism of the body often result in acute symptomatic seizures but the isolated occurrence of this is not well documented (Falco-Walter et al., 2018). Furthermore, auto-immunity is the etiology that is associated with the causation of epilepsy where the cells of the body attack the cells in the body leading to the formation of neuronal antibodies and neuronal cell surface antibodies. Sometimes there is no associated cause for epilepsy and in these cases, it is called idiopathic.
Like Craig, convulsive status epilepticus is one of the most common neurological medical emergencies which are faced in the pediatric department. In the case of Craig, it was a remote status epilepticus where is there might have an acute insult and the patient had a normal central nervous system but there is a history of epilepsy (Lu et al., 2018).
Convulsive status epilepticus has similar pathophysiology as that of epilepsy and its acute inception is most commonly seen in pediatric cases and accounts for 35% of cases (Brenton, 2019). The etiology of the condition is variant like it can be due to acute infection, head trauma, hypoxemia, hypoglycemia, and also due to withdrawal of the drug (Varelas & Claassen, 2017). Acute infection often sends systems in the body into a frenzy that affects the brain activity and in turn there is no linear release of neurotransmitter which leads to the condition and this is more common in pediatric patients. Head trauma is the next cause as it affects the brain directly similar to like hypoxia and hypoglycemia as the brain activity reduces which will cause the brain to release neurotransmitters causing status epilepticus (Dingman et al., 2018). The last reason which is most appropriate in the case of Craig is that he was diagnosed with epilepsy recently and there is recent history that due to self-management he is not taking his medication and it is the reason that the brain activity which was accustomed to the medication reacted differently.
Various types of nursing management exist depending on the patient and the area for which the management is required. Status epilepticus is a condition in which the patient has prolonged seizures but when these seizures get prolonged and the patient is not able to recover from it, management of the condition becomes urgent. The management of the seizures in pediatric cases is important and it should be followed in a systematic manner that should be evidence-based. The guidelines are given by the New South Wales government, health guidelines (2018) by which the management of the pediatric patients who have been diagnosed with seizure should be taken care of in the department. If the conscious state of the child has not improved after the seizure he may be in the subclinical state and the urgency of the treatment increases. The rationale behind the guidelines given is that in children who have an acute episode of epilepsy and the duration of the seizure is prolonged more than 30 minutes there is a chance of 0-2% mortality (New South Wales Government, 2018).
In the case of Craig, as he was previously diagnosed with epilepsy and the management of which was home administered but the history of follow-up is not mentioned in the case given and the child stopped his medication without any supervision. The support is always provided in a hospital care centre which the caretaker of the patient has ensured has happened with the patient. Before the commencement of the treatment proper nursing assessment must be done (New South Wales Government, 2018). For assessment, pediatric nursing assessment and care plan given by the New South Wales government template can be used. The nursing assessment section contains the weight, height, head circumference, diet in terms of frequency and quantity and documented allergies, any medication given to the patient. The other information that is recorded is child’s toilet trained bowel routines; sleep patterns and any other information that may be required. The planned nursing care is contained in the template and this portion is to be filled bedside. The portion contains the clinical pathway used, interval of standard observation, oxygen therapy used, special observations in addition to SPOC, nutritional needs, the toileting, hygiene maintenance, mobility, any pressure area care, skin inspection, risks of fall, safety and security, infection control measures, other care and the care discussed with the parent or carer (New South Wales Government, 2017). This assessment sheet also contains information of next of kin and this document is to be discussed with the parents and duly signed by them.
The acute management of the seizures for infants and children is time-sensitive and its management should commence from the moment the seizure activity starts. The first step towards the management is to assess and support the airway, breathing, and circulation for the patient. The reason behind doing this is to maintain oxygenation in the brain and ensure that the patient does not undergo oxidative stress. The airway is to be kept clear at all times if the airway is not it should be made clear by maintaining the head or chin is lifted which is called a jaw thrust manoeuver and this should be done only when the child is in the supine position. After the seizure has subsided, the child should be kept on the side to assist in easy breathing. The next is breathing and three things should be followed for the assessment of breathing namely, look, listen and feel and three things that should be checked for are the effort in breathing, efficacy of breathing and effects of breathing. In the efforts, the assessment to be done includes respiratory rate, recession, and breath sounds like grunting; in the efficacy of breathing, breath sounds, expansion of chest and the oxygen saturation of the arterial blood by the use of pulse oximeter; in effects, heart rate and skin colour are assessed (New South Wales Government, 2018).
Once the airway patency is established and if the child is struggling to breathe, a high flow of oxygen can be given to the patient by the use of bag-valve-mask-device. The circulation is assessed by the adequacy of the cardiovascular status of the patient, that is, by heart rate, pulse volume, capillary refill, and blood pressure. For the assessment of neurological function, alert, voice, pain, unresponsive (AVPU) score can be used. The posture of the child should be taken into consideration and signs of meningitis as it may cause cerebrovascular depression. The temperature of the patient should be measured and the fluid or electrolyte imbalance should be assessed and adequate replacement should be given. Continuous monitoring and reassessment of A-G and the documentation should be after each dose of antiepileptic medication, every five minutes while the seizure continues and after every 15 minutes after a seizure until the level of consciousness returns to normal (New South Wales Government, 2018).
In the emergency management for the prolonged seizure, the drug of choice is midazolam followed by diazepam and phenytoin and the routes of administration are oral and intravenous respectively. Even though the patient is known to the neurological team it is required that the focused history is taken and information required are any febrile illnesses, the neurologic state before the seizure, recent trauma, medical history, medications and allergies, and immunization history (New South Wales Government, 2018). The care planned should always be a patient-centric approach but as the patient is pediatrics and does not have consent so in that case, the family of the patient is the one that needs to be involved in the care. In recent times the guiding principles of pediatric health have shifted towards family-centred care (Hill et al., 2018).
The participation of the patient and family of the patient in the care plan development means they will have active participation in healthcare (Coyne et al., 2018). Person-centred care has the patient as the focus of the care but in pediatric setting the centre is the child but as they do not have autonomy but still keeping the child at the centre family-centred approach is advised. Craig is brought to the hospital by his grandmother and his parents are on the way, while grandmother is the family and the emergency treatment is required the assessment, monitoring and emergency management are done. Any significant decisions like conduction of any invasive procedure should be done only after the legal guardians have arrived in this case parents but complete disengagement of grandmother should not be there.
Epilepsy has often been associated with social stigma due to the medieval concept of health and disease (Reilly et al., 2018). The first step towards the self-management is to not let the stigma effect and prevention is always better than cure and prevention can be achieved by health promotion. Health promotion is to be provided to the child as well as their parents because the involvement of the family will increase the involvement of the child for his betterment. The child should be informed about his condition and age-appropriate material can be found on the website given by the government of Australia called Epilepsy Smart Schools (Epilepsy action Australia, n.d.). The information available is not limited merely to the ones needed by the children but also for the parents, teachers and anyone else who is involved in the care process of the child (Epilepsy action Australia, n.d.). The health promotion is achieved by complete involvement of the family and the child and leading a healthy life with epilepsy involves altering lifestyle to a healthy one such as eating healthy, having healthy sleep, less strain, etc. (Victoria State Government, n.d.).
Epilepsy is a neurological condition that causes seizures in the patient which occurs due to the release of neurotransmitters in an unexpected and synchronized pattern. In some conditions with or without the history of epilepsy, a patient may develop convulsive status epileptics and the patient may lose consciousness making its management critically important. There are many etiological factors which are responsible for the condition like acute infections, or withdrawal of drugs. Nurses are expected to follow the guidelines provided by the national guidelines and the documentation should be proper so that adequate care can be provided. As the patient is a child, the autonomy of the patient is dependent on the family and the care plan should be done accordingly and health promotion is the type of prevention that can be done to make sure that the episode is not repeated.
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