Seizure Disorder Nursing Care Plans

A seizure is a few minutes of chaos that you have to manage without panicking. Your job is to keep the patient from getting hurt, protect the airway, time what you see, and recognize when one seizure has stopped being a single event and become status epilepticus. The rest of the work, medication adherence, safety teaching, and the psychological weight of the diagnosis, happens between episodes. This guide covers the assessment, diagnoses, goals, and interventions you use at the bedside.

What are seizures?

Seizures are physical findings or behavior changes caused by uncontrolled electrical discharges from the nerve cells of the cerebral cortex. They present as sudden, brief attacks of altered consciousness, motor activity, and sensory phenomena. The term is often used interchangeably with convulsion. In 2017 the International League Against Epilepsy revised the terminology and classification, framing the changes as guiding principles rather than a wholly new system.

An epileptic seizure is a clinical event presumed to result from abnormal, excessive neuronal discharge. Epilepsy is diagnosed when two or more unprovoked seizures occur more than 24 hours apart with no immediately identifiable cause. Idiopathic epilepsy covers syndromes with age-related onset, specific clinical and electrographic features, and a presumed genetic mechanism. A cryptogenic seizure has unknown etiology and no known prior CNS insult, and is classified as unprovoked. A symptomatic seizure is caused by a known or suspected CNS disorder that raises the risk of epilepsy. An acute symptomatic (provoked) seizure follows a recent insult such as a metabolic or toxic derangement, CNS infection, stroke, brain trauma, cerebral hemorrhage, medication toxicity, or alcohol or drug withdrawal, for example a seizure within one week of a stroke or head injury. A remote symptomatic seizure occurs more than one week after such a disorder and is classified as unprovoked.

Seizures can be caused by head injuries, brain tumors, lead poisoning, maldevelopment of the brain, genetic and infectious illnesses, and fevers. Sensory symptoms arise from the parietal lobe; motor symptoms arise from the frontal lobe.

Nursing Care Plans and Management

The goals are to keep the patient safe during and after a seizure, prevent injury, and reduce the frequency and severity of seizures through medication management and education. Build in regular monitoring of seizure activity and medication side effects, and address the psychological and social fallout of the disorder.

Nursing Problem Priorities

1. Recognize and assess the signs and symptoms of seizures.
2. Keep the patient safe during the episode.
3. Give first aid as needed to prevent injury.
4. Monitor seizure frequency, duration, and triggers.
5. Give prescribed antiseizure medications as ordered.
6. Educate patient and caregivers on medication adherence, seizure precautions, and lifestyle changes.
7. Offer emotional support and counseling to patient and family.
8. Coordinate referrals to neurologists or epileptologists.
9. Schedule followup to monitor control, adjust medications, and address new symptoms.

Nursing Assessment

Assess for the following subjective and objective data:

• See the assessment cues under Nursing Interventions and Actions.

Nursing Goals

Goals and expected outcomes may include:

• The patient will verbalize understanding of the factors that raise the risk of trauma or suffocation and take steps to correct them.
• The patient will identify the actions to take when seizure activity occurs.
• The patient will identify and correct potential environmental risk factors and modify the environment to improve safety.
• The patient will demonstrate behaviors and lifestyle changes that reduce risk and protect against injury.
• The patient will maintain a treatment regimen that controls or eliminates seizure activity.
• The patient will recognize when assistance is needed to prevent injury.
• The patient will verbalize understanding of the disorder and the stimuli that may trigger seizures.
• The patient will participate in learning, ask questions, and take responsibility for their own care.
• The patient will adhere to the prescribed drug regimen.
• The patient will correlate signs and symptoms with causative factors and initiate the lifestyle changes indicated.

Nursing Interventions and Actions

1. Preventing Injuries and Suffocation

Loss of muscle control during a seizure leads to falls, head injuries, and difficulty breathing, and seizures during sleep carry a risk of suffocation from airway obstruction or aspiration. Injury risk also rises from comorbidities that affect cognition, vigilance, or balance, which are common in people with seizures.

Determine the factors and the extent of risk in this patient's situation. This sets the scope and intensity of your safety interventions. Conditions associated with seizures and a higher injury risk include stroke, brain tumor, dementia, diabetes mellitus, and psychiatric and developmental disorders.

Note age, sex, developmental age, decision-making ability, and level of cognition. These affect the patient's ability to protect themselves and others and guide your choice of interventions and teaching. Injury risk does not differ by seizure type and is similar between men and women, with women carrying a slightly lower risk. No increased risk is seen with seizures before age 15; all older age categories show higher risk among epilepsy cases.

Ascertain knowledge of the stimuli that may trigger seizures. Alcohol, various drugs, loss of sleep, flashing lights, and prolonged television viewing can increase brain activity and the potential for seizures. In a patient with a known seizure disorder, the most likely trigger is subtherapeutic antiepileptic levels, usually from nonadherence or a systemic problem that disrupts drug absorption, distribution, or metabolism.

Review diagnostic studies and labs for impairments and imbalances. These can cause or worsen confusion, tetany, and pathological fractures. For adults with new-onset seizures, an American College of Emergency Physicians policy recommends a serum glucose, serum sodium, and a pregnancy test in women of childbearing age.

Explore seizure warning signs and the patient's usual seizure pattern, and teach significant others to recognize them and how to care for the patient during and after an episode. This lets the patient protect themselves and recognize changes that need provider notification, and it cuts the family's sense of helplessness. There may be a cry at onset, and some patients describe a prodrome or aura beforehand.

Note pre-seizure activity, any aura or unusual behavior, and the type, location, duration, and frequency of seizure activity. Note whether the patient fell, vocalized, drooled, or had automatisms such as lip-smacking, chewing, or picking at clothes. This helps localize the involved cerebral area. Many patients with complex focal seizures have an aura, which is itself a simple focal seizure. Hyperventilation or photic stimulation often precipitates absence seizures, which usually begin in childhood or adolescence.

Do a neurological and vital sign check after the seizure: level of consciousness, orientation, ability to follow simple commands, ability to speak, memory of the event, weakness or motor deficits, blood pressure, pulse, and respiratory rate. This documents the postictal state and the time and completeness of recovery, and may surface new safety concerns. After a generalized tonic-clonic seizure the patient has a transient alteration of consciousness, and accurate vital signs can be hard to get during the event.

Investigate reports of pain. Pain may come from repetitive muscle contractions or from an injury sustained during the seizure. Ictal pain is a rare but real manifestation, can be severe, and is easily overlooked as a seizure when localized paroxysmal pain is the only sign.

Watch for status epilepticus, one tonic-clonic seizure after another in rapid succession. This is a life-threatening emergency that, untreated, can cause metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased intracranial pressure, airway obstruction, and respiratory arrest. Intervene immediately to control seizure activity and prevent permanent injury or death. Absence seizures can become continuous but are not usually life-threatening.

Monitor and document AED drug levels, side effects, and seizure frequency. A standard therapeutic level may not be optimal for a given patient if side effects develop or seizures continue. Even though nonadherence and subtherapeutic levels are common causes of seizures in the ED, screen for infectious or metabolic causes when indicated.

Monitor CBC, electrolytes, and glucose. These identify factors that lower the seizure threshold. The yield of extensive labs after a first single seizure is low; in one study, counts, glucose, and electrolytes were abnormal in as many as 15% of patients.

Pad the side rails and keep the bed in its lowest position, or place the bed against the wall and pad the floor if rails are not available. This minimizes injury when a seizure occurs in bed. Most patients seize in place, so a patient in the middle of the bed is unlikely to fall out. Padding cushions the limbs and body against the rails or floor and reduces bruises, cuts, and fractures.

Teach the patient not to smoke unless supervised. A dropped cigarette during an aura or seizure can cause burns. Smoking is also common in adults with epilepsy and may itself raise seizure risk; one study found a 32.1% smoking prevalence among 429 people with epilepsy, well above the 19% rate in the general population.

Evaluate the need for protective headgear. A helmet adds protection for patients with recurrent or severe seizures. These helmets are typically dense foam encased in leather with a chin strap, built up at the front or back depending on which way the patient tends to fall.

Avoid glass thermometers; use a tympanic thermometer. This removes the risk of the patient biting and breaking glass or being injured if a seizure starts suddenly. Tympanic thermometers read infrared radiation from the eardrum and give a quick, noninvasive temperature.

Keep the patient on strict bedrest during prodromal signs or an aura, and explain why. Patients may feel restless or need to walk or defecate during an aura, which takes them out of a safe, observable space. Explaining the reason improves cooperation.

Stay with the patient during and after a seizure. Staying lets you protect the patient from environmental hazards and closely observe the duration, intensity, and characteristics of the seizure.

Turn the head to the side and suction the airway as needed. Insert a plastic bite block only if the jaw is relaxed. This maintains airway patency and reduces oral trauma, but never force a bite block against clenched teeth, which damages teeth and soft tissue. Do not use wooden tongue blades, which can splinter in the mouth. Custom-made acrylic splints are more effective than stock mouthguards because of their fit, stability, and retention.

Support the head, place it on a soft surface, or help the patient to the floor if out of bed. Do not restrain. Supporting the extremities reduces injury when the patient has no voluntary muscle control. Restraint increases erratic movements and the chance of injury to the patient or others. Make sure the patient is in a padded bed or flat on the floor.

Reorient the patient after the seizure. The patient may be confused, disoriented, and amnesic and needs help regaining control and easing anxiety. Stay calm and give verbal reassurance as consciousness returns.

Allow postictal automatic behavior without interfering while protecting the environment. Behavior of motor or psychic origin may seem inappropriate, and trying to control it can make the patient aggressive or combative. Most patients have fatigue, confusion, muscle pain, or headache afterward, so let the patient sleep.

Give medications as indicated. Drug therapy depends on seizure type, and some patients need polytherapy or frequent adjustments.

Prepare for surgery or device implantation as indicated. A vagal nerve stimulator, magnetic beam therapy, or surgery such as temporal lobectomy may be done for intractable seizures or well-localized epileptogenic lesions when the patient is disabled and at high risk for injury. Gamma-ray radiosurgery has been used for multiple seizure foci that are otherwise hard to control. Vagal nerve stimulator efficacy at 18 months is 40 to 50%, and many patients report better seizure intensity and mood.

Tell the patient about noninvasive wearable seizure monitoring. Wearable biosensors have strong near-term potential for most people with seizures. Two are cleared by the FDA and EU for detecting convulsive seizures: a wrist-worn smartwatch (Empatica Embrace) linked to a smartphone, and an adhesive bicep patch that detects convulsions through electromyography (BrainSentinel SPEAC), which also runs a cloud platform and sends caregiver alerts.

Reinforce driving limitations. Restrictions vary by the patient's seizure features, degree of control, and state law. To resume commercial driving across state lines, a patient must have a 5-year seizure-free period.

Tell the patient to be cautious with water activities such as swimming and boating. Patients should not swim alone and should have an adult lifeguard present who can pull them out if needed, and they should wear a life jacket in a boat. A seizure while waiting for bath water to warm can cause hot-water burns.

Teach the patient to avoid activities that could cause injury during a seizure, such as using power tools. Injuries can come from power tools, cooking, and working at height. Advise supervision and safety devices such as an automatic shutoff switch.

2. Maintaining a Patent Airway and Preventing Aspiration

Neuromuscular impairment during a seizure can let the tongue obstruct the airway or cause aspiration of saliva or vomit. Increased secretions and decreased muscle tone add to the obstruction risk, and the perceptual and cognitive impairment during and after a seizure leaves the patient unable to protect their own airway.

Monitor respiratory rate, rhythm, depth, and effort. This gives baseline data on ventilation. Seizures interfere with normal breathing and can cause inadequate oxygenation, which matters most during prolonged or severe events.

Assess the patient's ability to cough effectively. Respiratory infection changes the amount and character of mucus, and an ineffective cough lets secretions accumulate. Seizures can lead to aspiration or respiratory arrest.

Assess for obstructive sleep apnea. Sleep disorders can worsen seizures. OSA comes from repeated narrowing of the upper airway during sleep; partial obstruction causes snoring, and complete obstruction is possible in the supine position.

Make sure the mouth is empty of dentures or foreign objects if an aura occurs, and have the patient avoid gum and lozenges if seizures happen without warning. This reduces aspiration and the risk of objects lodging in the pharynx. Patients who had a spoon forced into the mouth by a caregiver during seizures sustained lacerations, bruising, and dental subluxation or avulsion far more often than patients who had nothing inserted.

Keep the patient lying flat and turn the head to the side during seizure activity. This drains secretions and keeps the tongue off the airway. The prone position is an important risk factor for sudden unexpected death in epilepsy (SUDEP); a meta-analysis found 73% of patients who died from SUDEP died prone.

Loosen clothing at the neck, chest, and abdomen. This allows chest expansion and easier breathing. If the patient is clenching the teeth, do not force the mouth open, which causes severe damage.

Insert a plastic airway or soft roll only if the jaw is relaxed. Placed before the jaw tightens, these prevent tongue biting and allow suctioning or respiratory support. An airway adjunct may be needed after the seizure if the patient is unconscious and cannot keep the tongue in a safe position. Custom acrylic splints can be fixed in the mouth for recurrent seizures using bands, wire loops, or cement.

Suction as needed. This reduces aspiration and asphyxiation. Seizures can produce excess saliva and oral secretions, and the patient may vomit, so prompt suctioning keeps the airway patent.

Give supplemental oxygen or bag ventilation postictally as needed. This reduces cerebral hypoxia from decreased circulation or vascular spasm during the seizure. Ictal hypoxemia, marked by low oxygen saturation, raises the risk of prolonged seizures and may contribute to SUDEP, and NICE recommends high-flow oxygen in the hospital management of seizures.

Prepare for or assist with intubation if indicated. Prolonged postictal apnea may need ventilatory support, and respiratory depression in a seizing patient may require an endotracheal tube. Intubation carries its own risk of laryngotracheal injury, especially if prolonged.

Advise the patient to avoid sleeping prone and to use devices that monitor sleep posture. The prone position is a major SUDEP risk factor, and patients are least likely to end up prone if seizures start while supine. Sleepwear or wearable devices that monitor posture and wake the patient when they move into a dangerous position may be indicated.

Prepare for and assist with surgery such as obstruction-bypass surgery or tracheostomy as indicated. Neurosurgical techniques targeting specific cerebral areas can reduce seizure activity. Refractory epilepsy carries a higher incidence of cognitive and psychological disorders, injury, mortality, and social isolation.

3. Enhancing Self-Esteem

Social stigma, misconceptions, and the limits seizures place on daily life can drive down self-esteem. The unpredictability of seizures and the need to disclose the diagnosis add embarrassment, shame, and isolation.

Explore feelings about the diagnosis and the perceived threat to self, and encourage expression. Reactions vary, and prior knowledge or experience shapes acceptance of treatment. Patients facing greater illness demands and more seizures tend to report higher stress, more negative illness perceptions, and lower self-esteem.

Assess for psychiatric comorbidities. The rise in depression and anxiety in the year after an epilepsy diagnosis tracks with the patient's sense of lost self-control more than with the actual number of seizures, and quality of life correlates with depression symptoms.

Discuss likely public reactions and encourage the patient not to conceal the condition. This opens problem-solving and gives a sense of control. Concealment damages self-esteem, reinforces denial, and can raise the risk of injury or a bad reaction when a seizure does occur in public.

Discuss the patient's current and past successes and strengths. Focusing on the positive eases guilt and self-consciousness and helps the patient accept that the condition is manageable. Recurrent seizures, social restrictions, and financial strain all shape how a patient sees themselves.

Do not overprotect the patient; encourage activities with supervision when indicated. Taking part in as many experiences as possible lessens depression about limitations. Supervision may be needed for gymnastics, climbing, and water sports. Coping well in adolescence shows up as growing autonomy, a developing self-identity, and stronger peer relationships.

Know the attitudes and capabilities of significant others, and help the patient see that their feelings are normal while guilt and blame are not useful. Unfavorable expectations from family can undercut the patient's sense of competence and limit the support they receive. Parental support directly influences a child's mental health and quality of life.

Explain the value of staff and family staying calm during a seizure. Tension and anxiety are contagious and amplify the patient's own negative perceptions. Caregiver distress is linked to a poorer caregiver-child relationship and to anxiety and depression in children and adolescents with epilepsy.

Refer the patient and family to a support group such as the Epilepsy Foundation of America, the National Association of Epilepsy Centers, or a service dog organization. Shared experience provides information, support, and practical ideas. Some service dogs can sense or predict seizures, letting the patient take safety measures and gain independence.

Discuss referral for psychotherapy with the patient and family. Seizures hit self-esteem hard, and patients or family may feel guilt over perceived limits and public stigma. Counseling helps with feelings of inferiority, and behavioral health providers can optimize quality of life with evidence-based psychological treatment.

Encourage self- and family management. These are the steps an individual or family can take to control seizure frequency, including relaxation, exercise, and coping skills, drawn from the individual, family, community, or healthcare domains.

Provide information about adherence interventions. These help the patient follow professional advice, including taking medications as prescribed, following a ketogenic diet, and avoiding triggers. Adherence breaks down into pieces such as dose timing and frequency.

Encourage the patient's friends and peers to support them. Most young people get support from friends, and disclosure usually does not hurt their friendships. Friends often show concern by checking on the patient after a seizure, and some find that opening up strengthens the relationship.

Promote participation in social and leisure activities. Patients often feel that seizures, parent-imposed restrictions, and social barriers cut them off from friends, which erodes independence and autonomy. Regular social activities, supervised camps, and inclusive attitudes build acceptance and self-esteem.

Ascertain the presence of stigma in the patient's community. Stigma is a potential risk factor for psychopathology in people with epilepsy, and perceived stigma correlates positively with depression and anxiety.

Encourage positive coping behaviors. Problem-focused coping supports adaptation. Being optimistic, seeking social support, focusing on competence, and sticking with treatment all correlate with better psychosocial outcomes.

4. Promoting Adherence to Therapeutic Management

Nonadherence stems from medication side effects, forgetfulness, denial, financial constraints, and cultural or religious beliefs, and it leads to poor seizure control, more injuries, and worse quality of life. The prevalence of nonadherence to antiseizure therapy ranges from 26% to 79%.

Assess the patient's knowledge of seizures, their medical management, and the treatment plan. This lets you clarify information and build an individualized plan that supports adherence. Nurses are well placed to do this because they usually have the first interaction and perform the initial assessments during a visit.

Assess the causes of nonadherence: a history of noncompliance, socioeconomic status, forgetfulness, side effects, confusion about instructions, or difficulty with lifestyle change. Identifying the cause lets you target the plan. Nonadherence includes forgetting doses, taking more or less than prescribed or at the wrong time, stopping early, and failing to refill.

Evaluate the patient's view of how well treatment works and their level of adherence. This reveals how vulnerable the patient feels and whether they are in denial. Objective measures include pill counts, electronic monitoring, refill rates, directly observed therapy, and drug concentrations; subjective measures include self-report and a patient diary.

Assess the patient's support system. Family patterns can drive nonadherence. One marker of a young patient's growing autonomy is the shift of management responsibility from parent to child, though parents often keep the dominant role in deciding which activities are appropriate.

Assess the health literacy of the patient and family. Lower education is linked to nonadherence; one review found two-thirds of patients were illiterate or had no formal education, consistent with the lower educational attainment seen in people with epilepsy.

Explain how to handle common barriers such as financial constraints and workplace discrimination. Removing these barriers is essential to adherence. Local misunderstandings and stigma about epilepsy can affect treatment and the knowledge patients, families, and communities have about it.

Discuss and correct myths and stigmas with a realistic assessment of risk. This surfaces cultural, spiritual, or personal factors that affect adherence. In one setting epilepsy was seen as a disease caused by supernatural or ancestral forces, so education should be paired with culturally appropriate, sustained family teaching.

Provide information on steady drug blood levels and half-life, what to do about a missed dose, how to refill a lost or empty prescription, the schedule for lab followup, and the importance of telling the provider if a medication is stopped. Intermittent use is sometimes an attempt to gain control, and patients need to understand that stopping antiseizure medications abruptly can cause severe, life-threatening reactions. Counseling has been shown to cut forgetful dosing from more than 70% to 45%.

Help identify available support systems such as local epilepsy centers and epilepsy-specific organizations. Patients understand and feel supported better through others with the same condition. Poor perceived access to pharmacy services is a significant contributor to nonadherence, and value-added pharmacy services that ease access to the monthly medication supply can help.

Once the causes are identified, discuss revising the plan with the provider and teach measures to control medication side effects. Tell the patient to avoid alcohol, which adds sedation, and to take the drug with food to reduce gastric upset. An acute seizure action plan guides the patient and caregivers on dosing and what to do, which reduces apprehension, ED visits, and delays in giving benzodiazepines where emergency access is limited.

Suggest counseling or psychotherapy if indicated. This improves quality of life and psychological well-being when the disease itself is a reason for nonadherence. Reminder systems, cognitive education, behavioral counseling, social support, and multifaceted interventions all improve adherence.

Let the patient vent feelings of indifference, helplessness, powerlessness, and shame. Fear of stigma and discrimination from disclosure is common in young people with chronic illness. First seizures are often sudden and unexpected, patients may not feel ready for the information to be known, and expressing these feelings relieves stress and anxiety.

Establish a therapeutic relationship with the patient and family. Adherence depends on the clinician forming a relationship that encourages the patient to agree to treatment, which means patients are better informed and have more real power over their care.

Help the patient understand each medication, its dose, and its benefit. Complex regimens predict poor adherence because multiple medicines or frequent daily dosing make administration difficult.

Include family members and caregivers in teaching. Education must reach the family, not just the patient. Family support is a major strategy in epilepsy treatment but is hard when families feel ashamed, so communication about the disease and therapy must extend to them.

Encourage participation in behavioral interventions as indicated. These cognitive behavioral techniques target dysfunctional emotions, behaviors, and thoughts to promote healthy habits and positive change toward treatment.

5. Patient Education and Health Teaching

Misconceptions, inadequate education, and limited access to information leave patients struggling to manage the disorder, make informed decisions, and communicate their needs. Clear nursing guidelines for education are the first step toward better diagnosis, treatment, self-management, and psychosocial care.

Ascertain the level of knowledge and anticipatory needs. This gauges the readiness of the patient and family to learn. Patients often feel inadequately informed about treatment and management even though quality indicators exist to ensure they understand their disease, treatment, side effects, and safety issues such as adequate sleep and stress reduction.

Determine readiness and barriers to learning. The patient may not be physically, emotionally, or mentally ready. Many patients want to be active in self-management, but time limits and a lack of patient-centered communication often get in the way of shared goal-setting.

Review the pathology, prognosis, and lifelong need for treatment, and discuss the patient's specific triggers such as flashing lights, hyperventilation, loud noises, video games, and TV viewing. This dispels misconceptions and frames the condition as manageable within a normal life. Prognosis depends on the seizure type and epileptic syndrome, and impaired consciousness during a seizure can unpredictably cause injury or death.

Review the effects of hormonal changes. Hormonal shifts during menstruation and pregnancy can raise seizure risk. Seizures in pregnancy are a complication of severe untreated preeclampsia, and eclampsia can occur up to four weeks after delivery; late postpartum eclampsia carries a higher incidence of cerebral venous thrombosis, intracranial hemorrhage, and acute ischemic stroke.

Stress the need for routine followup and lab testing. Monitor CBC twice a year and whenever a sore throat, fever, or other sign of infection appears, since serious side effects such as agranulocytosis or toxicity can develop. Get antiepileptic blood levels in patients already on medication, and serum calcium in patients with a history of malignancy.

Discuss maintaining good general health: adequate diet, rest, moderate exercise, and avoiding exhaustion, alcohol, caffeine, and stimulant drugs. Regularity and moderation reduce precipitating factors and strengthen coping and self-esteem. Too little sleep or too much alcohol can trigger seizures, and barbiturate or benzodiazepine withdrawal can cause them, sometimes days or weeks after stopping.

Stress good oral hygiene and regular dental care. This reduces oral infections and gingival hyperplasia. Chronic tongue biting causes soft-tissue, vascular, and lymphatic injury that leads to edema and predisposes to further injury, and any intraoral protective device must be removable for hygiene.

Promote acceptance of real limitations and discuss safety around driving, mechanical equipment, ladders, swimming, and hobbies. This reduces injury risk, especially when seizures occur without warning. By law, patients cannot drive unless they have been seizure-free on medication for one year, and any high-risk recreational activity should be done with at least one other person who knows the condition and can intervene.

Review local laws and restrictions for people with epilepsy and encourage awareness. Restrictions still exist in some states for a driver's license, sterilization, workers' compensation, and mandatory reporting to state agencies. If the provider practices in a state that requires reporting to the DMV, they must comply and document it. Reporting requirements vary widely between countries.

Review the medication regimen, the need to take drugs as ordered, and not stopping therapy without provider supervision, including how to handle a missed dose. Poor cooperation with the regimen is a leading cause of breakthrough seizures, and abrupt withdrawal of anticonvulsants risks status epilepticus. About 75% of seizure relapses after stopping medication happen in the first year, and at least 50% of patients who have another seizure do so in the first three months.

Recommend taking drugs with meals when appropriate. This reduces gastric irritation, nausea, and vomiting, which are common but tolerable side effects. Carbamazepine cannot be taken with grapefruit juice or St. John's wort, which lower its level and effectiveness.

Discuss nuisance and adverse side effects: drowsiness, fatigue, lethargy, hyperactivity, sleep disturbance, gingival hypertrophy, visual disturbance, nausea and vomiting, rashes, syncope, ataxia, birth defects, and aplastic anemia. These may signal a need to change dose or drug and keep the patient involved in decisions about long-term therapy. Felbamate is a drug of last resort in refractory cases because of the risk of aplastic anemia and hepatic toxicity, which require regular blood tests.

Provide information on drug interactions and the need to tell other providers about the regimen. Knowing the anticonvulsant reduces the risk of prescribing an interacting drug that alters the seizure threshold or therapeutic effect. Phenytoin potentiates the anticoagulant effect of warfarin; isoniazid and chloramphenicol increase the effect of phenytoin; and some antibiotics can raise carbamazepine to toxic levels.

Familiarize the patient, family, and caregiver with diazepam rectal gel (Diastat). This controls serial or cluster seizures, can be given in any setting, and usually works within 15 minutes, reducing dependence on the ED. Patients can carry rectal diazepam for breakthrough seizures and learn to recognize an aura to prepare for one.

Encourage the patient to wear a medical ID tag or bracelet stating the seizure disorder. This speeds treatment and diagnosis in an emergency. In 2018 the FDA cleared the first smartwatch for seizure tracking, the Embrace, which detects convulsive seizures, alerts caregivers by text and phone, and records sleep, rest, and activity.

Establish a seizure action plan with the patient and caregivers. This guides medication administration and what to do before EMS arrives or a visit to the ED. Plans should be built with the primary provider or neurologist, and a generalized version can be given at discharge while the patient waits for followup; it should clarify when to give rescue medication, when to wait for an outpatient visit, and when to call 911 or go to the ED.

Use communication tools when providing care and information. Nurses without epilepsy specialization increasingly care for these patients, and a tool such as the Epilepsy Nursing Communication Tool can improve nurse-patient communication using a patient-centered model where knowledge is shared and decisions rest on the best available evidence.

Refer to a neurologist as indicated. Consider a neurology consult if the patient meets the definition of status epilepticus, a patient with known epilepsy has a breakthrough seizure, or the patient is in a prolonged postictal state. Nonadherence is a leading cause of breakthrough seizures, so a medication change may be needed.

Reinforce seizure precautions as appropriate. The unpredictability of recurrence makes this hard, but discussing and documenting precautions protects the patient and guards against future litigation. Use judgment for patients with only nocturnal epilepsy.

6. Administering Medications and Pharmacologic Support

Antiepileptic drugs (AEDs): phenytoin, primidone, carbamazepine, clonazepam, valproic acid, divalproex, acetazolamide, ethotoin, methsuximide, fosphenytoin. AEDs raise the seizure threshold by stabilizing nerve cell membranes, reducing neuronal excitability, or acting directly on the limbic system, thalamus, and hypothalamus. The goal is optimal seizure suppression at the lowest possible dose with the fewest side effects. Fosphenytoin reaches therapeutic levels within 24 hours and can be used for nonemergency loading while other agents take effect. Some patients need polytherapy or frequent adjustments, which raises the risk of adverse reactions and adherence problems.

Topiramate, ethosuximide, lamotrigine, gabapentin. These are adjunctive therapy for partial seizures or an alternative when other drugs do not control seizures. Lamotrigine is quickly absorbed orally, with 55% bound to plasma proteins. Topiramate is approved for generalized, primary generalized tonic-clonic, and partial-onset seizures.

Phenobarbital. This potentiates the effects of AEDs and allows a lower dose to reduce side effects. If the patient has received a benzodiazepine, the risk of respiratory suppression rises significantly. It is the best-studied barbiturate for status epilepticus.

Lorazepam. This aborts status seizure activity, is shorter acting than diazepam, and is less likely to prolong post-seizure sedation. It is thought to be the most effective benzodiazepine, has a longer seizure half-life than diazepam, and is favored when intravenous access is preferred.

Diazepam. This may be used alone or with phenobarbital to suppress status seizure activity. Diastat gel can be given rectally, even at home, to reduce seizure frequency and the need for additional care. Patients can carry rectal diazepam for breakthrough seizures and learn to recognize an aura to prepare for one.

Glucose, thiamine. These restore metabolic balance when a seizure is induced by hypoglycemia or alcohol. A 50 mL bolus of 50% dextrose IV and 100 mg thiamine can be given, especially in status epilepticus; where drug intoxication is likely, consider adding naloxone to the dextrose.