Chapter 2 Case Discussion/Presentation Chapter Overview This chapter presents the case discussion/presentation and the overview of related

literature and studies on the subjects made by the researcher during exploration stage of the case finding. Review of Anatomy and Physiology of the Nervous System

igure !" Picture of the #rain" (www.images-search/yahoo.com) The Nervous of ystem feelings is responsible initiate for sensory and and

perception

and

voluntary

19

involuntary actions based on signals transmitted through the nerves to the brain. The functions brain that and are the vital nervous for system have multiple of the

normal

functioning

body. ! nerve impulse is essentially an electrical stimulus that travels over the cell"s membrane. #t passes through

the axons and dendrites of the neurons. #t travels via the dendrites from the s$in and then reaches the cell body% axon% axon terminals and the The ynapse of the neuron.

ynapse is the junction between two neurons where

the impulse moves from one to the other. !t the synapse neurotransmitters are present These are chemical

transmitters of messengers that transmit the impulse. They include !cetylcholine and Noradrenaline. The impulse continues to the next dendrite% in a chain reaction till it reaches the brain that in turn instructs the s$eletal muscles to wor$. These reflexes are automatic% involuntary responses. They may or may not involve the brain for example blin$ing does not involve the brain. The &eflex arc is the main

20

functional unit of the nervous system that helps a person reacts to a stimulus. The brain is one of the largest and most complex

organs in the human body. #t is made up of more than '(( billion nerves that communicate in trillions of connections called synapses. The brain is made up of many speciali)ed areas that wor$ together* The Thin$ing cortex and is the outermost movements layer begin of in brain the cells. cortex.

voluntary

The brain stem is between the spinal cord and the rest of the brain. +asic functions li$e breathing and sleep are controlled here. The basal ganglia are a cluster of

structures in the center of the brain. The basal ganglia coordinate messages between multiple other brain areas.

The cerebellum is at the base and the bac$ of the brain and is responsible for coordination and balance.

The brain is also divided into several lobes* The frontal lobes are responsible for problem solving and judgment and motor function. and The body parietal position. and lobes The manage temporal The sensation% lobes are

handwriting% involved

with

memory

hearing.

occipital

lobes

contain the brain"s visual processing system.

21

The brain is surrounded by a layer of tissue called the meninges. The s$ull (cranium) helps protect the brain from injury (,ssentials of !natomy and -hysiology% .((/). Pathophysiology $%runner and Suddhart&s' 2(!2)

&is$ 1actors* 2enetics 3hildhood abuse or trauma to the head ,nvironmental factor ei)ure activity

3ells send electrochemica l signals even after the tas$ is done

The brain sending out abnormal signals to the erratic cells

ending abnormal brain signals/chemic al disturbance

,rratic cells perform erratically

3ontinuous sei)ures% ,pilepsy

igure 2" Pathophysiology of Sei*ure" %oo+,#ased" &is$ factors are the $ey factors that will determine if a person will have sei)ure or not. #f you have one or more of the ris$ factors% your brain cells tend to function abnormally when it send electrochemical signals. 0nce the erratic cells perform erratically% there will be an

22

abnormality

with

the

chemical

responsible

for

brain

activity. This will now lead to abnormal brain activity which will cause sei)ure activity. !nd if the sei)ures

occur repeatedly% then the client will be diagnosed with epileptic syndrome. (+runner and uddarth4s 5edical

urgical Nursing '(th edition). Pathophysiology $client,#ased)

&is$ 1actors* 2enetics

,arly

/ *

! very high fever% appeared confused and taring into space and

7ate ei)ure !ctivity

/ *

irritable. 6nusually sleepy (abnormal brain activity)heart racing% strong

&igid body parts and loss of consciousness

3ontinous sei)ure

,pilepsy

igure -" Pathophysiology" $Client,#ased)

23

The client has a family history of sei)ure disorder. !side from having familial tendencies% what triggered the sei)ure disorder in the client was having a very high fever of 8/.' degrees 3elsius after the first vaccination of

9epatitis + :accine. #t made the brain perform erratically by sending an abnormal signal. The client experienced the signs and symptoms of sei)ure activity. #t is called

febrile sei)ure because the sei)ure was triggered by the very high body temperature. Signs and Symptoms ,pilepsy signs and symptoms vary from person to person but there are symptoms that are generali)ed. .a#le /" Signs and Symptoms %oo+ #ased $%runner and Suddhart&s' 2(!2) Aura,a sensation at the start of a sei*ure' may involve the perception of an odd smell or sound' spots appearing in front of the eyes' or unusual stomach sensations0 an aura is a sei*ure The client was unable to verbali)e if there has been a feeling of aura. Client %ased

24

Staring

+efore the start of sei)ure% mother claims that the client was staring into space.

1oss of consciousness

The client lost consciousness a few moments after they noticed that the client was staring into space.

Repeated 2er+ing of a single lim#

The mother did not notice any jer$ing movement made by the client

3and ru##ing

The mother did not notice any hand rubbing

1ip smac+ing

The mother notice a lip smac$ing which sometimes lead to lips bleeding

Pic+ing at clothing

The mother did not notice any pic$ing at clothing

ear/Panic

The client did not exhibit any fear or panic

3eart racing' Palpitations

The mother claimed that the client exhibit heart racing and the strong pulse

Perception of an odor' taste or smell 1oss of #owel or #ladder

None as claimed by the client

Nothing was noted

25

control Postictal state a state of drowsiness' alteration in responsiveness' and or confusion oot stomping 4na#le to move #ody parts Nothing was noted The client was unable to move as noted by the mother before he lost consciousness The client seemed irritable and confused and unusually sleepy.

This table shows the signs and symptoms exhibited by the client on the onset of sei)ures as explained by her mother. The 3lient experiences loss of consciousness few moments after the noticing staring into space% then jer$ing of the extremities then he will pass out. Ris+ actors$#oo+ #ase) The ris$ factors include genetic factors% childhood abuse or head trauma% environmental factors% drug overdose% chemical sei)ures. #f you already have an epilepsy% the following factors can increase your chance of having an epilepsy* leep% abnormalities% and history of complex febrile

deprivation% !lcohol% 9ormonal changes (such as those that

26

occur

at

points

during

the

menstrual

cycle)%

tress%

1lashing lights% especially strobe lights% 6se of certain medicines% 5issing doses of anti-epileptic medicines.(+lac$ and 9aw$4s 5edical- urgical Nursing ;th edition) &is$ 1actor (3lient +ase) The 3lient has ris$ factors such as 2enetic. 9e

inherited the illness from his 2randfather. !nother ris$ factor is a history of febrile sei)ure when he was young and a <rug overdose that may trigger the sei)ure attac$s. Diagnostic .est $%oo+ %ase) !n 5lectro 5ncephalo 6ram (,,2) is a non-invasive and painless diagnostic test used to measure electrical

impulses between brain cells. +y placing electrodes on your scalp% the fre=uency of these impulses can be measured and recorded on a graph. !bnormalities in your regular brain waves can be used to identify the presence% location and severity of your sei)ures. #t will locate the focus of abnormal electric discharges% if present> to establish a diagnosis of epilepsy> and identify the specific type of sei)ure.

27

! Single,Photon 5mission Computed .omography ( -,3T) is a diagnostic imaging techni=ue that measures blood flow through your brain. ! small amount of a radioactive tracer will be introduced into your body that will emit particles measured by a more -,3T camera. The greater the blood flow% the are emitted. This allows doctors to

particles

visuali)e the functions of certain parts of your brain. !s the data is collected% an image of the brain is generated with different coloured areas to represent varying amounts of blood flow. This information will indicate if certain areas of your brain are getting too much or too little blood (and oxygen). !reas where sei)ures occur usually show increased blood flow. This test is not usually necessary for diagnosing epilepsy. #f your doctor recommends a -,3T

test% you will li$ely also re=uire an 5&#. ! Positron 5mission .omography (-,T) is an imaging

techni=ue that measures your brain4s activity through its use of sugar and oxygen. &adioactive tracers are introduced into your body These which release react tiny with particles electrons are using called in able the your to data

positrons.

positrons

bloodstream% generate

releasing of your

energy. brain

3omputers activity%

images

28

gathered

from

measuring

the

released

energy.

This

data

enables doctors to determine where your sei)ures occur. ! Computed A7ial .omography scan (3!T or 3T scan) is a non-invasive and painless test. 3T scans produce cross-

sectional images (tomographs) of areas in your body that will be examined by doctors to loo$ for abnormalities (eg. scar tissue% blood clots or tumours). 1or epilepsy% this usually involves a scan of your head to loo$ for possible origins of sei)ures. The machine loo$s li$e a large box with a donut shaped hole in the middle (a gantry). ?ou will lie on a platform that slides in and out of the gantry as the x-ray rotates around you. 7ow radiation x-rays pass through your body and are captured by detectors. 3omputers use this information to produce a .-< image of the area. ! 8agnetic Resonance 9maging (5&#) is a noninvasive diagnostic magnetic test that uses in a powerful brain. magnet 5&#s to measure many

field

changes

the

produce

detailed cross-sectional images (@slicesA) of the brain4s internal structure. These images can be used to detect

structural abnormalities and may help pinpoint the cause of sei)ures. This is considered to be the most important scan when diagnosing epilepsy because it produces a very

29

accurate representation of your brain. This procedure is generally non-invasive% by a although to a contrast the dye may with be a

administered clearer

needle

provide

doctor monitor

image.

1unctional

5&#s

(f5&#s)

neural

signals through changes in blood flow. ! 8agneto 5ncephalo 6raphy (5,2) is a new tool used to generate a representation of your brain4s magnetic fields. +y analy)ing brain activity% the 5,2 can help locali)e

areas in your brain causing the sei)ures. <octors can then use this information to help determine what is provo$ing your sei)ures. (+lac$ and 9aw$4s 5edical- urgical Nursing ;th edition) Diagnostic .est $Client %ase) There are diagnostic tests that are needed to

determine the final diagnosis of the client. The client had undergone diagnostic test which is ,lectro ,ncephalo 2ram the pattern of electrical activity produced on an ,,2 can be used to help diagnose a number of conditions that affect his brain. !n ,,2 is mainly used to diagnose and manage his epilepsy (a condition that causes repeated brain sei)ures). 9is ,,2 result was used also to manage his sleep

disorders(when he was still young)such as insomnia. !n ,,2

30

identify

the

areas This

of helps

his brain doctors to

that are

not

wor$ing properly.

ma$e decisions

about the type of his treatment that is most suitable for him. The client was supposed to have a 7umbar -uncture done but the family refused. Prevention To prevent sei)ures% the patient must avoid activities that trigger sei)ure activities. The client must record

every sei)ure activity and record all the things that the client did before the sei)ure occurred. #t is essential for a client to $now the things that could trigger sei)ure activities such as extraneous activities and alcohol

drin$ing. #t is advisable for a client to continue drin$ing the medications as prescribed by the doctor. !dvice the client to rest in between activities so that the client will not be too tired but at the same time% the client can function as well as a normal person can. ! person with sei)ure should warn the people around her to be aware of his/her condition since there is a safety

precaution to be followed if a person did have a sei)ure disorder. .(+lac$ and 9aw$4s 5edical- urgical Nursing ;th edition)

31

Complications 9ypoxic brain damage and mental retardation may follow repeated 7ong-term sei)ures. social <epression interaction and may anxiety also may develop. &epeated

occur.

sei)ures can lead to epileptic syndrome% wherein the person can experience sei)ure with serious complications such as tatus ,pilepticus. .(+lac$ and 9aw$4s 5edical- urgical

Nursing ;th edition) Nursing 8anagement/9nterventions $%oo+ #ase) 6eneral Care and 9n2ury Prevention -erform periodic physical examinations and laboratory tests for patients ta$ing medications $nown to have toxic hematopoietic% genitourinary% or hepatic effects. -rovide ongoing assessment and monitoring of cardiac and

respiratory functions. 5onitor the sei)ure type and general condition of patient. Turn patient to side-lying position to assist in draining pharyngeal secretions. 9ave suction e=uipment available if patient aspirates. 5onitor #: line closely for dislodgment during sei)ures. -rotect patient

from injury during sei)ures with padded side rails% and $eep under constant observation. <o not restrain patient4s

32

movements during sei)ure activity. <o not insert anything in patient4s mouth. 9n Controlling ear of Sei*ures

&educe fear that a sei)ure mat occur unexpectedly by encouraging compliance with prescribed treatment. ,mphasi)e that prescribed antiepileptic medication a continuing and basis and is not to as must be ta$en on !ssess that

habit-forming. factors

lifestyle precipitate

environment such

determine emotional

sei)ures%

disturbances%

environmental stressors% onset of menstruation% or fever. ,ncourage patient to avoid such stimuli. ,ncourage patient

to follow a regular and moderate routine in lifestyle% diet (avoiding excessive stimulants)% exercise and rest (regular sleep patterns). !dvise patient to avoid photic stimulation (e.g. bright flic$ering lights% television viewing)> dar$ glasses or covering one eye may help. attend classes in stress management. 9mproving Coping 8echanisms 6nderstand alienation% that epilepsy imposes feelings and of fear% social ,ncourage patient to

depression%

discrimination

isolation% and uncertainty. -rovide counseling to patient and family to help them understand the condition and

33

limitations imposed. ,ncourage patient to participate in social and recreational activities. avoid over-the-counter medications #nstruct patient to unless approved by

health care provider. -rovide comprehensive mental health services to patients who exhibit symptoms of schi)ophrenia or impulsive or irritable behavior. (+runner and 5edical urgical Nursing '(th ,dition) uddarth4s

Nursing 8anagement$Client %ased) Teaching patients of elf-care. #nstruct patient and

family about medication side effects and toxicity. -revent or control gingival hyperplasia% a side effect of -henytoin (<ilantin) therapy% by teaching patient to perform thorough oral hygiene and gum massage and see$ regular dental care. -rovide specific guidelines to assess and report signs and symptoms of medication overdose. #nstruct patient to $eep

a drug and sei)ure chart% noting when medications due to illness. Teach patient to $eep a drug and sei)ure chart%

noting when medications are ta$en and any sei)ure activity. #nstruct patient to notify physician if unable to ta$e

medications due to illness.

Teach patient to $eep a drug

and sei)ure chart% noting when medications are ta$en and any sei)ure activity. #nstruct patient to ta$e showers than to tub baths to avoid drowning and never swim alone.

34

,ncourage realistic attitude toward the disease> provide facts concerning epilepsy. #nstruct patient card to or carry wear to an an see$

emergency

medical

identification !dvise

identification

bracelet.

patient

preconception and genetic counseling if desired. 8edical 8anagement $%oo+ #ase) The management of epilepsy and status epilepticus is planned according to immediate and long-range needs and is tailored to meet the patient4s needs because some cases arise from brain damage and others are due to altered brain chemistry. The goals of treatment are to stop the sei)ures as =uic$ly as possible% to ensure ade=uate cerebral

oxygenation% and to maintain a sei)ure-free state. !n airway and ade=uate oxygenation as (intubate is an if

necessary)

are

established%

#: line for administering medications and obtaining blood samples for analysis. (6dan4s 5edical- urgical Nursing .nd ,dition) 5edical 5anagement(3lient-+ased) !s the 3lient was admitted on the hospital he was given an #: 1luids% #: 5edication and 0ral 5edication such as <ia)epam and <ilantin. 9e was also given a multivitamins

35

for him to regain his energy. 9is <r. also prescribe an 0xygenation if he supper from shortness of breath. Pharmacologic .herapy$#oo+ #ased) 5edications are used to achieve sei)ure control. The usual treatment or is single-drug is therapy. #: dia)epam% in an

lora)epam%

fosphenytoin

administered

slowly

attempt to halt the sei)ures. 2eneral anesthesia with a short-acting barbiturate may be used if initial treatment is unsuccessful. To maintain a sei)ure-free state% other anticonvulsant medications (carbame)ipine% primidone%

phenytoin% -henobarbital% ethosuximide% and valproate) are prescribed after the initial sei)ure is treated. (+runner and uddarth4s 5edical urgical Nursing '(th edition).

Pharmacologic .herapy$Client #ased) Bhen the client suffer from sei)ures the <octors

prescribed <rugs Tritab% 3iclodin% -henobarbital% <ilantin 7amictal. sei)ure These drugs by are !nticonvulsant ion which inhibits 5ay also

propagation

altering

transport.

decrease synaptic transmission that will prevent sei)ure activities. Surgical 8anagement

36

urgery

is

indicated

when

epilepsy

results

from

intracranial tumors% abscess% cysts% or vascular anomalies. urgical removal of the epileptogenic focus is done for sei)ures area that of originate the brain in that a wellcan be

circumscribed excised

without

producing

significant

neurological effects. urgical 5anagement (3lient-based) 3lient C.? does not undergone any surgical procedure.

37

.a#le :" Drug Study

<&62 N!5, -henobarbit al D(mg 'tab/day

!3T#0N 7ong-acting barbiturate . edative and hypnotic effects of barbiturate s appear to be due primarily to interferenc e with impulse transmissio n of cerebral cortex by inhibition of reticular activating system. 3N depression may range from mild sedation to coma% depending on dosage% route of administrat ion% degree of nervous system excitabilit y% and drug tolerance. #nitially%

37!

#1#3!T#0N #N<#3!T#0N 7ong-term management of tonicclonic (grand mal) sei)ures and partia l sei)ures> status epilepticu s% eclampsia% febrile convulsion s in young children. !lso used as a sedative in anxiety or tension states> in pediatrics as preoperati ve and postoperat ive sedation and to treat pylorospas m in infants.

30NT&!#N<#3!T#0N !cute intermittent porphyria% oversensitivity for barbiturates% prior dependence on barbiturates% severe respiratory insufficiency and hyper$inesia in children are contraindication s for phenobarbital use.

!<:,& , ,11,3T <rowsi ness or di))in ess> proble ms with memory or concen tratio n> excite ment% irrita bility % aggres sion% or confus ion

N6& #N2 30N #<,&!T#0N

38 ta$ing +efore phenobarbital % tell your doctor or pharmacist if you are allergic to it> or to other barbiturates (such as primidone% secobarbital) > or if you have any other allergies. This product may contain inactive ingredients% which can cause allergic reactions or other problems.

3,NT&!7 N,&:06 ? T,5 !2,NT> !NT#30N:67 !NT > ,<!T#:,9?-N0T#3> +!&+#T6&!T,

39

.a#le ;" Drug Study <&62 N!5, 2eneric Name* -henytoin +rand Name* <ilantin
100mg TID

!3T#0N 7imit sei)ure propagation by altering ion transport. 5ay also decrease synaptic transmissio n. Therapeu tic effect* <iminished sei)ure activity and decreased pain.

37!

#1#3!T#0N #N<#3!T#0N

30NT&!#N<#3!T#0N 3ontraindicated in patients with hypersensitivity to drug> inus bradycardia and heart bloc$.

!<:,& , ,11,3T 3N * nystagm us%atax ia% diplopi a%drows iness%l ethargy % coma%di ))iness %headac he%nerv ousness% dys$ine sia3:* hypoten sion ,,NT* gingiva lhyperp lasia

N6& #N2 30N #<,&!T#0N E !ssess oral hygiene. :igorous cleaning beginning within'(days of initiation of phenytoin therapy may help control gingival hyperplasia.E ei)ures* !ssess location% duration% fre=uency% and characteristi cs of sei)ure

!nticonvulsant Treatment and prevention of tonicclonic (grand mal) sei)ures and complex partial sei)ures.

40

&, -* respira torydep ression <,&5*hy pertric hosis%r ashes% exfolia tiveder matitis 2#* nausea% vomitin g%anore xia% weightl oss% constip ation%h epatiti s 26* pin$% red%red dishbrowndi scolora tion of urin e

activity. ,,2 may be monitored periodically throughout therapy.E 2eneral* #mplement sei)ure precautionsEB hen transferring from phenytoin to another anticonvulsan t% dosage adjustments are made gradually over several wee$s.E!ssess fluid inta$e and bowel function. #ncreased bul$ and fluids in the diet help minimi)e the

41

9,5!T* aplasti canemia %agranu locytos is% leucopenia , thrombocy topenia, megalobla sticanemia MISC: lymphade nopathy, fever, allergic reactions including StevensJohnson Syndrome MS: osteomala cia F and E: hypocalce mia

constipating effects of this medication. E !dminister with food or full glass of water or mil$ to minimi)e 2# irritation.E !dvise patient to ta$e medication exactly as directed and not to s$ip doses or double up on missed doses. #f a dose is missed% ta$e within ' hr or s$ip dose and return to regular schedule. !brupt withdrawal

42

may lead to gastritis% nausea% vomiting% di))iness% headache% tachycardia% and insomnia.E -henytoin may cause drowsiness or di))iness. 3aution patient to avoid other activities re=uiring alertness until response to medication is $nown.E #nstruct patient to use fre=uent mouth rinses% good oral hygiene% and sugarless gum

43

or candy to minimi)e dry mouth. .a#le <" Drug Study <&62 N!5, 2eneric Name* !3T#0N 37! #1#3!T#0N #N<#3!T#0N 30NT&!#N<#3!T# 0N 9ypersensitivi ty. #mpaired cardiac function. !<:,& , ,11,3T !taxia% di))iness % headache% nausea% vomiting% photosens itivity% rash (higher incidence in children% patients ca$ing% :-!% high initial doses% or rapid dosage increases N6& #N2 30N #<,&!T#0N #nstruct patient to ta$e medication exactly as directed. Ta$e missed doses as soon as possible unless almost time for next dose. <o not double doses. <o not discontinue abruptly> may cause increase in fre=uency of sei)ures. !dvise patient to notify health care

lamotrigine !nticonvulsant ei)ure inhibits disorder% voltagebipolar 7amotrigine sensitive disorder sodium Trade Name* channels% 7amictal thereby stabili)ing .(( mg -0 neuronal 9 membranes and conse=uently modulating presynaptic transmitter release of excitatory amino acids

44

professional immediately if s$in rash occurs or if fre=uency of sei)ures increases. 5ay cause di))iness% drowsiness% and blurred vision. 3aution patient to avoid driving or activities re=uiring alertness until response to medication is $nown. <o not resume driving until physician gives clearance based on control of sei)ure

45

disorder. 3aution patient to wear sunscreen and protective clothing to prevent photosensitivi ty reactions. #nstruct patient to notify health care professional of medication regimen prior to treatment or surgery. !dvice patient to carry identification at all times describing disease process and medication regimen.

46

.a#le =" Drug Study <&62 N!5, 2eneric Name* !scorbic acid +rand Name* 3econ F(( mg -0 0< !3T#0N 37! #1#3!T#0N #N<#3!T#0N 30NT&!#N<#3!T #0N !<:,& , ,11,3T N6& #N2 30N #<,&!T#0N .E !ssess for signs of :itamin 3 deficiency(fau lty bone and tooth development% gingivitis% bleeding gums%loosened teeth) before and during therapy.:itami n 3 deficiency is also called scurvy. E2eneral* 0ften ordered as a part of multivitami n supplementatio n% because

Necessary for :itamin(water- Treatment 3ontraindicat soluble) ed in patient collagen and formation prevention with $nown and tissue of vitamin Tartra)ine hypersensitiv repair. 3 #nvolved in deficiency ity oxidation (scurvy) reduction with reactions> dietary tyrosine% supplement folic acid% ation. iron% and upplemental carbohydrate therapy in metabolism> some 2# lipid and diseases% protein during synthesis% long-term cellular parenteral respiration> nutrition and or chronic resisting hemodialys infection. T is.E-reven

47

herapeutic ,ffects* &eplacement in deficiency states> upplementati on during increased re=uirements

tion of common cold

inade=uatediet often results in multiplevitamindeficie ncy. E,xtendedrelease tablets and capsules hould be swallowed whole without crushing% brea$ing% or chewing> contents of capsules maybe mixed with jelly or jam. 3hewable tablets should be chewed well or crushed before swallowing. E!dvice patient to ta$e this medication as directed and

48

not to exceed dose prescribed.,xce ss doses may lead to diarrhea and urinary stone formation. #f a dosed is missed% s$ip dose and return to dosage schedule . E,ncourage patient to comply with diet recommendation s of physician or other healthcare provider. ,xplain that the best source of vitamins is a wellbalanced diet.E1oods high in

49

ascorbic acid include citrus fruits% tomatoes% strawberries% and raw peppers. 2radual loss of ascorbic acid occurs when fresh food is stored but not when fro)en. &apid loss is caused by drying% salting% and coo$ing

50

Nursing Care Plan .a#le =

Assessment Su#2ective* @Gapag inaata$e ng sei)ure Hyung ana$ $o $ina$abahan a$o hindi $o alam ang gagawinA% as verbali)ed by the client4s mother. O#2ective> 0verprotection of the client tressed out as manifested by restlessness

Diagnosis Gnowledge <eficiency of the <isease -rocess related to interpretatio n of misinformatio n as evidence by verbali)ation of -roblems.

Outcome Planning 9dentification To improve the $nowledge of the client4s mother regarding the disease process Bithin I hours of 9ealth Teaching% the mother of the client will be able to* ,xplain again about the disease% Gnow the needs of the care and treatment without worry

9ntervention 9ealth Teaching about ,pilepsy. <emonstrate what to do first then letting the mother do it by him. <emonstrate what to do before% during% and after the sei)ure then let the mother do it so he will clearly understand what to do if sei)ure occurs. ,xplain purpose of activity restrictions and need for balance between activity/rest. +ecause rest reduces oxygen and nutrient needs of compromised tissues and decreases ris$ of

5valuation
51 !fter I hours of 9ealth Teaching% the client4s mother verbali)ed understanding of the disease process. 9e demonstrated understanding of what to do before% during% and after the sei)ure.

2oal met.

52

Nursing Care Plan .a#le !( !ssessmen t

Objective: - sleepy, unconscious and coherent - eyes only response to painful stimuli - utters inappropriate words - no body movements VS taken as follows: TE !: "#$% & '': () cpm !': *+ bpm ,!: ((+-)+ mm./

<iagnosis &is$ for aspiration related to impaired swallowing% depressed cough and gag reflexes% and decreased level of consciousness .

0utcome 0bjective* !fter D hours of nursing interventio n the patient will not aspirate secretions or foods/fluid s as evidenced by*

-lanning 0bjective* !fter D hours of nursing interventio n the patient will not aspirate secretions or foods/fluid s as evidenced by*

#nterventio n - withhold oral foods/fluid s -client in side-lying position

&ationale - To prevent aspiration - To mobili)e thic$ened secretions that may interfere with swallowing. -To clear secretions while reducing potential for aspiration of secretions

,valuation !fter ; hours of nursing intervention % ris$ for aspiration has been decreased. 2oals are met.

- clear breath sounds - resonant percussion

- clear breath sounds - resonant percussion

- uction as needed but avoid triggering of gag mechanism

53

note over lungs - !bsence of cough% tachypnea% and dyspnea.

note over lungs - !bsence of cough% tachypnea% and dyspnea. - 0bserve for nec$ and facial edema -articularl y ris$ for airway obstruction and inability to handle secretions.

54

Nursing Care Plan .a#le !! !ssessment ubjective* @+igla na lang nanginig Hyung ana$ $oA% as verbali)ed by the client4s mother. 0bjective* Bea$ness 1acial grimace #rritability :/ ta$en as follows* +-* '.(//( T* 8J.8 -&* /( &&* .( <iagnosis &is$ for Trauma related to loss of large muscle coordination . 0utcome #dentification -atient will demonstrate behaviors% lifestyle changes to reduce ris$ factors and protect itself from injury. -lanning Bithin ; hours of nursing the -atient will demonstrat e behaviors% lifestyle changes to reduce ris$ factors and protect itself from injury. #ntervention ,xplore with the patient the various stimuli that may precipitate sei)ure activity. ,valuation !fter ; hours of nursing interventions % the patient was able to demonstrate behaviors% lifestyle changes to reduce ris$ factors and protect her son from injury.

<iscuss sei)ure warning signs and usual sei)ure signs

2oal met. ,valuate need for protective head gear

55

5aintain strict bed rest if prodromal signs or aura experienced

&eorient patient following sei)ure activity

3ollaborative * !dminister medications as prescribed

56

Review of Related 1iterature oreign 1iterature ,pilepsy is recogni)ed as a collection of heterogeneous

syndromes characteri)ed by additional conditions that coexist with sei)ures and impacts over F( million people worldwide.

3ognitive% emotional% and behavioral co morbidities are common. ei)ures are typically divided into two main categories* partial (focal) and generali)ed. 2enerali)ed sei)ures affect both

cerebral hemispheres from the onset of the sei)ure.

ei)ures

produce loss of consciousness% either for long periods of time or temporarily% and are sub-categori)ed into generali)ed tonicclonic% myoclonic% absence% or atonic subtypes. -artial sei)ures affect an area within one cerebral hemisphere of the brain and are the most recurring type of sei)ure experienced by patients with epilepsy. -artial sei)ures are further subdivided into

simple partial sei)ures% where consciousness is retained> and complex partial sei)ures% where consciousness is diminished or lost. #n the treatment of epilepsy% no one anti-epileptic drug (!,<) has been shown to be the most effective% and all !,<s have published side effects. !,<s are selected following

consideration of side effects% ease of use% cost% and physician $nowledge. -atients with newly diagnosed epilepsy who re=uire treatment can be started on standard% first-line !,<s such as

57

carbama)epine%

phenytoin%

valproic

acid%

or

phenobarbital.

!lternatively% newer !,<s introduced in the past decade may be used. These include gabapentin% lamotrigine% oxcarba)epine% or topiramate. +etween J(K and ;(K of individuals are successfully treated with one of the !,<s now available and success rates primarily 9owever% depend the or on the etiology .(KL8(K of of the sei)ure disorder. either

remaining

patients or suffer

have

intractable

uncontrolled

sei)ures

significant

adverse side effects to medication. !s with the selection of first-line treatment therapy% of choosing the appropriate must be drug based for on the the

refractory

epilepsy

appreciation of each drug4s characteristics and ris$s for each individual patient. !n emerging mar$et economy is defined as an economy with low-to-middle per capita income. uch countries

constitute approximately ;(K of the global population% are often rapidly-growing and represent about .(K of the world4s

economies. !lthough the term emerging mar$et is loosely defined% countries that fall into this category% range from big to small% and are often considered emerging because of development and reform programs that have been put in place to launch their mar$ets globally. 3onse=uently% although 3hina is considered one of the world4s foremost economic leaders% it is grouped into the emerging mar$et category together with much smaller economies with fewer resources% such as udan or +ulgaria. ,pilepsy is

58

common in patients admitted to hospitals in emerging mar$ets. 9owever% economic there are reported differences of in the in epidemiology% these regions

burden%

and

outcome

epilepsy

compared to high-income countries> although few data from the former regions exist. !pplying the #nternational 7eague against ,pilepsy definition of epilepsy is problematic in these areas% as patients often arrive at health facilities without ade=uate documentation of the sei)ure duration. The goal of treatment for patients with epilepsy is no sei)ures with little to no side effects. 9owever% due to variabilities in clinical presentation and available resources% treatments are highly individuali)ed and vary widely. review The the objective literature of on this study to is to

systematically

epilepsy

identify

incidence and prevalence rates% economic data% unmet needs% and treatment patterns in those emerging mar$ets which contain the majority of the world4s population. (!ngala$uditi% .('') ,pilepsy is a chronic disease characteri)ed by the ris$ of recurrent sei)ures. #n developed countries% an average of I or F of every '%((( people has epilepsy. #n developing countries% this rate can be as high as I8 per '%((( people. !ccording to the Borld 9ealth 0rgani)ation% the disability caused by epilepsy accounts for about (.FK of the global burden of the disease measured by disability-adjusted life-years. !s a result%

59

epilepsy ran$s just after psychiatric conditions such as alcohol dependence. comparable The to global of health breast care or bur-den of epilepsy ome is

that

lung

cancer.

cultures

believe that epilepsy represents demonic possession. !lthough epilepsy arises from a transient dysfunction in the brain% fear and ignorance still lead to discrimination and feelings of

shame. #n the public mind and in the laws of some countries% epilepsy cognitive is strongly associated M with mental illness and that

disabilities

unfortunate

generali)ations

unfairly affect many people with epilepsy.

uch pervasive social

stereotyping is difficult to overcome. -revious surveystesting $nowledge% epilepsy atitudes% have focused beliefs on and treatment of people students with or

the

general

public%

teachers. <entists and other health care wor$ers% who represent one of the more highly have educated been and influential groups in

society%

however%

not

surveyed.

6ndoubtedly%

their

perspectives about people with epilepsy have an impact on their professional interactions with this patient population. Their social response to this population% independent of their

provision of medical care% may influence the way their community views people with epilepsy. +ecause the dental care of patients with epilepsy is important% there may be and some reports in in the care%

literatureindicate

disparities

their

compared with that of the general population% we surveyed all

60

the dentists in 7ondon% 0ntario% to determine their $nowledge about and attitudes to epilepsy% and their willingness to

provide dental care to people with epilepsy. (!ragon% .((;) ,pilepsy is the second most occurring neurological disorder with an incidence rate of ' K of the entire population. #n <enmar$ alone approximately I.((( new cases are seen every year. To be diagnosed with epilepsy often means a big change in a persons life% and affects the daily rutines of the entire

family. 7uc$ily% it is today possible to treat most epileptics and to $eep them sei)ure free% but around .FK will have to find a way of living with the sei)ures to a smaller or larger degree. 5pileptic sei*ures There exists a high number of different types of epilepsy% and also an e=ually high number of sei)ure types. These sei)ures range from the common muscle spasms% many people would recognise as an epileptic sei)ure% to a short term% almost undetectable% loss of awareness. 5ost epileptic individuals

however will experience the same sei)ure type from time to time. Bhat is common for all epileptic sei)ures is that during the sei)ure the affected person is unable to fully control his or her body. The loss of control is sudden and unexpected.

,pi-3are is produced with an aim of warning relatives or medical personal when nightly sei)ures or spasms% with muscle activity occur.The majority of people suffering from epilepsy can be

61

treated with medicine.

ome will even improve from complicated

brain surgery% however this is only a minority.The best care is decided from an individual and thorough description of sei)ures% sei)ure types% as well as sei)ure duration and fre=uency. ! thorough sei)ure description will often mean that the time from diagnose to the optimal sei)ure treatment is significantly

shortened. ,pi-3are can be of significant help in creating a thorough sei)ure description. The ,pi-3are log can $eep trac$ of the numbers of nightly sei)ures% and at the same time% warn if or when a major sei)ure should occur.( http*//danishcare.d$/u$/N pageOidP8J) The li$elihood of young people ta$ing their epilepsy medication as prescribed might be improved by ensuring they have a good understanding of their condition and its treatment% research

suggests. cientists at the 6niversity of 5ichigan carried out a study involving ;; adolescents with epilepsy and their

parents. urveys were carried out to assess both patients4 and parents4 $nowledge of epilepsy and expectations of treatment% as well as their adherence to medication.The findings show that young people with a good understanding of epilepsy tended to adhere to their treatment regimes more closely than those with poor $nowledge of the condition.! good understanding among

parents was also found to be beneficial% according to a report

62

in the journal ,pilepsy Q +ehaviour.The researchers concluded* @#nterventions that enhance adolescents4 $nowledge of epilepsy and their treatment plan% while ensuring that teens and parents are in agreement with regard to epilepsy treatment% might

contribute to better adherence.A,ncouraging young people to ta$e their medication is vital for improving outcomes% as non-

adherence is associated with a high fre=uency of sei)ures and a worsened prognosis.?et a study in the Cournal of the !merican 5edical !ssociation% published in .('' by researchers at

3incinnati 3hildren4s 9ospital% found evidence that more than half of children with newly diagnosed epilepsy do not ta$e their sei)ure ( medications as prescribed.

http*//www.epilepsyresearch.org.u$/improving-youngsters-

$nowledge-of-epilepsy-may-boost-treatment-adherence/) 1ocal 1iterature The !nnual held &oom. the on Neuroscience '(% .((/ <epartment &esearch at the <epartment 3ontest was 3onference

eptember

There were ten original papers that were presented from ections of 3ase !dult and -ediatric eries% Neurology in three and

categories*

&eport/3ase

<escriptive%

!nalytical. The !nnual -hilippine

Neurologic

!ssociation research forum was held on 0ctober 'J% .((/ at 6 T 9ospital. 1our original papers from -29 were presented as

63

finalists -ediatric

by

their

primary won

authors. in

<r.

Canet

!dajar

of

Neurology

8rd place

the

<escriptive

category

with her paper on the ,,2 findings of patients with 3omplex 1ebrile ei)ures while <r. Cude +ayana of -ediatric Neurology

won Ith place in the same category with his paper on the use of newer antiepileptics of !dult her for neonatal won sei)ures. in <r. the Natasha 7.

1abiaRa 3ategory

Neurology paper

8rd place &is$

!nalytical for the

for

entitled%

1actors

<evelopment of in a Tertiary

ei)ures and ,pilepsy among -ost 9ospital* ! &etrospective

tro$e -atients tudy. <r

3ohort

!loysius <omingo of !dult Neurology won Ithplace for his metaanalysis% econdary -revention !fter 3erebrovascular ,vents* The

Bill !ngiotensin &eceptor bloc$ers -rotectN ( -!3,-B!&-). other original papers which submitted was held were =ualified the for -N!

poster !nnual

presentation 3onvention. entitled

during

#n the said event% the paper of <r Chaphet !gunias as se=uela of cyanide poisoning by

-ar$insonism

intentional silver jewelry cleaner ingestion* ! 3ase &eport won .nd place in poster presentation. (pgh.gov.ph) Treating the patient at home is appropriate when the patient is $nown to experience sei)ures% and if his sei)ures are brief. !ccording to the -hilippine 7eague !gainst ,pilepsy% the

64

following steps can be done when helping out a patient during an acute sei)ure episode*

tay calm. 7oosen clothing around nec$. Turn the patient"s head to one side to avoid cho$ing and/or aspiration.

<o not hold the patience down or sha$e and slap in an attempt to rouse him% as they can injure the patient.

<o not put anything inside the patient"s mouth. 3all a doctor when it is a first time sei)ure% of if the sei)ure recurs or is prolonged (more than F minutes)

Ta$ing prescribed anti-sei)ure medication regularly can help prevent recurrent sei)ures. The removal of brain tissue where sei)ures ta$e place is also a preventive measure. 1or those with severe cases of epilepsy% a special diet is advised to alter body chemistry. !voiding conditions $nown to trigger sei)ures (such as bars with rapid% flashing lights% sleep deprivation) can help prevent sei)ures from occurring. ei)ures in the -hilippines% The following medical centers in the -hilippines have available Neurology/ ei)ure clinics*

65

Cose &eyes 5emorial 9ospital 5a$ati 5edical 3enter -hilippine 3hildren"s 5edical 3enter ei)ure 3linic

t. 7u$e"s 5edical 3enter* 3omprehensive ,pilepsy -rogram 6,&5 6---29 ei)ure 3linic ei)ure 3linic ei)ure 3linic (health.com.ph)

6 T 9ospital

-eople with epilepsy in the -hilippines suffer from anxiety and from depression. affecting 7iving many with aspects epilepsy of presents many

challenges

life%

including

relationships with family and friends% school% employment and leisure activities (9a)el -atagua% .('.). oreign Study -rimary care physicians% including pediatricians% admit

that they are not as familiar about specific aspects of epilepsy as they should be and that they need more training in management of the disease. everal recent surveys of health care

professionals who care for children with epilepsy revealed what epilepsy specialists would consider to be misconceptions about treatment and management of pediatric epilepsy. #n a survey that focused on surgery practices for intractable epilepsy% nearly

66

two-thirds

of

responding

physicians

(F;K

were

pediatricians)

were unsure whether surgical intervention should be considered for patients who fail anticonvulsant drug therapy% although

specialists $now that surgery is the current guideline. !nother survey of pediatricians in 3anada found that only 8IK of respondents said they $new of sudden unexplained death in

epilepsy ( 6<,-)% a rare but serious complication of fre=uent sei)ures% and just FJK $new that children with epilepsy are at increased ris$ for sudden% unexpected% unexplained death.

pecialists say that awareness of of behavioral health

6<,- is vital. ! third survey who treat children with

professionals

epilepsy found that ;IK wanted more training in managing the psychopathologies of pediatric epilepsy in order to play a more effective role in multidisciplinary ociety% .('.) subjects% ;;.FK (nPFF.) had a postgraduate care for such patients.

(!merican ,pilepsy 0ut of all

education% while ''.FK (nPJ.) had only an undergraduate degree. The authors found that physical lower educators% scores on nutritionists their and

physiotherapists

received

epilepsy

$nowledge than other health professionals. 9ealth professionals are considered with better-educated regards to group inside issues. the society% it is

especially

healthcare

Thus%

important they also have an accurate and correct $nowledge about

67

epilepsy.

The

findings

of

the

present

study

indicate

an

imperative improvement in education about epilepsy% as well as an inclusion for of formal programmes for epilepsy !n an education in in

especially epilepsy

non-medical might

professionals. contribute to

improvement improvement

education

epilepsy care and management. (:ancini% .('.) #n the arm of the survey that focused on physician

attitudes toward referral of children for surgical evaluation% only F'K of respondents agreed that epilepsy surgery after 8 years of failed antisei)ure medication should be considered> I/K either disagreed or were unsure. !bout a =uarter (.FK) felt patients in whom the $etogenic diet fails should be considered for surgery% with more than half (FIK) being unsure and .8K not thin$ing this would be helpful. 0nly I8K agreed that patients should be evaluated for surgery after failed vagus nerve

stimulation. -erhaps most concerning was that D8K of the survey population was unsure whether surgery would be effective for children with partial (or focal) epilepsy and JK didn"t thin$ this would be an effective option. SThis one really bro$e my heart%S said <r. -er$ins. S1ocal epilepsy surgery has the

highest positive response rates% and having two thirds plus of respondents saying they don"t agree with it or aren"t sure that it would be beneficial% tells me that we have completely failed

68

in

communicating

what

we

do

to

professionals

who

would

be

referring to us.S 6p to /(K of patients with partial epilepsy respond to surgery% noted <r. 9ovinga. !ll $ids with epilepsy should be considered for surgery% but that doesn"t mean all of them should get it% <r. -er$ins stressed. S#t"s important to identify children with intractable epilepsy who might benefit from surgery. Be need to go bac$ to our baseline and reevaluate% especially as evolving technologies have rolled in% and we have better imaging and better diagnostic procedures determining if a particular person =ualifies for surgery or not.SCust because a patient comes to an epilepsy center for an evaluation doesn"t mean that patient is removed from primary care. SBe"re here as an augmentation% if others want us to comanage or guide%S said <r. -er$ins. SThese patients need to be getting the evaluations and there"s a bloc$ in that process.S !s$ed about referring patients with generali)ed epilepsy for surgery% D'K of survey participants were unsure and .IK disagreed. !lthough such

referrals are Sa bit tric$ier than focal epilepsyS because the surgery may be for palliative care reasons% the surgery would still Svastly improve =ualify of life for many of patients and their families%S said <r. -er$ins. #ronically% more than half of the doctors agreed that surgery might improve =uality of life for children. S#t"s another one of those discordancesS where doctors might thin$ a particular intervention might help but

69

they"re not sure about the specifics% said <r. -er$ins. 3hanging attitudes can be accomplished only through education% perhaps using webinars or other electronic tools% but most li$ely

through old-fashioned Sshoe leatherS -- getting in your car and visiting doctors in the field% said <r. -er$ins. S0n a local basis% it"s incumbent on us to reach out to our referral sources outside of neurology and neurosurgery who are nonepileptologists -- into the pediatrician and family practice offices -- and ma$e sure they understand these things.S(!nderson% .('.) 9ealth professionals need good s$ills in communication and patient education They play an essential role in educating

patients and families about the epilepsies and in directing them to accurate and s$ills% reliable and resources and tools #n to improve poor

$nowledge%

self-management.

contrast%

clinician-patient communication is a major barrier to patients" ability to successfully navigate the health care system% act on basic health health instructions% tudies and self-manage that chronic or other as

conditions.

indicate

patients

recall

little as half of what their physicians tell them during an outpatient appointment. -hysicians need to confirm that patients understand their condition (e.g.% specific sei)ure type%

epilepsy syndrome% sei)ure triggers)% how to carry out treatment and medication instructions% and ris$s associated with their

70

condition and nonadherence or discontinuation of their treatment regimen. 9owever% in one diabetes study% physicians assessed

patients" recall and comprehension of new concepts in only one in five patient encounters% even though such practices have been shown to improve clinical outcomes. Therefore% it is critically important that health professionals provide patients and their families with written information about their specific sei)ure type% epilepsy syndrome% and treatment plan to augment

discussions that happen in the clinical setting. #n order to educate patients and families effectively% health care providers and must be $nowledgeable information of and that ! s$illed meets 6G to in the

communicating individual highlighted physicians

conveying and

needs the who

preferences of both

patients. with

survey have

desire are

patients

epilepsy and

$nowledgeable

effective

communicators. #n addition% patient-rated =uality of care also increases when health care providers use patient-centered

communication and shared decision ma$ing. it is important that health professionals learn how to

recogni)e

the

critical

junctures

for

patient

and

family

educationMat diagnosis% during the first year% when there is a change% in treatment options (e.g.% introduction%

switch% discontinuation)% or when a new concern develops>

71

understand the specific information needs and preferences of patients and their families and ta$e into consideration factors related to health literacy and culture% including cultural differences that may exist between them and their patients>

listen actively and put the patients and their needs first when providing education and counseling>

be

competent

in

patient

and

family

education to

and the

communication%

including

targeting

education

specific needs of the patient>

be

comfortable

discussing

ris$s

associated

with

the

epilepsies and their treatments including

6<,-% suicide%

and status epilepticus be aware of informational resources for patients and families that are available online and through local epilepsy organi)ations> and

promote

the

use

of

self-management

tools

and

programs.

( tuart% 5uir% .((;) 1ocal Studies !bout .F percent of individuals begin to have sei)ures

during puberty. There are also studies pointing to higher rates of sei)ures advised among her @low-functioningA audience to treat persons the with autism. cause <r. of

osa

underlying

72

sei)ure in order to have good sei)ure control and thus improve the =uality of life of the person affected. Bith other pediatric neurologists =uality li$e her% 3N promotes for and provides access to

neurological

healthcare

1ilipino

children.

3N -

conducts teaching and training seminars to the physicians as a way to improve the level of child neurology practice. #n

partnership with organi)ations li$e !utism

ociety -hilippines% amar and 7ucena.

3N - 3aravans already reached Naga% <agupan%

<octors% parents% rural health physicians% midwives and nurses are the target audience in each identified locality. The thrust of the caravan project is to teach the participants in

identifying neurodevelopmental disability in children and then providing basic developmental intervention techni=ues to the

community(5anila +ulletin% .('.). +rain and <evelopment% Twelve patients diagnosed to have infantile spasms at .L'F months were included% with a male*female ratio of '*'. The proportion of B cases among

epileptic children under age 8 was 8.';K. The etiologies were idiopathic/cryptogenic in four (88K) and symptomatic in eight (DDK). ymptomatic cases include hypoxic-ischemic

encephalopathy% neonatal sepsis% bacterial meningitis% inborn error of metabolism% congenital brain anomaly and intracranial hemorrhage. -henobarbital was the first line drug in JFK of

73

cases. 0ther drugs used were valproic acid% clona)epam and pyridoxine. Bith a follow-up duration of 'LI( months% only three patients became sei)ure free and most had poor neurodevelopmental outcome. !mong practicing child neurologists% the preferred ideal drug was adrenocorticotrophic hormone (!3T9) and valproic acid for idiopathic and symptomatic cases% respectively. 9owever% in actual clinical practice valproic acid or prednisone was the initial drug used. -yridoxine was usually added on. The proportion of B in our patient population may

not reflect the true prevalence in our country since our data came from a biased population% i.e. referral centers. ! national statistics is currently not available. !3T9% which was perceived by most child neurologists as the ideal first line drug was not used primarily because it is unavailable and unaffordable. The poor sei)ure control and developmental outcome may be due to the treatment given or directly related to the etiology of B . ( alongaa% .((/) #n the -hilippines alone% ;( percent of the population $now little about the disease. <espite affordable medicines% some

people resort to alternative solutions li$e exorcism or herbs from traditional healers. (www.thepoc.net) 9owever% about .( percent of people with a disorder will continue to experience sei)ures even with the best available

74

treatment.

<octors

call

this

situation

intractable

epilepsy.

5ore than two million people in the -hilippines -- about ' in 'F( -- have experienced an unprovo$ed sei)ure or been diagnosed with a sei)ure disorder. 1or about ;( percent of those diagnosed with a disorder% and sei)ures can be controlled (-hilippine with modern for

medicines

surgical

techni=ues.

3enter

,pilepsy% .('.).