Drugs for seizures chapter 15
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15. Drugs for Seizures Chapter 15. (“analeptics”). OVERVIEW: Neuro System. escitalopram (Lexapro). Tri-Cyclic Antidepressant. Antidepressant / Anxiolytic. MAOIs. Benzodiazepines. lorazepam (Ativan) diazepam (Valium). GABA Antagonist. zolpidem (Ambien). A.

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Drugs for Seizures Chapter 15

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Drugs for seizures chapter 15

15

Drugs for Seizures

Chapter 15

(“analeptics”)


Drugs for seizures chapter 15

OVERVIEW:

Neuro System

escitalopram (Lexapro)

Tri-Cyclic Antidepressant

Antidepressant /

Anxiolytic

MAOIs

Benzodiazepines

lorazepam (Ativan)

diazepam (Valium)

GABA Antagonist

zolpidem (Ambien)

A

phenytoin (Dilantin)

valproic acid (Depakote)

Phenytoin-Like

Drugs

Succinimides

ethosuximide (Zarontin)

phenobarbital (Luminal)

Barbiturates

Phenothiazines

chlorpromazine (Thorazine)

Non-Phenothiazines

halperidol (Haldol)

Opioids

morphine (Infumorph)

Atypical Antipsychotics

risperidone (Risperdal)

aspirin (ASA)

Salicylates

ibuprofen (Motrin)

NSAIDs

acetaminophen (Tylenol)

Non-Opioid

tramadol (Ultram)

Central Acting

ergotamine (Cafergot)

Sumatriptan (Imitrex)

Anti-Migraine

Opioid Antagonists

naloxone (Narcan)


Learning outcomes

Learning Outcomes

  • 1. Describe the nurse’s role in the pharmacologic management of seizures of an acute nature and epilepsy.

  • 2. Categorize drugs used in the treatment of seizures based on their classification and mechanism of action.

  • 3. Use the nursing process to care for patients receiving drug therapy for epilepsy and seizures.

  • 4. For each of the drug classes, know representative drug examples and explain their mechanism of drug action, primary actions, and important adverse effects.


Anti seizure pharmacotherapy

Anti-seizure Pharmacotherapy

  • Goal: suppress neuronal activity enough to prevent abnormal or repetitive firing

  • Drugs act through three mechanisms:

    • Stimulating an influx of chloride ions

    • Delaying an influx of sodium

    • Delaying an influx of calcium

  • Directed at controlling movement of electrolytes across neuronal membranes or affecting neurotransmitter balance

  • Some drugs act by more than one mechanism


Drugs for seizures chapter 15

Pharmacotherapy Illustrated: Model of the GABA Receptor–Chloride Channel Molecules in Relationship to Antiseizure Pharmacotherapy


Barbiturates and gaba agents

Barbiturates and GABA Agents

Monitor Patient’s condition

Liver and kidney function

Pregnancy Category D

Common side effects


Patient teaching

Patient Teaching

Use reliable contraception

Immediately report pregnancy

Report excessive signs of bleeding

Report drowsiness and bone pain


Drugs that potentiate gaba action

Drugs that Potentiate GABA Action

Act by changing the action of gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter in the brain

Predominate effect of GABA potentiation is CNS depression


Benzodiazepines schedule iv drug

Benzodiazepines—Schedule IV Drug

Monitor for drug-abuse potential

Pregnancy risk—Pregnancy Category D

Contraindicated in narrow-angle glaucoma

Respiratory depression may result with other CNS depressants.

Common side effects include dizziness, drowsiness

Overdose—give flumazenil (Romazicon)


Patient teaching1

Patient Teaching

Avoid alcohol, OTC drugs, and herbal medications

Avoid nicotine

Avoid driving and hazardous activities

Rebound seizures if discontinued abruptly

Take with food

Drug often used illegally


Hydantoin and phenytoin like drugs

Hydantoin and Phenytoin-like Drugs

Monitor serum-drug levels

Monitor for signs of toxicity

Monitor for blood dyscrasias and bleeding disorders

Monitor liver and kidney function

Fatal hepatotoxicity can occur


Hydantoin and phenytoin like drugs contraindications

Hydantoin and Phenytoin-like Drugs Contraindications

Patients with hypersensitivity to hydantoin products should be cautious.

Rash, seizures due to hypoglycemia, sinus bradycardia, and heart block


Patient teaching2

Patient Teaching

Routine labs for serum level

Routine labs for liver and kidney function

Immediately report signs of toxicity

Immediately report unusual bleeding

Immediately report liver or brain disease

Immediately report heart block, hypoglycemia, or pregnancy


Succinimides

Succinimides

Do not abruptly withdraw medication

Use with caution with antiseizure medications, phenothiazines, and antidepressants

Pregnancy risk—pregnancy Category C


Common adverse reactions

Common Adverse Reactions

Drowsiness, headache, fatigue, dizziness

Depression or euphoria

Nausea, vomiting, weight loss

Abdominal pain


Life threatening reactions

Life-Threatening Reactions

Severe mental depression with suicide intent

Stevens-Johnson syndrome

Blood dyscrasias


Patient teaching3

Patient Teaching

Immediately report mood changes or suicidal thoughts

Avoid driving and hazardous activities

Do not suddenly stop taking

Take with food

Report symptoms of fever or sore throat

Report weight loss and anorexia


Dosage procedure

Dosage Procedure

Start with smallest initial dose

Add additional drugs, if necessary

Ensure compatibility with other medications

Monitor serum-drug levels


Withdrawal of antiseizure medications

Withdrawal of Antiseizure Medications

Should be seizure free at least three years

Withdraw gradually over several months

Resume medications if seizures return

Be aware of rebound seizures


Drugs that potentiate gaba action1

Drugs That Potentiate GABA Action

Barbiturates

Benzodiazepines

Miscellaneous GABA agents


Barbiturates

Barbiturates

Prototype drug: phenobarbital (Luminal)

Mechanism of action: changing the action of GABA

Primary use: controlling seizures

Adverse effects: dependence, drowsiness, vitamin deficiencies, laryngospasm


Prototype drug phenobarbital luminal

Prototype Drug: Phenobarbital (Luminal)


Benzodiazepines

Benzodiazepines

Prototype drug: diazepam (Valium)

Mechanism of action: similar to that of barbiturates but safer

Primary use: for short-term seizure control

Adverse effects: drowsiness and dizziness


Prototype drug diazepam valium

Prototype Drug: Diazepam (Valium)


Diazepam animation

Diazepam Animation

Click here to view an animation on the topic of diazepam.


Hydantoins

Hydantoins

Prototype drug: phenytoin (Dilantin)

Mechanism of action: to densitize sodium channels

Primary use: treating all types of epilepsy except absence seizures

Adverse effects: CNS depression, gingival hyperplasia, skin rash, cardiac dysrhythmias, and hypotension


Prototype drug phenytoin dilantin

Prototype Drug: Phenytoin (Dilantin)


Prototype drug phenytoin dilantin1

Prototype Drug: Phenytoin (Dilantin)


Phenytoin like drugs

Phenytoin-Like Drugs

Prototype drug:Valproic acid (Depakene)

Mechanism of action:to desensitize sodium channels

Primary use:for absence seizures

Adverse effects:limited CNS depression, visual disturbances, ataxia, vertigo, headache

Additional adverse reactions:gastrointestinal effects, hepatotoxicity, pancreatitis


Valproic acid animation

Valproic Acid Animation

Click here to view an animation on the topic of valproic acid.


Prototype drug valproic acid depakene depakote

Prototype Drug: Valproic Acid (Depakene, Depakote)


Succinimides1

Succinimides

Prototype drug:ethosuximide (Zarontin)

Mechanism of action:suppress calcium influx

Primary use:for absence seizures

Adverse effects:rare but include drowsiness, dizziness, lethargy

Very rare but serious side effects:systemic lupus erythematosis, leukopenia, aplastic anemia, Stevens-Johnson syndrome


Prototype drug ethosuximide zarontin

Prototype Drug: Ethosuximide (Zarontin)


Drugs that potentiate gaba action2

Drugs That Potentiate GABA Action

Include barbiturates, benzodiazepines, and miscellaneous GABA agents

Suppress the firing ability of neurons


Treating seizures with barbituates

Treating Seizures with Barbituates

Low margin for safety

High potential for dependence, and they cause

Profound CNS depression

Overall effective against all major seizure types except absence seizures


Examples of barbiturates

Examples of Barbiturates

Phenobarbital (Luminal)

Amobarbital (Amytal)

Secobarbital (Seconal)

Pentobarbital (Nembutal)


Treating seizures with benzodiazepines

Treating Seizureswith Benzodiazepines

Indications include absence seizures and myoclonic seizures

Tolerance may develop quickly

one of most widely prescribed classes, used also for anxiety, skeletal muscle spasms, and alcohol withdrawal symptoms


Examples of benzodiazepines

Examples of Benzodiazepines

Clonazepam (Klonopin)

Clorazepate (Tranxene)

Lorazepam (Ativan)

Diazepam (Valium)


Newer gaba related drugs

Newer GABA-related Drugs

Gabapentin (Neurontin)

Pregabalin (Lyrica)

Tiagabine (Gabitril)

Topiramate (Topamax)


Hydantoin and newer drugs

Hydantoin and Newer Drugs

Delay an influx of sodium ions across neuronal membranes

Sodium movement is factor that determines whether neuron will undergo an action potential

Sodium channels are not blocked; they are just desensitized


Treating seizures with hydantoins and related drugs

Treating Seizures With Hydantoins and Related Drugs

Useful in treating all types of epilepsy except absence seizures

Provides effective seizure suppression, without the abuse potential or CNS depression associated with barbiturates

Phenytoin-related drugs used less frequently


Examples of hydantoins

Examples of Hydantoins

Phenytoin (Dilantin)—most common

Fosphenytoin (Cerebyx)


Examples of phenytoin like drugs

Examples of Phenytoin-like Drugs

Carbamazepine (Tegretol)—tonic-clonic and partial seizures

Felbamate (Felbatol)

Lamotrigine (Lamictal)

Valproic acid (Depakene, Depakote)—absence seizures

Zonisamide (Zonegran)


Treating seizures with succinimides

Treating Seizures with Succinimides

Suppress seizures by delaying calcium influx into neurons

Generally only effective against absence seizures

Ethosuximide (Zarontin) is the most commonly prescribed drug in this class


Succinimides2

Succinimides

Examples of succinimides

Ethosuximide (Zarontin)

Methsuximide (Celontin)

Phensuximide (Milontin)


Nclex rn review question 1

NCLEX-RN ReviewQuestion 1

The nurse evaluates patient teaching related to causes of seizures. Further teaching is needed if the patient makes which of the following statements?

  • “Seizures can be caused by inflammation of the brain.”

  • “Seizures can be caused by low blood sugar.”

  • “My relative had seizures because of a large tumor growing in his muscles.”

  • “Seizures may occur after a head injury.”


Nclex rn review question 1 answer

NCLEX-RN ReviewQuestion 1 – Answer

“Seizures can be caused by inflammation of the brain.”

“Seizures can be caused by low blood sugar.”

“My relative had seizures because of a large tumor growing in his muscles.”

“Seizures may occur after a head injury.”


Nclex rn review question 1 rationale

NCLEX-RN ReviewQuestion 1 – Rationale

Rationale: Seizures may be caused by inflammation, head injuries, or low blood sugar levels. Rapid-growing, space-occupying lesions in the brain, which increase intracranial pressure, may cause seizures, but not tumors, within the muscles.


Nclex rn review question 2

NCLEX-RN ReviewQuestion 2

The nursing student asks the nurse to explain the action of the antiseizure medication, phenytoin. The nurse explains the mechanism of action as:

  • Suppression of the influx of chloride into the neuron

  • Stimulation of the influx of calcium into the neuron

  • Suppression of the influx of sodium into the neuron

  • Stimulation of calcium and sodium needed to suppress seizure activity


Nclex rn review question 2 answer

NCLEX-RN ReviewQuestion 2 – Answer

Suppression of the influx of chloride into the neuron

Stimulation of the influx of calcium into the neuron

Suppression of the influx of sodium into the neuron

Stimulation of calcium and sodium needed to suppress seizure activity


Nclex rn review question 2 rationale

NCLEX-RN ReviewQuestion 2 – Rationale

Rationale: The influx of sodium into a neuron enhances neuronal activity. The delay of an influx suppresses neurotransmitter frequency.


Nclex rn review question 3

NCLEX-RN ReviewQuestion 3

The nurse recognizes that several chemicals inhibit neurotransmitter function in the brain. The primary inhibitory transmitter in the brain is:

  • Sodium

  • GABA

  • Chloride

  • Calcium


Nclex rn review question 3 answer

NCLEX-RN ReviewQuestion 3 – Answer

Sodium

GABA

Chloride

Calcium


Nclex rn review question 3 rationale

NCLEX-RN ReviewQuestion 3 – Rationale

Rationale: GABA drugs mimic GABA by stimulating the influx of chloride ions into the neuron, leading to the suppression of neuron firing.


Nclex rn review question 4

NCLEX-RN ReviewQuestion 4

The patient, age 8, is prescribed valproic acid (Depakene) for treatment of a seizure disorder. The nurse should monitor the patient closely for:

  • Hyperthermia

  • Vitamin B deficiency

  • Restlessness and agitation

  • Respiratory distress


Nclex rn review question 4 answer

NCLEX-RN ReviewQuestion 4 – Answer

Hyperthermia

Vitamin B deficiency

Restlessness and agitation

Respiratory distress


Nclex rn review question 4 rationale

NCLEX-RN ReviewQuestion 4 – Rationale

Rationale: Valproic acid may produce an idiosyncratic response in children, including restlessness and psychomotor agitation.


Nclex rn review question 5

NCLEX-RN ReviewQuestion 5

Discharge teaching for a patient receiving carbamazepine (Tegretol) should include:

  • Monitoring blood glucose and reporting decreased levels

  • Expecting a discoloration of contact lenses

  • Immediately reporting unusual bleeding or bruises to the health care provider

  • Expecting a green discoloration of urine


Nclex rn review question 5 answer

NCLEX-RN ReviewQuestion 5 – Answer

Monitoring blood glucose and reporting decreased levels

Expecting a discoloration of contact lenses

Immediately reporting unusual bleeding or bruises to the health care provider

Expecting a green discoloration of urine


Nclex rn review question 5 rationale

NCLEX-RN ReviewQuestion 5 – Rationale

Rationale: Carbamazepine affects vitamin K metabolism and may lead to blood dyscrasias and bleeding.


Drugs for seizures chapter 15

Pathophysiology

Of Seizures

/

Discussion


Seizures

Seizures

Abnormal or uncontrolled neuronal discharges in the brain

Affect

Consciousness

Motor activity

Sensation

Symptom of an underlying disorder


Convulsion

Convulsion

Involuntary violent spasm of large muscles of face, neck, arms, and legs

Not synonymous with seizure


Different etiologies of seizure activity

Different etiologies of seizure activity

Most common serious neurologic problem affecting children

May present as an acute situation, or they may occur on a chronic basis


Known causes of seizures

Known Causes of Seizures

Infectious diseases

Trauma

Metabolic disorders

Vascular diseases

Pediatric disorders

Neoplastic disease


Additional known causes of seizures

Additional Known Causes of Seizures

Medications

High doses of local anesthetics

Eclampsia

Drug abuse

Withdrawal syndromes from alcohol or sedative-hypnotic drugs


Pregnancy and epilepsy

Pregnancy and Epilepsy

Several antiseizure drugs decrease effectiveness of oral contraceptives

Most antiseizure drugs are pregnancy category D

Eclampsia - severe hypertensive disorder of pregnancy, characterized by seizures, coma, and perinatal mortality


Epilepsy

Epilepsy

Seizures occurring chronically

International Classification of Epileptic Seizures

Partial (focal)

Generalized

Special epileptic syndromes


Seizures in neonates infants and children

Seizures in Neonates, Infants, and Children

Congenital abnormalities of CNS

Perinatal brain injury

Metabolic imbalances


Later childhood etiology

Later-Childhood Etiology

CNS infections

Neurological degenerative disorders

Inherited epilepsies


Adult etiology

Adult Etiology

Cerebral trauma

Cerebrovascular disorders

Neoplastic disease


Signs and symptoms of seizures

Signs and Symptoms of Seizures

Related to area of brain with abnormal activity

International Classification of Epileptic Seizures: classifies seizures


Simple partial seizures

Simple Partial Seizures

Olfactory, auditory, and visual hallucinations

Intense emotions

Twitching of arms, legs, and face


Complex partial psychomotor seizures

Complex Partial (psychomotor) Seizures

Aura (preceding)

Brief period of confusion or sleepiness afterward with no memory of seizure (postictal confusion)

Fumbling with or attempting to remove clothing

No response to verbal commands


Generalized seizures

Generalized Seizures

Absence (petit mal)

Atonic (drop attacks)

Tonic-clonic (grand mal)


Absence seizures

Absence Seizures

Lasting a few seconds

Seen most often in children (child stares into space, does not respond to verbal stimulation, may have fluttering eyelids or jerking)

Misdiagnosed often (especially in child) as ADD or daydreaming


Atonic seizures

Atonic Seizures

Falling or stumbling for no reason

Lasting a few seconds


Tonic clonic seizures

Tonic-Clonic Seizures

Preceeded by aura

Intense muscle contraction (tonic phase) followed by alternating contraction and relaxation of muscles (clonic phase)

Crying at beginning as air leaves lungs; loss of bowel/bladder control; shallow breathing with periods of apnea; usually lasting 1–2 minutes

Disorientation and deep sleep after seizure (postictal state)


Special syndromes

Special Syndromes

Febrile seizures

Myoclonic seizures

Status epilepticus


Febrile seizures

Febrile Seizures

Tonic–clonic activity lasting 1–2 minutes

Rapid return to consciousness

Occurs in children usually between 3 months and 5 years of age


Myoclonic seizures

Myoclonic Seizures

Large jerking movements of a major muscle group, such as an arm

Falling from a sitting position or dropping what is held


Status epilepticus

Status Epilepticus

Considered a medical emergency

Continuous seizure activity, which can lead to coma and death


Choice of drug depends upon

Choice of Drug Depends Upon

Type of seizure

Patient’s history and diagnostic studies

Associated pathologies


Once medication is selected

Once Medication is Selected

Patient placed on low initial dose

Amount gradually increased

If seizure activity remains, different medication added in small increments

Newer antiseizure drugs have less adverse side effects than older drugs

Most cases require only a single drug


New fda warnings

New FDA Warnings

Study included patients with epilepsy, bipolar disorder, psychoses, migraines, and neuropathic pain

Popular antiseizure examples found to almost double risk of suicidal behavior and ideation


Drugs for seizures chapter 15

Nursing

Process


Drug therapy for epilepsy

Drug Therapy for Epilepsy

Assessment

History of seizure activity

Allergies and drug history

Knowledge of disease process

Knowledge of drug therapy

Patient lifestyle


Drug therapy for epilepsy cont d

Drug Therapy for Epilepsy (cont'd)

Nursing Diagnoses

Low Self-Esteem (situational or chronic; related to disease effects)

Impaired Social Interaction (related to disease, lack of seizure control)

Deficient Knowledge (drug therapy)

Risk for Injury (related to seizures or adverse drug effects)


Drug therapy for epilepsy cont d1

Drug Therapy for Epilepsy (cont'd)

Planning

Experience therapeutic effects dependent on the reason the drug is given

Be free from, or experience minimal, adverse effects.

Understanding of disease and drug regimen and purpose

Understanding of drug regimen

Demonstrate proper self-administration


Drug therapy for epilepsy cont d2

Drug Therapy for Epilepsy (cont'd)

Implementation

Monitoring neurological status

Ensuring lab values in normal range

Patient/family teaching about disease

Patient/family teaching about drugs

Patient/family teaching about care during seizure activity


Drug therapy for epilepsy cont d3

Drug Therapy for Epilepsy (cont'd)

Evaluation

Effectiveness of drug therapy

Patient goals


Nursing process focus patients receiving antiseizure drug therapy

Nursing Process Focus: Patients Receiving Antiseizure Drug Therapy


Nursing process focus patients receiving antiseizure drug therapy1

Nursing Process Focus: Patients Receiving Antiseizure Drug Therapy


Nursing process focus patients receiving antiseizure drug therapy2

Nursing Process Focus: Patients Receiving Antiseizure Drug Therapy


Nursing process focus patients receiving antiseizure drug therapy3

Nursing Process Focus: Patients Receiving Antiseizure Drug Therapy


Nursing process focus patients receiving antiseizure drug therapy4

Nursing Process Focus: Patients Receiving Antiseizure Drug Therapy


Nursing process focus patients receiving antiseizure drug therapy5

Nursing Process Focus: Patients Receiving Antiseizure Drug Therapy


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