Nursing care in the patient with epilepsy/seizures

According to the Pan American Health Organization (PAHO), epilepsy is, in turn, a global public health problem and a clinical condition with self-referral in up to 50% of cases. According to reports from the World Health Organization (WHO), an estimated 50 to 69 million people suffer from this disease, the majority living in developing countries, where the quality of life is worse and the incidence of infections of the nervous system central nervous system (CNS) is greater, and it can be asserted that epilepsy affects 1-2% of the population [6-10].


Introduction
Epilepsy is considered as old as humanity itself and can occur in anyone without distinction of age, sex, race, social origin or geographical characteristics. It is one of the most frequent Central Nervous System (CNS) disorders and for some the second neurological disease [1]. International statistics show annual mortality rates of 2.1 per 100,000 inhabitants per year, varying from 1 to 8 in the different countries [11][12][13][14][15].
The fi rst treatments included everything from exorcism to the practice of bloodletting [16].
However, modern and scientifi c therapy dates back to the 19th century with the accidental discovery of bromide salts. From then on, a variety of drugs were incorporated into the therapeutic arsenal of this disease and more recently in the management of it, different techniques and alternative methods [17][18][19][20].
Recently, it is considered that the treatment should be comprehensive, therefore it is conceived as prophylactic / preventive, pharmacological and non-pharmacological, in which the management and care of the nursing staff is essential [2]. That is why we intend in this context to describe from a scholastic point of view, the aspects to be taken into account by the nursing staff, when faced with a patient with the diagnosis of epilepsy, or the same present epileptic-type cerebral seizures and attempts are made to minimize the devastating aspects of this disease.

Materials and methods
The document aims to summarize the scientifi c evidence available regarding nursing care in patients with epileptic seizures, whether they have a diagnosis of epilepsy or not in order to guide the nursing staff in the management of these patients. To prepare it, the search engine Google Academic and the descriptors epileptic seizures, epilepsy, and nursing care were used.
The information sources were the databases: Medline / PubMed, Scielo / Scopus and Medscape. The search was carried out using keywords, in English or Spanish, without a time limit, and all types of publications. The 40 articles related to epilepsy, seizures and nursing care were selected, which were considered of higher scientifi c quality and the reviews were prioritized. Articles with similar scientifi c information were excluded.

Concepts in epilepsy
The International League Against Epilepsy (ILAE) and League Against Epilepsy (ILAE) working group, specifi es that the transient appearance of signs and / or symptoms is called "seizure" caused by excessive or simultaneous abnormal neuronal activity in the brain and that epilepsy is a brain disorder characterized by a continuous predisposition to the appearance of epileptic seizures and by the neurobiological, cognitive, psychological and social consequences of this disease. The defi nition of epilepsy requires the presence of at least one epileptic seizure [21].
Recently (2014) a group of experts from the ILAE has published, with the consensus of the epileptologists from the different chapters, the operational (practical) clinical defi nition of epilepsy: It is considered by consensus that epilepsy is a brain disease that is defi ned by any of the following circumstances: 1. At least two unprovoked (or refl ex) seizures> 24 hours apart.
2. An unprovoked (or refl ex) seizure and a probability of presenting new seizures during the next 10 years similar to the general risk of recurrence (at least 60%) after the appearance of two unprovoked seizures.

Diagnosis of an epilepsy syndrome.
According to these criteria, a patient who has suffered a seizure has epilepsy and whose brain, for whatever reason, shows a pathological and continued tendency to suffer recurrent seizures. This trend can be imagined as a pathological reduction in the seizure threshold compared to people who do not have the disease [22].
Epileptic seizures appear suddenly and unexpectedly in almost all occasions, both in patients with known epilepsy and in those with an initial seizure. They can occur in any place, situation and with a short or long duration in the form of status epilepticus; therefore, all health professionals must be familiar with the actions to be carried out in the event of an epileptic seizure, since an inappropriate action can have irreparable consequences [2].
Due to the complexity of this pathology, due to the social involvement that it presents and its psychobiological and even economic consequences, the patient with epilepsy and therefore, a carrier of epileptic seizures, must be managed with a multidisciplinary nature [23,24]. Therefore, specifi c training in epilepsy for nursing staff is essential, and it must be based on specialized protocols and having a trained team is of vital importance to ensure correct patient management, adequate quality of care and avoid preventable complications [25,26].

Evaluation
The evaluation of the epileptic seizures presented by hospitalized patients will be carried out using a model established for this purpose and which includes the following aspects (Table 1)

Controls
The control of this procedure will be carried out through the review in the inspections that are carried out in each Clinic by the Supervisor.

Precipitating factors
In this regard, the common precipitating factors of epileptic seizures will be taken into account, such as [2,28]: Action in front of an epileptic seizure in the hospital environment [29,30].
In this section we refer to the nursing action on those people who have a focal or generalized seizure and who are in the emergency service or admitted, in which case we may know from their previous history, the risk they have of suffering an epileptic seizure or its history is unknown [31].
That is, we can be in the presence of a patient known as epileptic or who has epileptic seizures, without a previous history of the disease.
Focal and generalized onset seizure in the hospital environment ( Figure 1) [32,33]: • The doctor will be notifi ed.
• The patient will be placed in a horizontal plane and care will be taken that he does not receive trauma to the skull, with the head tilted and the clothing lopsided.
• We will control and assess in the patient: • The duration of the seizure.
• What has consisted of the seizure / type of seizure.
• The level of consciousness.
• The coloring of the skin and mucous membranes.
• We will take vital signs: • Heart rate.
• O2 saturation • We will perform a capillary blood glucose.
• We will put a peripheral road.
• We will administer oxygen with a nasal catheter at two liters / minute and we will aspirate the patient due to the possibility of respiratory secretions.
• We administer medications prescribed by the doctor.

Tonic-clonic onset seizures [34]
-In those patients with previous epileptic seizures or with signifi cant risk factors in treatment with antiepileptic drugs, severe brain injury, exposure to drugs and hallucinogens, etc.: -Maintain the necessary material for oxygen therapy and aspiration, in optimal conditions.
-Have a Guedell cannula near the patient (emergency stock).
-Facilitate the accessibility of calls to the nursing staff, especially if there are prodromes.
-Provide a suitable and safe environment, free of furniture and objects that can cause harm during the epilepticseizure.
-Protect the patient from all potentially harmful objects.
-Maintain a patent venous line if necessary.  -Inform the patient and the family about the action before the appearance of prodromes: --Remove the teeth or other objects from the mouth.
-Remove the eye lenses.
-Lay him down on the fl oor or in bed.

During tonic-clonic onset epileptic seizures [35]
1. Keep calm and serenity as much as possible and we will transmit it to the patient, relatives.
2. Identify that it is a tonic-clonic epileptic seizure.
3. Alert: Notify the doctor on duty.

Protect the patient:
-If the patient is out of bed, help him to lie down if possible, or lay him on the fl oor; avoiding as much as possible the fall.
-Do not leave the patient alone under any circumstances and monitor him.
-Remove nearby objects and / or furniture with which it may hit.
-Loosen clothing that is tight.
-Remove the glasses if you wear them.
-Do not immobilize or restrain the patient by force during the epileptic seizure, but control and guide their movements to avoid injuries.
-Protect the head by placing a pillow or a towel underneath.

5.
Guarantee the patency of the airway: -Remove, if possible, dentures and dental implants that are not permanent.
-Remove food from the mouth in case this process is carried out.
-Insert a Guedell cannula, if possible, but do not do it by force, since we could injure the oral mucosa and / or cause the teeth to break.

7.
Put a peripheral line as soon as the seizures stop.

9.
Carry out the complementary tests requested by the doctor.
10. We will control and assess: -Duration of the tonic-clonic phase. It is very important, since the severity of the seizure will depend on the duration of it.
-Type of epileptic seizure.
-Where does the movement or begin contracture.
-Eye position and / or eye movements.
-The pupils: relationship between them, size and reactivity.
-Whether or not there is urinary and / or fecal incontinence.
-Time the patient is unconscious. 1. When the epileptic seizures cease, place the patient in the RECOVERY POSITION.
2. Do not administer anything by mouth.
3. If after the crisis he is excited, calm him down and reassure him. Administer the drug directed by the doctor.
4. If there is any bleeding lesion, press with a sterile compress until the bleeding stops.
5. Ensure that the environment is quiet and safe, without excessive lighting or noise.
6. Carry out a new check of vital signs and serum glycemia.
7. In case of incontinence, proceed to clean the patient.
8. In case of drowsiness, let him rest.
9. When he wakes up, redirect and reassure him. 10. Carry out the complementary tests requested by the doctor.
11. We will control and assess: -Duration of the post-seizure phase.
-Degree of confusion, if he is drowsy, let him sleep and do not wake him up or shake him.
-Color of the skin and / or mucous membranes.
-If the patient can get up.
-Whether he speaks or not. If there is paralysis or weakness in the arms and / or legs.
12. The following will be recorded: • The vital signs on the vital signs sheet found in the medical record.
• In the nursing evolution sheet and seizure control model (Annex 1): the characteristics and duration of the different phases of the epileptic seizure.
• Apply GLASGOW scale where necessary.
• Report to the nursing department in the registry and report of epileptic seizures (Table 2).

Conclusions
Epilepsy is a disease that carries a signifi cant comorbidity, which can lead to death and therefore social and psychobiological involvement, which is why comprehensive management by health personnel and primarily by nursing staff is necessary.
Specialized protocols must be followed to provide a safe environment and thus avoid injury to patients with epileptic seizures, improving the quality of care for patients with epileptic seizures and thus avoid the appearance of possible complications.