A seizure is a sudden, abnormal, excessive discharge of neurons that changes movement, sensation, behavior, or consciousness. It reflects an imbalance between excitatory (glutamate) and inhibitory (GABA) signaling.

Epilepsy is a tendency to have recurrent unprovoked seizures — generally at least two unprovoked seizures more than 24 hours apart, or one unprovoked seizure with a high risk of recurrence, or an epilepsy syndrome.

Provoked (acute symptomatic) seizures have an immediate cause: hypoglycemia, hyponatremia, hypocalcemia, hypoxia, alcohol or benzodiazepine withdrawal, drug toxicity, fever, stroke, head injury, CNS infection, tumor, or eclampsia. Treat the cause.

Seizure classification (ILAE 2025 update) — four main classes: focal, generalized, unknown whether focal or generalized, and unclassified. The 2025 update uses consciousness (awareness plus responsiveness) rather than "awareness" alone.

Status epilepticus is a medical emergency: a seizure lasting 5 minutes or more, or repeated seizures without return to baseline between them. Prolonged seizures cause hypoxia, lactic acidosis, hyperthermia, rhabdomyolysis, and neuronal injury, and become harder to stop the longer they last.

Febrile seizures occur in children about 6 months to 5 years old with fever and no CNS infection; simple febrile seizures are brief, generalized, and do not recur within 24 hours.

Observe and document (the nurse is often the only witness):

• Time of onset and duration; what the client was doing; any warning (aura)
• Where it started and how it spread; type of movements; eye and head deviation
• LOC during the event; automatisms; incontinence; tongue biting; color, breathing
• Postictal state: confusion, sleepiness, headache, muscle soreness, Todd paralysis (temporary weakness of one side, lasting hours)
• Injuries; blood glucose; medication adherence; triggers (sleep deprivation, alcohol, missed doses, flashing lights, stress, illness, menstruation)

EEG preparation: wash hair the night before, no oils or sprays; avoid caffeine if instructed; eat normally (hypoglycemia alters the recording); sleep deprivation may be ordered. Photic stimulation (flashing lights) and hyperventilation may be used to provoke abnormal activity — explain this to the client or parents in advance.

Status epilepticus — time-based treatment

Benzodiazepines cause respiratory depression and hypotension — have bag-valve-mask and airway equipment ready. Underdosing benzodiazepines is a common error.

Maintenance antiseizure medications (ASMs) — choose by seizure type, age, sex, pregnancy potential, and interactions.

All ASMs carry an FDA warning for increased suicidal thoughts — screen mood.

Other therapies: epilepsy surgery (e.g., temporal lobe resection) for drug-resistant focal epilepsy; vagus nerve stimulation; responsive neurostimulation; ketogenic diet.

Listed in priority order.

1. During a tonic-clonic seizure
   • Stay with the client, call for help, and note the time.
   • Protect from injury: ease to the floor or keep in bed with the bed low; turn onto the side (side-lying) to let secretions drain and keep the airway open; move hard objects away; cushion the head; loosen tight clothing.
   • Do not restrain and do not put anything in the mouth (no tongue blades, fingers, or airway during clenching).
   • Oxygen and suction as needed; prepare benzodiazepine and IV access if the seizure reaches 5 minutes.
2. After the seizure (postictal)
   • Assess airway, breathing, and LOC first; keep side-lying; suction; oxygen; vital signs; check glucose.
   • Reorient; check for injuries (tongue, head); allow rest; neuro checks.
   • Document the full description.
3. Seizure precautions (per policy): bed low, oxygen and suction at bedside, IV access for high-risk clients, padded rails only if agency policy, supervised bathing.
4. Medication management
   • Give ASMs on time; do not skip doses when NPO — clarify alternative route.
   • Monitor levels and adverse effects (sodium, CBC, liver tests, gums, rash, mood).
5. Psychosocial — address stigma, anxiety, employment and driving concerns; refer to support groups.

• Take ASMs every day at the same time — link doses to a daily routine (meals, brushing teeth), use pill organizers and phone alarms.
• Never stop or change the dose on your own, even if seizure-free or experiencing side effects — abrupt withdrawal can trigger status epilepticus. Report side effects instead.
• Check with a pharmacist before taking any other drug, supplement, or herbal product — many interact with ASMs.
• Blood levels are checked when starting therapy, after dose changes, and when control changes or toxicity is suspected — not only once a year.
• Avoid triggers: sleep deprivation, excess alcohol, recreational drugs, skipped meals, stress. Photosensitive clients may use screens with breaks, adequate room lighting, and avoidance of flashing content — complete avoidance of computers is not necessary.
• Safety: showers instead of baths, never swim alone, avoid heights, wear a helmet for cycling; follow local driving laws.
• Family first aid: time the seizure, turn on the side, nothing in the mouth; call emergency services if a seizure lasts 5 minutes or more, repeats without recovery, occurs in water, causes injury or breathing difficulty, or if it is the first seizure. Rescue medication (intranasal or buccal midazolam, rectal diazepam) as prescribed.
• Pregnancy planning: discuss before conception; take folic acid daily; valproate carries the highest risk of birth defects; enzyme-inducing ASMs reduce hormonal contraceptive effectiveness.
• Wear medical identification.
• Febrile seizure (parents): usually harmless; place child on side, time the event, do not put anything in the mouth or put the child in a bath; call emergency services if it lasts 5 minutes or more or breathing is difficult; fever reducers make the child comfortable but do not prevent recurrence.

• ILAE 2025: focal (preserved or impaired consciousness, focal-to-bilateral tonic-clonic), generalized, unknown, unclassified.
• Status epilepticus = ≥ 5 minutes → IV access and benzodiazepine (IV lorazepam or IM midazolam), then fosphenytoin, valproate, or levetiracetam.
• Check glucose in any seizure.
• During a seizure: side-lying, clear surroundings, time it, nothing in the mouth, no restraint.
• Postictal priority: airway, breathing, LOC.
• Phenytoin: gingival hyperplasia, nystagmus, ataxia; level 10–20 mcg/mL; IV with saline only, ≤ 50 mg/min.
• Carbamazepine: hyponatremia, agranulocytosis, SJS (HLA-B*1502); dizziness and blurred vision.
• Valproate: hepatotoxicity, pancreatitis, neural tube defects — pregnancy counseling.
• Lamotrigine: rash; slow titration.
• EEG may use flashing lights and hyperventilation to provoke activity.
• Adherence: link doses to daily routines; never stop abruptly.
• Febrile seizure: call emergency services if ≥ 5 minutes or breathing difficulty.