Disclaimer: This toolkit is intended to provide resources for school nursing practice as it relates to the care of students with seizures. This is not medical or nurse practice advice and is not prescriptive as it relates to individual students or individual nursing practice. These resources do not override individual assessment and clinical judgement.
Epilepsy
Seizures represent an unregulated, abnormal electrical discharge that occurs within the brain. The symptoms of seizures vary but often cause changes in awareness or levels of consciousness, change in cessation, involuntary movement or muscle contraction. Seizures may be epileptic or non-epileptic in nature.
Epilepsy is a chronic neurological disorder characterized by recurrent unprovoked seizures. Although epilepsy is often idiopathic, certain underlying conditions may provoke symptomatic epilepsy. There are different types of seizures which are dependent about which part of the brain is affected (National Library of Medicine, 2021).
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Focal Seizures, also referred to as simple partial seizures, occur when one abnormal electrical activity occurs in one area of the brain.
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Complex focal/complex partial seizures may occur in more than one area of the brain (Kumar, et al., 2022; Johns Hopkins, 2021)
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Generalized seizures occur when abnormal activities occur on both sides of the brain; these may include absence seizures, atonic seizures, generalized tonic clonic seizures and myoclonic seizures (CDC, 2021)
Epilepsy is a relatively common chronic disease. Individuals with epilepsy have a higher incidence of mood disorder, learning disorders and chronic headaches or migraines. (Huff & Murr, 2022)
Non-epileptic seizures may be related to injury, illness, electrolyte or cardiac anomalies or underlying mental health issues, such as psychogenic non-epileptic seizures (Beghi et al., 2006, Shenkar et al., 2018)
Psychogenic Non-epileptic Seizures
Psychogenic non-epileptic seizures (PNES), formerly referred to as “pseudoseizures,” are paroxysmal changes that mimic epileptic seizures. While PNES are often misdiagnosed and treated as epilepsy, they are considered psychiatric or personality pathological and significantly regarded as behavioral manifestations of underlying mental health diagnosis (Huff & Murr, 2020; Jafari et al., 2020).
While PNES are not related to cortical electrical activity, the presentation of seizures in the school setting provokes both a safety response and advocacy response on behalf of the nurse.
Safety:
- While students are experiencing PNES, response in the school setting should include the response measures which may include standard first aid, in order to prevent injury to the student. Staff should be notified and educated in response to the student's health condition. Note that the student’s clinical plan of care from their providers should be applied.
- Because PNES may appear prolonged at times, it may provoke concern in staff, due to lack of emergency rescue medications or VNS use. It is critical to provide appropriate education on the underlying cause of PNES, while maintaining student dignity and reducing stigma to ensure the understanding that anoxic brain injury is not a risk.
(Epilepsy Foundation, 2022; Jafari et al., 2020)
Advocacy:
- Because the underlying condition is psychiatric in nature, it is important to advocate for the student to receive appropriate therapeutic intervention. Note this can be more complicated in cases where students also have comorbid epilepsy.
- Because adolescents are at a vulnerable age, PNES are most common in teenage years, but occur in all ages. PNES are more common in females, but occur in both genders.
- Students with underlying learning disabilities, language disorders, anxiety, depression, PTSD and ADHD are at higher risk.
- Because the condition is psychiatric in nature, it is important to provide education to staff in order to protect student dignity and reduce stigma. PNES are regarded as an unintentional means of dissociating from stress and should not be regarded as malingering.
(Epilepsy Foundation, 2022; Jafari et al., 2020)
For more information, please redirect to the
Basic Disease Information
For Epilepsy Pathophysiology
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Anwar, H., Khan, Q. U., Nadeem, N., Pervaiz, I., Ali, M., & Cheema, F. F. (2020). Epileptic seizures. Discoveries (Craiova, Romania), 8(2), e110. https://doi.org/10.15190/d.2020.7
For Psychogenic Non-epileptic Seizures
Evidence Based Practice
Legal Practice Standards
At the forefront of nurse case management for school nurses, is the understanding of scope of practice as it relates to case management and delegation of nursing tasks in a community setting:
Nurse Practice
Public Access Resources
The professional nurse in the school setting should understand the existing resources and framework for care of students with seizures.
Note: the following are national or regional resources that serve as a reference, they may or may not be consistent with Oregon law and do not supersede Oregon Nurse Practice.
National Association of School Nurses (NASN)
Centers for Disease Control and Prevention (CDC)
American Academy of Pediatrics
Epilepsy Foundation
Nationwide Childrens
Mass General
Professional Development
Nurses must ensure that they have proficiency in areas of practice in which they delegate care tasks. The following include Free Continuing Education resources for Nursing related to seizure:
Most CE or PD Resources included are free of charge, any that have associated expense are noted with $
National Library of Medicine: Continuing Education Activities
(Must create and account for CE’s)
- Huff JS, Murr N. Seizure. [Updated 2021 Sep 13]. In: StatPearls [Internet]. Treasure Island (FL); 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430765/
- Albuja AC, Khan GQ. Absence Seizure. [Updated 2022 Oct 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499867/
- Kumar A, Maini K, Arya K, et al. Simple Partial Seizure. [Updated 2022 Sep 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK500005/
Epilepsy Foundation
Lecturio Medical
Nurse CE4Less
UAP Training
In the state of Oregon there are specific trainings required for care of students with medications that are prerequisite to individualized training. These include medication administration.
Oregon Department of Education (ODE)
Staff Education
Provision of staff education is critical for students who experience seizures at school, both in terms of understanding the student’s condition, signs and symptoms, and academic impact.
Epilepsy Foundation
Video:
Seizure Medications
Family Resources
Templates
The following templates are modifiable for use by school nurses as it relates to their practice and should be used consistently with Oregon State Board of Nursing, delegation laws and local school policy. These templates are editable to be individually modified by school nurses in Oregon for their practice.
Population Based Response
In the school setting students with diagnosed seizure disorders have an Individual Health Plan (IHP) that indicates the type of seizure, trigger and response, including emergency medication or use of a Vagal Nerve Stimulator (VNS). For students who experience a seizure for the first time at school or who do not have diagnosed epilepsy, an evidence based response to the seizure activity should still be endorsed, a standard seizure response would be part of staff training for unanticipated events.
Individual Health Plans
An individual Health Plan (IHP) includes all applicable procedures for students with chronic disease. Because these are intended to be individualized, the attached is an example of a compiled IHP:
Teacher Notification
Teacher notifications, sometimes referred to as health status notifications or health information pages, can be used or combined with emergency action plans to ensure that all staff working with a student with asthma are informed of diagnosis and immediate actions when necessary. These are abbreviated documents to provide critical information, but less comprehensive information than a complete IHP. This is a modifiable form for teacher notification:
Nursing Care Plan
For districts that utilize nursing care plans for case management, below is a sample for seizures.
Procedures
Procedures also greatly vary by student health status, needs, level of care and type of regimen. The following are sample templates for specific procedures. A complete student assessment should be made to determine appropriate procedures:
Seizure Logs
In some cases the nurse or provider may necessitate a log of seizure activity be kept in the school setting. This can be tracked in a variety of ways. OSNA highly promotes the use of electronic documents that are portable and shareable with families and clinicians ( with appropriate permissions)
History
When a new seizure diagnosis has occurred or a student transfers to another school with a documented seizure disorder, a seizure history or intake may be appropriate.
Authorizations
An authorization for specialized care in an IHP may warrant parent authorization.
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IEP Assessments
Nurses are a critical part of the IEP Team. A nurse may be asked to consult in a variety of means for a student with a seizure disorder such as for accommodations, eligibility, placement or designation of a 1:1 assignment. As is the role of other IEP team members, the nurses should complete an assessment. Below are sample redacted assessments and an editable document.
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References
Al Sawaf A, Arya K, Murr N. (2022). Seizure Precautions. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK536958/
American Academy of Pediatrics. (2021). Seizure Management in Schools. https://www.aap.org/en/patient-care/school-health/management-of-chronic-conditions-in-schools/seizure-management-in-schools/
Basit H, Kahwaji CI. (2022). Clonazepam.Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556010/
Beghi M, Cornaggia CM, Frigeni B, Beghi E. (2006). Learning disorders in epilepsy. Epilepsia. 47 Suppl 2:14-8. doi: 10.1111/j.1528-1167.2006.00681.x. PMID: 17105453.
Carter JM, McGrew C. (2021). Seizure Disorders and Exercise/Sports Participation. Curr Sports Med Rep.20(1):26-30. doi: 10.1249/JSR.0000000000000799. PMID: 33395128.
Cedars Sinai. (2022). Non-Epileptic Seizures. http://www.cedars-sinai.org/health-library/diseases-and-conditions/n/non-epileptic-seizures.html
Centers for Disease Control and Prevention (2021). Seizure first aid. https://www.cdc.gov/epilepsy/about/first-aid.htm
D'Andrea Meira, I., Romão, T. T., Pires do Prado, H. J., Krüger, L. T., Pires, M., & da Conceição, P. O. (2019). Ketogenic Diet and Epilepsy: What We Know So Far. Frontiers in neuroscience, 13, 5. https://doi.org/10.3389/fnins.2019.00005
Di Giovine, M. (2020). Epilepsy in Children and Teens: Diagnosis & Treatment, https://www.healthychildren.org/English/health-issues/conditions/seizures/Pages/Epilepsy-in-Children-Diagnosis-and-Treatment.aspx
Epilepsy Foundation ( 2022). Seizure Training for School Nurses: Caring for Students with Psychogenic Seizures (On Demand) https://learn.epilepsy.com/courses/take/seizure-training-for-school-nurses-caring-for-students-with-psychogenic-seizures/lessons/24955771-module-2-diagnosing-pnes
Beghi E: The Epidemiology of Epilepsy. Neuroepidemiology 2020;54:185-191. doi: 10.1159/000503831
Huff JS, Murr N. (2022). Seizure. https://www.ncbi.nlm.nih.gov/books/NBK430765/
Huff JS, Murr N. (2022) Psychogenic Nonepileptic Seizures. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 28722901.
Jafari A, Rezaei Tavirani M, Parvareshi Hamrah M, Ahmadi Karvigh S, Bashi Zadeh Fakhar H. (2020) Psychogenic Non-Epileptic Seizures; a Narrative Review. Arch Acad Emerg Med. 20;8(1):e10. PMID: 32607501; PMCID: PMC7286438.
Johns Hopkins. (2021) Types of seizures. https://www.hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/types-of-seizures
Kumar A, Maini K, Arya K, Sharma S. (2022) Simple Partial Seizure. 2StatPearls Publishing. PMID: 29763181.
Kumar A, Sharma S.(2022). Complex Partial Seizure.Treasure Island (FL): StatPearls Publishing; PMID: 30085572.
Masood W, Annamaraju P, Uppaluri K,R. (2021) Ketogenic Diet. https://www.ncbi.nlm.nih.gov/books/NBK499830/
Morano, A., Fanella, M., Albini, M., Cifelli, P., Palma, E., Giallonardo, A. T., & Di Bonaventura, C. (2020). Cannabinoids in the Treatment of Epilepsy: Current Status and Future Prospects. Neuropsychiatric Disease and Treatment, 16, 381–396. https://doi.org/10.2147/NDT.S203782
Mutanana, N., Tsvere, M., & Chiweshe, M. K. (2020). General side effects and challenges associated with anti-epilepsy medication: A review of related literature. African Journal of Primary Health Care & Family Medicine, 12(1), e1–e5. https://doi.org/10.4102/phcfm.v12i1.2162
National Institutes of Health[NIH]. (2016). Seizures disrupt memory networks. https://www.nih.gov/news-events/nih-research-matters/seizures-disrupt-memory-network
National Library of Medicine. (2021). Understanding different kinds of seizures. https://magazine.medlineplus.gov/article/understanding-different-kinds-of-seizures
Patel PR, De Jesus O. (2022) Partial Epilepsy. Treasure Island (FL): StatPearls Publishing. PMID: 33232046.
Sarmast ST, Abdullahi AM, Jahan N. (2020). Current Classification of Seizures and Epilepsies: Scope, Limitations and Recommendations for Future Action. Cureus. 12(9):e10549. doi: 10.7759/cureus.10549. PMID: 33101797; PMCID: PMC7575300.
Shankar R, Rowe C, Van Hoorn A, Henley W, Laugharne R, Cox D, Pande R, Roy A, Sander JW. (2018), Under representation of people with epilepsy and intellectual disability in research. PLoS One.13(6):e0198261. doi: 10.1371/journal.pone.0198261. PMID: 29927966; PMCID: PMC6013187.
Smith, G., Plueger, M., Wagner, J. (2019). Evidence based epilepsy care. https://www.myamericannurse.com/evidence-based-epilepsy-care/
University of San Francisco. (2016). Neuro report pearls: Evaluating a first seizure. https://ucsfmed.wordpress.com/2016/07/21/neuro-report-pearls-evaluating-a-suspected-first-seizure/
US Food and Drug Administration. (2018) FDA Approves First Drug Comprised of an Active Ingredient Derived from Marijuana to Treat Rare, Severe Forms of Epilepsy. https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-comprised-active-ingredient-derived-marijuana-treat-rare-severe-forms