Seizure disorders and epilepsy.

Seizures are uncontrolled hypersynchronous electrical discharges of neurons in the brain that interfere with normal function. They are a symptom of an underlying disorder. Epilepsy is a condition of recurring seizures that do not have a reversible metabolic cause. Seizures can be confused with a variety of other conditions, so an understanding of seizure manifestations is crucial in making an accurate diagnosis. Drug therapy is the mainstay of epilepsy treatment, but surgery and vagal nerve stimulation are options for selected refractory cases. Psychosocial consequences of recurring seizures are often more significant to patients than the seizures themselves.

Ethical dilemmas in people with epilepsy who drive.

Concern about driving safety in people with epilepsy has been present since the automobile became a widely used source of transportation (Siegel, 1988). Unfortunately, we still do not have adequate means to determine who can and cannot drive. Clinicians must use their best medical judgment to make these determinations. They then must consider the aspects of their state's driving laws and legal consequences of their judgments. In the 44 states that do not require clinician reporting of seizures, they must deliberate about breaching or maintaining the confidentiality of patients with uncontrolled seizures who continue to drive. In making this deliberation they should consider both the probability and magnitude of harm posed by continued driving of an individual patient. Judgments to breach confidentiality should include assessment of risks and benefits to the patient and to society by taking such action. Ultimately, each patient must be judged individually.

Pharmacologic management of epilepsy: an update.

A fifteen-year hiatus separated the availability of established AEDs and the new AEDs, after which the 1990s brought four new AEDs on the market. The new AEDs offer many alternatives that were unavailable before this decade for people with refractory epilepsy. Because AED clinical trials are usually based on efficacy in refractory patients, new drugs have an indication only for adjunctive therapy in people with poorly controlled seizures. In spite of their indication as adjunctive therapy, the new AEDs may eventually prove to be useful in monotherapy and even initial therapy of partial and secondarily generalized seizures. Although none of the new AEDs met all the criteria of an ideal AED, namely high oral bioavailability, rapid absorption, linear kinetics, negligible protein binding, long half life, renal excretion and low potential for drug interactions, they represent significant advances over the established AEDs. The only major barrier to broader use of the new AEDs appears to be cost.

New antiepileptic therapies.

This is an exciting time for AED development. Four new AEDs have been approved for use in the last 3 years and several more are being evaluated. New formulations of traditional therapies, such as Tegretol XR, and IV and IM fosphenytoin offer alternatives for the management of acute and chronic seizure disorders (see "Clip & Save" and "What's News"). With these new treatments options, providers will be challenged to choose the most appropriate drug or drug combination for their patients based on seizure type, AED mechanisms of action, pharmacokinetic properties, adverse effects, and drug interactions.

Persistent vegetative state: important considerations for the neuroscience nurse.

Persistent vegetative state is a rare condition but one which evokes many emotional, psychosocial, bioethical, legal and economic concerns. Because neuroscience nurses are among the caregivers most likely to be involved in caring for patients in PVS, they need to be knowledgeable in the diagnosis, prognosis and ethical management of these patients and be able to assist families, loved ones and surrogates make informed decisions about treatment choices.

A nursing bioethics program.

In 1985 the Seattle Veterans' Administration Medical Center nursing service implemented a nursing program for bioethics with three goals: (1) to expand the nurse's knowledge of bioethical principles, (2) to develop the nurse's ability and confidence in analyzing bioethical dilemmas, and (3) to increase bioethical application at the bedside. Two psychosocial clinical nurse specialists (CNSs) led this highly successful nursing program that prepared nurses to more actively and responsibly participate in bioethical decision making within the medical center. The program offers an annual workshop for new members, holds a monthly discussion group, conducts a yearly enrichment program, and completes an annual evaluation report. This article describes nursing service bioethics program from planning through evaluation and the role of the CNS as program coordinator, facilitator, and educator in the expanding field of bioethics.

Interactions between calcium channel blockers and the anticonvulsants carbamazepine and phenytoin.

We describe a retrospective analysis of the frequency of adverse interactions between calcium channel blockers and anticonvulsant drugs (phenytoin and carbamazepine) in a series of 43 patients. Ten patients receiving carbamazepine and three patients receiving phenytoin exhibited symptoms or signs of toxicity. Toxicity occurred with both diltiazem and verapamil, but not with nifedipine. These results emphasize the need for careful clinical and laboratory monitoring of patients receiving both classes of medication.

Role delineation and test specification validation study for the CNRN examination.

The American Board of Neuroscience Nursing conducted a role delineation and validation study to determine practice areas to be tested. In addition, weighting for each area to be included in the certification examination was determined. This article describes steps taken in the validation process and discusses findings along with application of results to certification examination revision.

An experience with epidural morphine in lumbar surgery patients.

A chart review of the patients who received epidural morphine for lumbar surgery during the first year of implementation of the procedure was conducted. This article reviews the pharmacology and side effects of epidural morphine, describes the procedure of administering epidural morphine, discusses side effects and technical problems encountered, and presents implications for nursing practice.

Alterations in mentation: nursing assessment and intervention.

Physical assessment for nursing purposes is necessarily different from that of medicine because the focus of nursing is to diagnose and treat human responses to disease rather than the disease itself. Nursing assessment pathophysiology, implications for daily living, and nursing interventions for selected functional aspects of mentation, namely language, remembering, and performing learned movements, are presented in this article.

Effect of enteral tube feeding on serum phenytoin levels.

The primary purpose of the present study was to determine if altering the timing of phenytoin administration in relation to delivery of tube feedings increased serum phenytoin levels. Stopping tube feedings for two hours before and two hours after administration is a procedure that nurses could employ independently for better patient care. However, this adds an extra procedure to the nurse's already busy routine. It also requires the nurse to adjust either the tube feeding flow rate or bolus amount in order to deliver the same amount of calories per day. Based on this study, it appears that this intervention procedure is not effective for the patient and is time-consuming for the nurse. Instead, the focus for increasing phenytoin serum levels in patients receiving tube feedings should probably be on increasing the dosage.

Moving the patient in bed: effects on intracranial pressure.

Intracranial pressure (ICP) was measured in 20 patients before and after each of eight nursing care activities: turning the body to four positions, passive range of motion (arm extension and hip flexion), and rotation of the head to the right and to the left. Technically usable data was available for 18 patients. Mean ICP increased for at least five minutes in all patients after one of the four turns and in 88 percent after half the turns. Change in mean ICP with one of a pair of lateral or supine turns was strongly predictive of the direction of change (increase or decrease) of the other turn of the pair. Large increases in ICP occurred in the five patients for whom head rotation was done, while there was minimal change in ICP with both passive range of motion procedures. A cumulative increase in ICP occurred with activities spaced 15 minutes apart, regardless of the nature of the activity. No cumulative increase in ICP was found with procedures spaced at least one hour apart.