Rose Lea Quiamco NURSING CARE PLAN NAME: Asher Gil Roa SEX: Male DATE OF BIRTH: 04/26/2011

AGE: 1 y/o dehydration, OCCUPATION: none @ 174cc/h DATE OF ADMISISON: 01/10/2013

ER/PEDIA

PATIENTS HEALTH PROFILE: A case of Roa Nigel Gil, admitted due to episodes of vomiting with experienced an episode of convulsion, with ongoing IVF of D50.3 Nacl

at right hand, febrile T 38. C, warm to touch & non dyspneic, asleep. Diagnosis: Status Epilepticus secondary to CNS infection, vomiting & dehydration Nursing Goal Nursing Interventions Independent: Monitor and record patients vital signs Explore with the client the various stimuli that may precipitate seizure activity Turn patients head to side/suction airway as indicated. Insert plastic bite block per facility protocol only if jaw relaxed Maintain strict bed rest if prodromal signs/aura experienced. Explain necessity for these actions. Rationale To obtain baseline data Alcohol, drugs & other stimuli (e.g loss of sleep, flashing lights, prolonged television viewing) may increase potential seizure activity Helps maintain airway & reduce risk of oral trauma but should not be forced or inserted when teeth are clenched. Evaluation After 6-8 hours of effective nursing intervention, the patients SO was able to demonstrate behaviors & interventions to reduce risk factors & protect patient from injury, verbalized understanding about factors that may contribute to possibility of trauma & identify measure to take when seizure occurs.

Nursing Diagnosis Problem: Risk trauma related to loss of large or small muscle coordination secondary to status epilepticus. Subjective: Nikalit lang siyag kurog unya init ky siya kron as verbalized by the patients mother. thirsty Objective: Vital sings: T 38. C, febrile P 105bpm

Scientific Analysis Status Epilepticus is a convulsive or generalized tonicclonic continuous seizure that last >30 mins, or consist of 2 consecutive seizure without mental clearing in between, A continuous seizure state, status epilepticus can occur in all seizure types and is considered an emergency. A seizure or convulsion is the visible sign of a problem in the electrical system that controls your brain. A single seizure can have many causes,

After 6-8hrs of nurseclient intervention the SO will be able to : Identify measures to take when seizure activity occurs Verbalized understanding factors that may contribute to possibility of trauma Demonstrate interventions to reduce risk factors and protect patient from future seizure events

Client may feel

restless/need to ambulate or even defecate during aural phase, thereby

R 32cpm Warm to touch with flushing Irritable

such as a high fever and lack of oxygen. Hemoglobin is a protein red blood cell that carries oxygen. Therefore, Low levels of hemoglobin in the human body may result to seizure. During episodes of convulsion, patients are prone to injuries since they may strike different objects due to uncontrollable muscle spasms.

Discuss seizure warnings signs and usual seizure pattern

Stay with the client during after seizure Observe for Status Epilepticus, that is one tonic-clonic seizure after another in rapid succession

removing self from safe environment and easy observation Can enable SO to protect individual from injury and recognize changes that require notification of physician/further intervention to prevent injury. Promote client safety and reduces sense of isolation during event. A life threatening emergency that if left untreated could cause metabolic acidosis, hyperthermia, hypoglycemia, hyperthermia, arrhythmias, hypoxia, increased ICP, airway obstruction & respiratory arrest. Promote client safety and make patients SO understand about the condition To control seizure activity. AED prevent

SOURCE: Med-Surg Lippincott Williams & Wilkins page 287 NCP 5th edition by Lynda Juall CarpenitoMoyet page 295 NCP 7th edition page 208-210

Educate patients SO about the condition and factors to prevent injury Collaborative:

Administer

medications as indicated antiepileptic AED ( e.g .phenytoin ), anti -pyretic ( lower high temperature)

seizure by raising the seizure threshold, stabilizing nerve cell membrane, reducing excitability of neurons, through direct action on limbic system, thalamus & hypothalamus.