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Chapter 2
Case Discussion/Presentation
Chapter Overview
This chapter presents the case discussion/presentation
and the overview of related literature and studies on the
subjects made by the researcher during exploration stage of
the case finding.
Review of Anatomy and Physiology of the Nervous System
Figure 1. Picture of the brain.
(www.images-search/yahoo.com)
The Nervous System is responsible for sensory and
perception of feelings and initiate voluntary and
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involuntary actions based on signals transmitted through the
nerves to the brain.
The brain and the nervous system have multiple
functions that are vital for normal functioning of the body.
A nerve impulse is essentially an electrical stimulus that
travels over the cell's membrane. It passes through the
axons and dendrites of the neurons. It travels via the
dendrites from the skin and then reaches the cell body,
axon, axon terminals and the Synapse of the neuron.
The Synapse is the junction between two neurons where
the impulse moves from one to the other. At the synapse
neurotransmitters are present These are chemical
transmitters of messengers that transmit the impulse. They
include Acetylcholine and Noradrenaline.
The impulse continues to the next dendrite, in a chain
reaction till it reaches the brain that in turn instructs
the skeletal muscles to work.
These reflexes are automatic, involuntary responses.
They may or may not involve the brain for example blinking
does not involve the brain. The Reflex arc is the main
functional unit of the nervous system that helps a person
reacts to a stimulus.
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The brain is one of the largest and most complex organs
in the human body. It is made up of more than 100 billion
nerves that communicate in trillions of connections called
synapses. The brain is made up of many specialized areas
that work together:
The cortex is the outermost layer of brain cells.
Thinking and voluntary movements begin in the cortex.
The brain stem is between the spinal cord and the rest of
the brain. Basic functions like breathing and sleep are
controlled here. The basal ganglia are a cluster of
structures in the center of the brain. The basal ganglia
coordinate messages between multiple other brain areas.
The cerebellum is at the base and the back of the brain and
is responsible for coordination and balance.
The brain is also divided into several lobes: The frontal
lobes are responsible for problem solving and judgment and
motor function. The parietal lobes manage sensation,
handwriting, and body position. The temporal lobes are
involved with memory and hearing. The occipital lobes
contain the brain's visual processing system.
The brain is surrounded by a layer of tissue called the
meninges. The skull (cranium) helps protect the brain from
injury (Essentials of Anatomy and Physiology, 2009).
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Pathophysiology (Brunner and Suddhart’s, 2012)
Figure 2. Pathophysiology of Seizure. Book-based.
Risk factors are the key factors that will determine if
a person will have seizure or not. If you have one or more
of the risk factors, your brain cells tend to function
abnormally when it send electrochemical signals. Once the
erratic cells perform erratically, there will be an
abnormality with the chemical responsible for brain
activity. This will now lead to abnormal brain activity
which will cause seizure activity. And if the seizures occur
Risk Factors: Genetics
Childhood abuse or trauma to the head
Environmental
Seizure activity
Continuous seizures, Epilepsy
Sending abnormal brain signals/chemical disturbance
Erratic cells perform erratically
The brain sending out abnormal signals to the erratic cells
Cells send electrochemical signals even after the task is done
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repeatedly, then the client will be diagnosed with epileptic
syndrome.
Pathophysiology (client-based)
Risk Factors:
Genetics
Figure 3. Pathophysiology. (Client-based)
The client has a family history of seizure disorder.
Aside from having familial tendencies, what triggered the
seizure disorder in the client was having a very high fever
of 39.1 degrees Celsius after the first vaccination of
Hepatitis B Vaccine. It made the brain perform erratically
by sending an abnormal signal. The client experienced the
signs and symptoms of seizure activity. It is called febrile
seizure because the seizure was triggered by the very high
body temperature.
A very high fever of 39.1
Staring into space and appeared confused and irritable. Unusually sleepy (abnormal brain activity)heart racing, strong pulse.
Rigid body parts and loss of consciousness
Seizure Activity
Continous seizure
Epilepsy
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Signs and Symptoms
Epilepsy signs and symptoms vary from person to person
but there are symptoms that are generalized.
Table 5. Signs and Symptoms
Book based (Brunner and
Suddhart’s, 2012)
Client Based
Aura-a sensation at the start
of a seizure, may involve the
perception of an odd smell or
sound, spots appearing in
front of the eyes, or unusual
stomach sensations; an aura
is a seizure
The client was unable to
verbalize if there has been a
feeling of aura.
Staring Before the start of seizure,
mother claims that the client
was staring into space.
Loss of consciousness The client lost consciousness
a few moments after they
noticed that the client was
staring into space.
Repeated jerking of a single
limb
The mother did not notice any
jerking movement made by the
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client
Hand rubbing The mother did not notice any
hand rubbing
Lip smacking The mother notice a lip
smacking which sometimes lead
to lips bleeding
Picking at clothing The mother did not notice any
picking at clothing
Fear/Panic The client did not exhibit
any fear or panic
Heart racing, Palpitations The mother claimed that the
client exhibit heart racing
and the strong pulse
Perception of an odor, taste
or smell
None as claimed by the client
Loss of bowel or bladder
control
Nothing was noted
Postictal state a state of
drowsiness, alteration in
responsiveness, and or
confusion
The client seemed irritable
and confused and unusually
sleepy.
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Foot stomping Nothing was noted
Unable to move body parts The client was unable to move
as noted by the mother before
he lost consciousness
This table shows the signs and symptoms exhibited by
the client on the onset of seizures as explained by her
mother. The Client experiences loss of consciousness few
moments after the noticing staring into space, then jerking
of the extremities then he will pass out.
Risk Factors
The risk factors include genetic factors, childhood
abuse or head trauma, environmental factors, drug overdose,
chemical abnormalities, and history of complex febrile
seizures.
If you already have an epilepsy, the following factors
can increase your chance of having an epilepsy:
Sleep deprivation
Alcohol
Hormonal changes (such as those that occur at points
during the menstrual cycle)
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Stress
Flashing lights, especially strobe lights
Use of certain medicines
Missing doses of anti-epileptic medicines
Diagnostic Test (Book Base)
EEG
An Electro Encephalo Gram (EEG) is a non-invasive and
painless diagnostic test used to measure electrical impulses
between brain cells. By placing electrodes on your scalp,
the frequency of these impulses can be measured and recorded
on a graph. Abnormalities in your regular brain waves can be
used to identify the presence, location and severity of your
seizures. It will locate the focus of abnormal electric
discharges, if present; to establish a diagnosis of
epilepsy; and identify the specific type of seizure.
SPECT
A Single-Photon Emission Computed Tomography (SPECT) is
a diagnostic imaging technique that measures blood flow
through your brain. A small amount of a radioactive tracer
will be introduced into your body that will emit particles
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measured by a SPECT camera. The greater the blood flow, the
more particles are emitted. This allows doctors to visualize
the functions of certain parts of your brain. As the data is
collected, an image of the brain is generated with different
coloured areas to represent varying amounts of blood flow.
This information will indicate if certain areas of your
brain are getting too much or too little blood (and oxygen).
Areas where seizures occur usually show increased blood
flow. This test is not usually necessary for diagnosing
epilepsy. If your doctor recommends a SPECT test, you will
likely also require an MRI.
PET
A Positron Emission Tomography (PET) is an imaging
technique that measures your brain’s activity through its
use of sugar and oxygen. Radioactive tracers are introduced
into your body which release tiny particles called
positrons. These positrons react with electrons in your
bloodstream, releasing energy. Computers are able to
generate images of your brain activity, using the data
gathered from measuring the released energy. This data
enables doctors to determine where your seizures occur.
CT Scan
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A Computed Axial Tomography scan (CAT or CT scan) is a
non-invasive and painless test. CT scans produce cross-
sectional images (tomographs) of areas in your body that
will be examined by doctors to look for abnormalities (eg.
scar tissue, blood clots or tumours). For epilepsy, this
usually involves a scan of your head to look for possible
origins of seizures. The machine looks like a large box with
a donut shaped hole in the middle (a gantry). You will lie
on a platform that slides in and out of the gantry as the x-
ray rotates around you. Low radiation x-rays pass through
your body and are captured by detectors. Computers use this
information to produce a 2-D image of the area.
MRI
A Magnetic Resonance Imaging (MRI) is a noninvasive
diagnostic test that uses a powerful magnet to measure
magnetic field changes in the brain. MRIs produce many
detailed cross-sectional images (“slices”) of the brain’s
internal structure. These images can be used to detect
structural abnormalities and may help pinpoint the cause of
seizures. This is considered to be the most important scan
when diagnosing epilepsy because it produces a very accurate
representation of your brain. This procedure is generally
non-invasive, although a contrast dye may be administered by
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a needle to provide the doctor with a clearer image.
Functional MRIs (fMRIs) monitor neural signals through
changes in blood flow.
MEG
A Magneto Encephalo Graphy (MEG) is a new tool used to
generate a representation of your brain’s magnetic fields.
By analyzing brain activity, the MEG can help localize areas
in your brain causing the seizures. Doctors can then use
this information to help determine what is provoking your
seizures.
Diagnostic Test (Client Base)
These are the diagnostic tests that are needed to
determine the final diagnosis of the client. The client had
undergone the following diagnostic test:
The client was supposed to have a Lumbar Puncture done
but the family refused.
Prevention
To prevent seizures, the patient must avoid activities
that trigger seizure activities. The client must record
every seizure activity and record all the things that the
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client did before the seizure occurred. It is essential for
a client to know the things that could trigger seizure
activities such as extraneous activities and alcohol
drinking. It is advisable for a client to continue drinking
the medications as prescribed by the doctor.
Advice the client to rest in between activities so that
the client will not be too tired but at the same time, the
client can function as well as a normal person can. A person
with seizure should warn the people around her to be aware
of his/her condition since there is a safety precaution to
be followed if a person did have a seizure disorder.
Complications
Hypoxic brain damage and mental retardation may follow
repeated seizures. Depression and anxiety may develop. Long-
term social interaction may also occur. Repeated seizures
can lead to epileptic syndrome, wherein the person can
experience seizure with serious complications such as Status
Epilepticus.
Nursing Management/Interventions (Book base)
General Care and Injury Prevention
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Perform periodic physical examinations and laboratory
tests for patients taking medications known to have
toxic hematopoietic, genitourinary, or hepatic effects.
Provide ongoing assessment and monitoring of cardiac
and respiratory functions.
Monitor the seizure type and general condition of
patient.
Turn patient to side-lying position to assist in
draining pharyngeal secretions.
Have suction equipment available if patient aspirates.
Monitor IV line closely for dislodgment during
seizures.
Protect patient from injury during seizures with padded
side rails, and keep under constant observation.
Do not restrain patient’s movements during seizure
activity. Do not insert anything in patient’s mouth.
Controlling Fear of Seizures
Reduce fear that a seizure mat occur unexpectedly by
encouraging compliance with prescribed treatment.
Emphasize that prescribed antiepileptic medication
must be taken on a continuing basis and is not habit-
forming.
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Assess lifestyle and environment to determine factors
that precipitate seizures, such as emotional
disturbances, environmental stressors, onset of
menstruation, or fever. Encourage patient to avoid such
stimuli.
Encourage patient to follow a regular and moderate
routine in lifestyle, diet (avoiding excessive
stimulants), exercise and rest (regular sleep
patterns).
Advise patient to avoid photic stimulation (e.g. bright
flickering lights, television viewing); dark glasses or
covering one eye may help.
Encourage patient to attend classes in stress
management.
Improving Coping Mechanisms
Understand that epilepsy imposes feelings of fear,
alienation, depression, discrimination and social
isolation, and uncertainty.
Provide counseling to patient and family to help them
understand the condition and limitations imposed.
Encourage patient to participate in social and
recreational activities.
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Instruct patient to avoid over-the-counter medications
unless approved by health care provider.
Provide comprehensive mental health services to
patients who exhibit symptoms of schizophrenia or
impulsive or irritable behavior.
Promoting Home and Community-Based Care
Teaching patients of Self-care
Instruct patient and family about medication side
effects and toxicity.
Prevent or control gingival hyperplasia, a side effect
of Phenytoin (Dilantin) therapy, by teaching patient to
perform thorough oral hygiene and gum massage and seek
regular dental care.
Provide specific guidelines to assess and report signs
and symptoms of medication overdose.
Instruct patient to keep a drug and seizure chart,
noting when medications due to illness.
Teach patient to keep a drug and seizure chart, noting
when medications are taken and any seizure activity.
Instruct patient to notify physician if unable to take
medications due to illness.
Teach patient to keep a drug and seizure chart, noting
when medications are taken and any seizure activity.
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Instruct patient to take showers than to tub baths to
avoid drowning and never swim alone.
Encourage realistic attitude toward the disease;
provide facts concerning epilepsy.
Instruct patient to carry an emergency medical
identification card or wear an identification bracelet.
Advise patient to seek preconception and genetic
counseling if desired (inherited transmission of
epilepsy has not been proved).
Medical Management (Book base)
The management of epilepsy and status epilepticus is
planned according to immediate and long-range needs and is
tailored to meet the patient’s needs because some cases
arise from brain damage and others are due to altered brain
chemistry. The goals of treatment are to stop the seizures
as quickly as possible, to ensure adequate cerebral
oxygenation, and to maintain a seizure-free state.
An airway and adequate oxygenation (intubate if
necessary) are established, as is an
IV line for administering medications and obtaining blood
samples for analysis.
Pharmacologic Therapy
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Medications are used to achieve seizure control. The
usual treatment is single-drug therapy.
IV diazepam, lorazepam, or fosphenytoin is
administered slowly in an attempt to halt the
seizures.
General anesthesia with a short-acting barbiturate
may be used if initial treatment is unsuccessful.
To maintain a seizure-free state, other
anticonvulsant medications (carbamezipine,
primidone, phenytoin, Phenobarbital, ethosuximide,
and valproate) are prescribed after the initial
seizure is treated.
Surgical Management
Surgery is indicated when epilepsy results from
intracranial tumors, abscess, cysts, or vascular anomalies.
Surgical removal of the epileptogenic focus is
done for seizures that originate in a well-
circumscribed area of the brain that can be
excised without producing significant neurological
effects.
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Table 6. Drug Study
DRUG NAME ACTION CLASSIFICATION INDICATION CONTRAINDICATION ADVERSE EFFECT
NURSING CONSIDERATION
Phenobarbital 60mg 1tab/day
Long-acting barbiturate. Sedative and hypnotic effects of barbiturates appear to be due primarily to interference with impulse transmission of cerebral cortex by inhibition of reticular activating system. CNS depression
CENTRAL NERVOUS SYSTEM AGENT; ANTICONVULSANT; SEDATIVE-HYPNOTIC; BARBITURATE
Long-term management of tonic-clonic (grand mal) seizures and partial seizures; status epilepticus, eclampsia, febrile convulsions in young children. Also used as a sedative in anxiety or tension states; in
Acute intermittent porphyria, oversensitivity for barbiturates, prior dependence on barbiturates, severe respiratory insufficiency and hyperkinesia in children are contraindications for phenobarbital use.
Drowsiness or dizziness;problems with memory or concentration;excitement, irritability, aggression, or confusion
Before taking phenobarbital, tell your doctor or pharmacist if you are allergic to it; or to other barbiturates (such as primidone, secobarbital); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic
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may range from mild sedation to coma, depending on dosage, route of administration, degree of nervous system excitability, and drug tolerance. Initially, barbiturates suppress REM sleep, but with chronic therapy REM sleep returns to normal.
pediatrics as preoperative and postoperative sedation and to treat pylorospasm in infants.
reactions or other problems.
Nursing Care Plan
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Table 7
Assessment Diagnosis Outcome Identification
Planning Intervention Evaluation
Subjective:
“Kapag inaatake ng seizure ‘yung anak ko kinakabahan ako hindi ko alam ang gagawin”, as verbalized by the client’s mother.
Objective:
Overprotection of the client
Stressed out as manifested by
Knowledge Deficiency of the Disease Process
To improve the knowledge of the client’s mother regarding the disease process
Within 4 hours of nursing interventions, the mother of the client will verbalize understanding of the disease process
Health Teaching about Seizure.
Demonstrate what to do first then letting the mother do it by himself.
Demonstrate what to do before, during, and after the seizure then let the mother do it so he will clearly understand what to do if seizure occurs.
After 4 hours of nursing interventions, the client’s mother verbalized understanding of the disease process. He demonstrated understanding of what to do before, during, and after the seizure.
Goal met
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restlessness
Nursing Care Plan
Table 8
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Assessment Diagnosis Outcome Identification
Planning Intervention Evaluation
Subjective:
“Bigla na lang nanginig ‘yung anak ko”, as verbalized by the client’s mother.
Objective:
Weakness Facial
grimace Irritability
V/S taken as follows:
BP 120/90
T 37.3
PR 110
RR 20
Risk for Trauma related to loss of large muscle coordination.
Patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect itself from injury.
Within 8 hours of nursing the Patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect itself from injury.
Explore with the patient the various stimuli that may precipitate seizure activity.
Discuss seizure warning signs and usual seizure signs
Evaluate need for protective head gear
Maintain strict bed
After 8 hours of nursing interventions, the patient was able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect her son from injury.
Goal met.
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rest if prodromal signs or aura experienced
Reorient patient following seizure activity
Collaborative:
Administer medications as prescribed
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Review of Related Literature
Foreign Literature
Epilepsy is recognized as a collection of heterogeneous
syndromes characterized by additional conditions that coexist
with seizures and impacts over 50 million people worldwide.
Cognitive, emotional, and behavioral comorbidities are common.
Seizures are typically divided into two main categories: partial
(focal) and generalized. Generalized seizures affect both
cerebral hemispheres from the onset of the seizure. Seizures
produce loss of consciousness, either for long periods of time or
temporarily, and are sub-categorized into generalized tonic-
clonic, myoclonic, absence, or atonic subtypes. Partial seizures
affect an area within one cerebral hemisphere of the brain and
are the most recurring type of seizure experienced by patients
with epilepsy. Partial seizures are further subdivided into
simple partial seizures, where consciousness is retained; and
complex partial seizures, where consciousness is diminished or
lost.In the treatment of epilepsy, no one anti-epileptic drug
(AED) has been shown to be the most effective, and all AEDs have
published side effects. AEDs are selected following consideration
of side effects, ease of use, cost, and physician knowledge.
Patients with newly diagnosed epilepsy who require treatment can
be started on standard, first-line AEDs such as carbamazepine,
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phenytoin, valproic acid, or phenobarbital. Alternatively, newer
AEDs introduced in the past decade may be used. These include
gabapentin, lamotrigine, oxcarbazepine, or topiramate. Between
70% and 80% of individuals are successfully treated with one of
the AEDs now available and success rates primarily depend on the
etiology of the seizure disorder. However, the remaining 20%–30%
of patients have either intractable or uncontrolled seizures or
suffer significant adverse side effects to medication. As with
the selection of first-line therapy, choosing the appropriate
drug for the treatment of refractory epilepsy must be based on
the appreciation of each drug’s characteristics and risks for
each individual patient. An emerging market economy is defined as
an economy with low-to-middle per capita income. Such countries
constitute approximately 80% of the global population, are often
rapidly-growing and represent about 20% of the world’s economies.
Although the term emerging market is loosely defined, countries
that fall into this category, range from big to small, and are
often considered emerging because of development and reform
programs that have been put in place to launch their markets
globally. Consequently, although China is considered one of the
world’s foremost economic leaders, it is grouped into the
emerging market category together with much smaller economies
with fewer resources, such as Sudan or Bulgaria. Epilepsy is
common in patients admitted to hospitals in emerging
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markets.However, there are reported differences in the
epidemiology, economic burden, and outcome of epilepsy in these
regions compared to high-income countries; although few data from
the former regions exist. Applying the International League
Against Epilepsy definition of epilepsy is problematic in these
areas, as patients often arrive at health facilities without
adequate documentation of the seizure duration. The goal of
treatment for patients with epilepsy is no seizures with little
to no side effects. However, due to variabilities in clinical
presentation and available resources, treatments are highly
individualized and vary widely. The objective of this study is to
systematically review the literature on epilepsy to identify
incidence and prevalence rates, economic data, unmet needs, and
treatment patterns in those emerging markets which contain the
majority of the world’s population. (Angalakuditi, 2011)
Epilepsy is a chronic disease characterized by the risk of
recurrent seizures. In developed countries, an average of 4 or 5
of every 1,000 people has epilepsy. In developing countries, this
rate can be as high as 43 per 1,000 people. According to the
World Health Organization, the disability caused by epilepsy
accounts for about 0.5% of the global burden of the disease
measured by disability-adjusted life-years. As a result, epilepsy
ranks just after psychiatric conditions such as alcohol
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dependence. The global health care bur-den of epilepsy is
comparable to that of breast or lung cancer. Some cultures
believe that epilepsy represents demonic possession. Although
epilepsy arises from a transient dysfunction in the brain, fear
and ignorance still lead to discrimination and feelings of shame.
In the public mind and in the laws of some countries, epilepsy is
strongly associated with mental illness and cognitive
disabilities — unfortunate generalizations that unfairly affect
many people with epilepsy. Such pervasive social stereotyping is
difficult to overcome. Previous surveystesting knowledge,
atitudes, beliefs and treatment of people with epilepsy have
focused on the general public, students or teachers. Dentists and
other health care workers, who represent one of the more highly
educated and influential groups in society, however, have not
been surveyed. Undoubtedly, their perspectives about people with
epilepsy have an impact on their professional interactions with
this patient population. Their social response to this
population, independent of their provision of medical care, may
influence the way their community views people with epilepsy.
Because the dental care of patients with epilepsy is important,
and some reports in the literatureindicate there may be
disparities in their care, compared with that of the general
population, we surveyed all the dentists in London, Ontario, to
determine their knowledge about and attitudes to epilepsy, and
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their willingness to provide dental care to people with epilepsy.
(Aragon, 2008)
Epilepsy is the second most occurring neurological disorder
with an incidence rate of 1 % of the entire population. In
Denmark alone approximately 4.000 new cases are seen every year.
To be diagnosed with epilepsy often means a big change in a
persons life, and affects the daily rutines of the entire family.
Luckily, it is today possible to treat most epileptics and to
keep them seizure free, but around 25% will have to find a way of
living with the seizures to a smaller or larger degree. Epileptic
seizures There exists a high number of different types of
epilepsy, and also an equally high number of seizure types. These
seizures range from the common muscle spasms, many people would
recognise as an epileptic seizure, to a short term, almost
undetectable, loss of awareness. Most epileptic individuals
however will experience the same seizure type from time to time.
What is common for all epileptic seizures is that during the
seizure the affected person is unable to fully control his or her
body. The loss of control is sudden and unexpected.
Epi-Care is produced with an aim of warning relatives or medical
personal when nightly seizures or spasms, with muscle activity
occur.The majority of people suffering from epilepsy can be
treated with medicine. Some will even improve from complicated
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brain surgery, however this is only a minority.The best care is
decided from an individual and thorough description of seizures,
seizure types, as well as seizure duration and frequency. A
thorough seizure description will often mean that the time from
diagnose to the optimal seizure treatment is significantly
shortened. Epi-Care can be of significant help in creating a
thorough seizure description. The Epi-Care log can keep track of
the numbers of nightly seizures, and at the same time, warn if or
when a major seizure should occur.( http://danishcare.dk/uk/?
page_id=37)
The likelihood of young people taking their epilepsy medication
as prescribed might be improved by ensuring they have a good
understanding of their condition and its treatment, research
suggests.Scientists at the University of Michigan carried out a
study involving 88 adolescents with epilepsy and their
parents.Surveys were carried out to assess both patients’ and
parents’ knowledge of epilepsy and expectations of treatment, as
well as their adherence to medication.The findings show that
young people with a good understanding of epilepsy tended to
adhere to their treatment regimes more closely than those with
poor knowledge of the condition.A good understanding among
parents was also found to be beneficial, according to a report in
the journal Epilepsy & Behaviour.The researchers concluded:
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“Interventions that enhance adolescents’ knowledge of epilepsy
and their treatment plan, while ensuring that teens and parents
are in agreement with regard to epilepsy treatment, might
contribute to better adherence.”Encouraging young people to take
their medication is vital for improving outcomes, as non-
adherence is associated with a high frequency of seizures and a
worsened prognosis.Yet a study in the Journal of the American
Medical Association, published in 2011 by researchers at
Cincinnati Children’s Hospital, found evidence that more than
half of children with newly diagnosed epilepsy do not take their
seizure medications as prescribed.(
http://www.epilepsyresearch.org.uk/improving-youngsters-
knowledge-of-epilepsy-may-boost-treatment-adherence/)
Local Literature
People with epilepsy in the Philippines suffer from anxiety
and from depression. Living with epilepsy presents many
challenges affecting many aspects of life, including
relationships with family and friends, school, employment and
leisure activities (Hazel Patagua, 2012).
The Annual Neuroscience Department Research Contest was held
on September 10, 2009 at the Department Conference Room. There
were ten original papers that were presented from the Sections of
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Adult and Pediatric Neurology in three categories: Case
Report/Case Series, Descriptive, and
Analytical. The Annual Philippine Neurologic Association research
forum was held on October 17, 2009 at UST Hospital. Four original
papers from PGH were presented as finalists by their primary
authors. Dr. Janet Adajar of Pediatric Neurology won 3rd place
in the Descriptive category with her paper on the EEG findings of
patients with Complex Febrile Seizures while Dr. Jude Bayana of
Pediatric Neurology won 4th place in the same category with his
paper on the use of newer antiepileptics for neonatal
seizures. Dr. Natasha L. Fabiaña of Adult Neurology won
3rd place in the Analytical Category for her paper entitled, Risk
Factors for the Development of Seizures and Epilepsy among Post
Stroke Patients in a Tertiary Hospital: A Retrospective Cohort
Study. Dr Aloysius Domingo of Adult Neurology won 4thplace for
his meta-analysis, Secondary Prevention After Cerebrovascular
Events: Will Angiotensin Receptor blockers Protect? (SPACE-
WARP). The other original papers submitted were qualified for
poster presentation which was held during the PNA Annual
Convention. In the said event, the paper of Dr Jhaphet Agunias
entitled Parkinsonism as sequela of cyanide poisoning by
intentional silver jewelry cleaner ingestion: A Case Report won
2nd place in poster presentation. (pgh.gov.ph)
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Treating the patient at home is appropriate when the patient
is known to experience seizures, and if his seizures are brief.
According to the Philippine League Against Epilepsy, the
following steps can be done when helping out a patient during an
acute seizure episode:
Stay calm.
Loosen clothing around neck.
Turn the patient's head to one side to avoid choking and/or
aspiration.
Do not hold the patience down or shake and slap in an
attempt to rouse him, as they can injure the patient.
Do not put anything inside the patient's mouth.
Call a doctor when it is a first time seizure, of if the
seizure recurs or is prolonged (more than 5 minutes)
Taking prescribed anti-seizure medication regularly can help
prevent recurrent seizures. The removal of brain tissue where
seizures take place is also a preventive measure. For those with
severe cases of epilepsy, a special diet is advised to alter body
chemistry. Avoiding conditions known to trigger seizures (such as
bars with rapid, flashing lights, sleep deprivation) can help
prevent seizures from occurring.
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Seizures in the Philippines, The following medical centers in
the Philippines have available Neurology/Seizure clinics:
Jose Reyes Memorial Hospital
Makati Medical Center
Philippine Children's Medical Center Seizure Clinic
St. Luke's Medical Center: Comprehensive Epilepsy Program
UERM Seizure Clinic
UP-PGH Seizure Clinic
UST Hospital Seizure Clinic (health.com.ph)
Foreign Study
Primary care physicians, including pediatricians, admit that
they are not as familiar about specific aspects of epilepsy as
they should be and that they need more training in management of
the disease.
Several recent surveys of health care professionals who care for
children with epilepsy revealed what epilepsy specialists would
consider to be misconceptions about treatment and management of
pediatric epilepsy. In a survey that focused on surgery practices
for intractable epilepsy, nearly two-thirds of responding
physicians (58% were pediatricians) were unsure whether surgical
intervention should be considered for patients who fail
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anticonvulsant drug therapy, although specialists know that
surgery is the current guideline.
Another survey of pediatricians in Canada found that only 34% of
respondents said they knew of sudden unexplained death in
epilepsy (SUDEP), a rare but serious complication of frequent
seizures, and just 57% knew that children with epilepsy are at
increased risk for sudden, unexpected, unexplained death.
Specialists say that awareness of SUDEP is vital.
A third survey of behavioral health professionals who treat
children with epilepsy found that 84% wanted more training in
managing the psychopathologies of pediatric epilepsy in order to
play a more effective role in multidisciplinary care for such
patients.(American Epilepsy Society, 2012)
Out of all subjects, 88.5% (n=552) had a postgraduate
education, while 11.5% (n=72) had only an undergraduate degree.
The authors found that physical educators, nutritionists and
physiotherapists received lower scores on their epilepsy
knowledge than other health professionals. Health professionals
are considered better-educated group inside the society,
especially with regards to healthcare issues. Thus, it is
important they also have an accurate and correct knowledge about
epilepsy. The findings of the present study indicate an
imperative improvement in education about epilepsy, as well as an
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inclusion of formal programmes for epilepsy education especially
for non-medical professionals. An improvement in epilepsy
education might contribute to an improvement in epilepsy care and
management. (Vancini, 2012)
In the arm of the survey that focused on physician attitudes
toward referral of children for surgical evaluation, only 51% of
respondents agreed that epilepsy surgery after 3 years of failed
antiseizure medication should be considered; 49% either disagreed
or were unsure. About a quarter (25%) felt patients in whom the
ketogenic diet fails should be considered for surgery, with more
than half (54%) being unsure and 23% not thinking this would be
helpful. Only 43% agreed that patients should be evaluated for
surgery after failed vagus nerve stimulation. Perhaps most
concerning was that 63% of the survey population was unsure
whether surgery would be effective for children with partial (or
focal) epilepsy and 7% didn't think this would be an effective
option. "This one really broke my heart," said Dr. Perkins.
"Focal epilepsy surgery has the highest positive response rates,
and having two thirds plus of respondents saying they don't agree
with it or aren't sure that it would be beneficial, tells me that
we have completely failed in communicating what we do to
professionals who would be referring to us." Up to 90% of
patients with partial epilepsy respond to surgery, noted Dr.
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Hovinga. All kids with epilepsy should be considered for surgery,
but that doesn't mean all of them should get it, Dr. Perkins
stressed. "It's important to identify children with intractable
epilepsy who might benefit from surgery. We need to go back to
our baseline and reevaluate, especially as evolving technologies
have rolled in, and we have better imaging and better diagnostic
procedures determining if a particular person qualifies for
surgery or not."Just because a patient comes to an epilepsy
center for an evaluation doesn't mean that patient is removed
from primary care. "We're here as an augmentation, if others want
us to comanage or guide," said Dr. Perkins. "These patients need
to be getting the evaluations and there's a block in that
process." Asked about referring patients with generalized
epilepsy for surgery, 61% of survey participants were unsure and
24% disagreed. Although such referrals are "a bit trickier than
focal epilepsy" because the surgery may be for palliative care
reasons, the surgery would still "vastly improve qualify of life
for many of patients and their families," said Dr. Perkins.
Ironically, more than half of the doctors agreed that surgery
might improve quality of life for children. "It's another one of
those discordances" where doctors might think a particular
intervention might help but they're not sure about the specifics,
said Dr. Perkins. Changing attitudes can be accomplished only
through education, perhaps using webinars or other electronic
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tools, but most likely through old-fashioned "shoe leather" --
getting in your car and visiting doctors in the field, said Dr.
Perkins. "On a local basis, it's incumbent on us to reach out to
our referral sources outside of neurology and neurosurgery who
are nonepileptologists -- into the pediatrician and family
practice offices -- and make sure they understand these
things."(Anderson, 2012)
Health professionals need good skills in communication and
patient education They play an essential role in educating
patients and families about the epilepsies and in directing them
to accurate and reliable resources and tools to improve
knowledge, skills, and self-management. In contrast, poor
clinician-patient communication is a major barrier to patients'
ability to successfully navigate the health care system, act on
basic health instructions, and self-manage chronic or other
health conditions. Studies indicate that patients recall as
little as half of what their physicians tell them during an
outpatient appointment. Physicians need to confirm that patients
understand their condition (e.g., specific seizure type, epilepsy
syndrome, seizure triggers), how to carry out treatment and
medication instructions, and risks associated with their
condition and nonadherence or discontinuation of their treatment
regimen. However, in one diabetes study, physicians assessed
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patients' recall and comprehension of new concepts in only one in
five patient encounters, even though such practices have been
shown to improve clinical outcomes. Therefore, it is critically
important that health professionals provide patients and their
families with written information about their specific seizure
type, epilepsy syndrome, and treatment plan to augment
discussions that happen in the clinical setting.
In order to educate patients and families effectively, health
care providers must be knowledgeable and skilled in communicating
and conveying information that meets the individual needs and
preferences of patients. A UK survey highlighted the desire of
patients with epilepsy to have physicians who are both
knowledgeable and effective communicators. In addition, patient-
rated quality of care also increases when health care providers
use patient-centered communication and shared decision making. it
is important that health professionals learn how to
recognize the critical junctures for patient and family
education—at diagnosis, during the first year, when there is
a change, in treatment options (e.g., introduction, switch,
discontinuation), or when a new concern develops;
understand the specific information needs and preferences of
patients and their families and take into consideration
factors related to health literacy and culture, including
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cultural differences that may exist between them and their
patients;
listen actively and put the patients and their needs first
when providing education and counseling;
be competent in patient and family education and
communication, including targeting education to the specific
needs of the patient;
be comfortable discussing risks associated with the
epilepsies and their treatments including SUDEP, suicide,
and status epilepticus be aware of informational resources
for patients and families that are available online and
through local epilepsy organizations; and
promote the use of self-management tools and programs.
(Stuart, Muir, 2008)
Local Studies
About 25 percent of individuals begin to have seizures
during puberty. There are also studies pointing to higher
rates of seizures among “low-functioning” persons with
autism. Dr. Sosa advised her audience to treat the
underlying cause of seizure in order to have good seizure
control and thus improve the quality of life of the person
affected. With other pediatric neurologists like her, CNSP
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promotes and provides access to quality neurological
healthcare for Filipino children.
CNSP conducts teaching and training seminars to the
physicians as a way to improve the level of child neurology
practice. In partnership with organizations like Autism
Society Philippines, CNSP Caravans already reached Naga,
Dagupan, Samar and Lucena. Doctors, parents, rural health
physicians, midwives and nurses are the target audience in
each identified locality. The thrust of the caravan project
is to teach the participants in identifying
neurodevelopmental disability in children and then providing
basic developmental intervention techniques to the
community(Manila Bulletin, 2012).
In the Philippines alone, 80 percent of the population know
little about the disease. Despite affordable medicines, some
people resort to alternative solutions like exorcism or
herbs from traditional healers. (www.thepoc.net)
More than two million people in the Philippines -- about 1
in 150 -- have experienced an unprovoked seizure or been
diagnosed with a seizure disorder. For about 80 percent of
those diagnosed with a disorder, seizures can be controlled
with modern medicines and surgical techniques.
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However, about 20 percent of people with a disorder will
continue to experience seizures even with the best available
treatment. Doctors call this situation intractable epilepsy
(Philippine Center for Epilepsy, 2012).