Problem
Scenario: J.G. is a 34-year-old woman who underwent an emergency caesarean delivery after a prolonged labor, during which she had a sudden change in neurologic functioning and had a tonic-clonic (grand mal) seizure. After delivery, J.G. had 2 more seizures and demonstrated dyskinesia, resulting in frequent falls when ambulating. She was diagnosed with a basal ganglion hematoma with infarct and started on phenytoin (Dilantin). Once the seizure disorder appeared to be under control, she was transferred to a rehabilitation facility for evaluation and 2 weeks of intensive physical therapy (PT). She is now home. She still has occasional falls but has had no seizures. She is receiving PT 3 times a week in her home. As case manager for J.G.'s health maintenance organization, you make a home visit with her and her family for evaluation of long-term follow-up care.
I. A seizure is not a disease in itself but a symptom of a disease. What is the term for chronically recurring seizures?
II. Does J.G. have epilepsy?
III. In addition to the brain injury, what are some other possible conditions that could be contributing to J.G.'s lowered seizure threshold?
IV. What is the pathophysiology of a seizure?
V. J.G. had tonic-clonic, or grand mal, seizures. Describe this type of seizure.
VI. They ask how phenytoin (Dilantin) works in preventing seizures. How would you respond?
VII. What factors are considered when determining which seizure medication, a patient should take?
VIII. J.G. tells you she is having trouble remembering to take her medication. Why does this concern you?
IX. What are some strategies you could suggest to J.G. and her husband to help her with remembering to take the phenytoin?
X. You check the chart and note that J.G.'s last phenytoin level was 12.7 mcg/mL (50.3 mcmol/L). What action do you expect based on this level?
i. Because this level is on the border of therapeutic, notify the neurologist.
ii. This level is dangerously high, and an immediate reduction in dose is necessary.
iii. J.G. is at immediate risk for a seizure so she should go to the emergency department.
iv. Because this level is within normal limits, J.G. would continue therapy as prescribed.
XI. J.G. asks, "Will my blood levels stay under control as long as I take my medicine?" How would you answer her question?
XII. J.G.'s husband asks if the phenytoin could harm his wife in any way. What general information would you review with them about phenytoin?
XIII. J.G. says that because she has not had a seizure since she was in the hospital, she questions how long she will have to continue taking the phenytoin. Which is your best response?
i. "Your seizures are cured only as long as you take the medication."
ii. "This medication might need to be continued for the rest of your life."
iii. "This medication can be stopped after you are seizure free for 6 months."
iv. "This medication will have to be taken only when you are experiencing stress."
XIV. J.G.'s husband asks you what he should do if she has a seizure at home. What should you teach him?
XV. Her husband states that he is afraid for J.G. to take care of the baby. What would you say to him?
XVI. What aspects of the home environment do you need to inspect and why?
XVII. Describe safety measures you can teach J.G. that will minimize her risk of injury should she have a seizure.
XVIII. You would determine further teaching is needed regarding modifying their home environment to reduce J.G.'s risk of falling if J.G. or her husband states:
i. "The decorative rugs are all going to be put into storage."
ii. "We will put some non-skid strips in the shower in the master bath."
iii. "We will keep the stairway free of clutter and turn the light on as needed."