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A CASE PRESENTATION ON SEIZURE DISORDER

Presented to the Faculty of the School of Nursing


Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

BORRES, MARY RUCILE Z.

February 2019

i
TABLE OF CONTENTS

PAGE

I. TITLE PAGE i
II. TABLE OF CONTENTS ii
III. LIST OF TABLE iii
IV. LIST OF FIGURES iv
V. OBJECTIVES 1
General Objective
Specific Objectives

VI. DEFINITION OF TERMS 2


VII. INTRODUCTION 3-4
VIII. NURSING HEALTH HISTORY
Vital Information 5
History of Present Health Concern 6
Past Health History 6
Family Health History (Genogram) 7
Physical Examination and Review of Systems 8-9
Gordon’s Functional Health Patterns Assessment 10
Diagnostic test 11 - 15

IX. NORMAL ANATOMY AND PHYSIOLOGY 16


X. CONCEPT MAPPING 17 - 18
XI. DRUG STUDY 19 - 24
XII. NURSING CARE PLAN 25 - 29
XIII. DISCHARGE PLAN 30 - 31
XIV. REFERENCES 32

ii
LIST OF TABLES

TABLE PAGE

1 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS 8-10

2 GORDON’SFUNCTIONAL HEALTH PATTERN 11-12


ASSESSMENT
3 NORMAL ANATOMY AND PHYSIOLOGY 16

NURSING CARE PLAN

4 Ineffective Airway Clearance related to Altered 25


Level of Consciousness

5 Risk for Injury related to Seizure Activity 26

6 Risk for impaired Skin Integrity related to Immobility 27

7 Disturbed sensory perception related to Neurologic Impairment 28

8 Self-care Deficit related to Unconscious State 29

iii
LIST OF FIGURES

FIGURE PAGE

1 Genogram showing the Family History of Mr. Peach 7

2 Concept Map 17 - 18

iv
OBJECTIVES

General Objective

At the end of one and a half hour of case presentation, the participant will be able to learn
about the disease process of Seizure Disorder.

Specific Objectives:

At the end of one and a half hour of case presentation, the participant will be able to:

1. Identify the medical terms used related to the case;


2. Formulate the nursing health data;
3. Relate the anatomical structures and functions involved in Seizure attack;
4. Summarize the pathophysiology, risk factors, manifestations and complications of
Seizure;
5. Create a concept map for Seizure Disorders;
6. Construct a nursing care plan for patient with Seizure; and
7. Organize a health education and discharge plan.

1
DEFINITION OF TERMS

ATHEROSCLEROTIC – inflammatory process involving the accumulation of lipids, calcium,


blood components, carbohydrates, and fibrous tissue on the intimal layer of a large or medium-
sized artery. (Hinkle & Cheever, 2018)

ACUTE SUBDURAL HEMATOMA - is a clot of blood that develops between the surface of
the brain and the dura mater, the brain's tough outer covering, usually due to stretching and
tearing of veins on the brain's surface. These veins rupture when a head injury suddenly jolts or
shakes the brain. (Hinkle & Cheever, 2018)

BILATERAL PTB – is an infectious disease that primarily affects the lung parenchyma.
(Hinkle & Cheever, 2018)

LUMBAR SPONDYLITIS – degenerative changes in a disc and adjacent vertebral bodies.


(Hinkle & Cheever, 2018)

POTT’S DISEASE - is a form of tuberculosis that occurs outside the lungs whereby disease is
seen in the vertebrae. (Hinkle & Cheever, 2018)

2
INTRODUCTION

Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity that
results from sudden excessive discharge from cerebral neurons (Hickey, 2014). A localized area
or all of the brain may be involved. The International League Against Epilepsy (ILAE) has
defined epilepsy as at least two unprovoked seizures occurring more than 24 hours apart (Fisher,
Acevedo, Azimanoglou, et al., 2014). The ILAE differentiates between three main seizure types:
focal, generalized and unknown seizures. Generalized seizures occur in and rapidly engage
bilaterally distributed networks. Focal seizures are thought to originate within one hemisphere in
the brain. The unknown type includes epileptic spasms. Unclassified seizures are so termed
because of incomplete data but are not considered a classification (Fisher et al., 2014). Seizure
may also be characterized as “provoked” or related to acute, reversible conditions such as
structural, metabolic, immune, infectious or unknown etiologies (Scheffer, French, Hirsch, et al.,
2016).

Seizures that appear to involve all areas of the brain are called generalized seizures.
Different types of generalized seizures include Absence seizures, previously known as petit mal
seizures, often occur in children and are characterized by stari ng into space or by subtle body
movements, such as eye blinking or lip smacking. These seizures may occur in clusters and
cause a brief loss of awareness. Tonic seizures cause stiffening of your muscles. These seizures
usually affect muscles in your back, arms and legs and may cause you to fall to the ground.
Atonic seizures, also known as drop seizures, cause a loss of muscle control, which may cause
you to suddenly collapse or fall down. Clonic seizures are associated with repeated or rhythmic,
jerking muscle movements. These seizures usually affect the neck, face and arms. Myoclonic
seizures usually appear as sudden brief jerks or twitches of your arms and legs. And Tonic-
clonic seizures, previously known as grand mal seizures, are the most dramatic type of epileptic
seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and
sometimes loss of bladder control or biting your tongue.

Seizure episodes are a result of excessive electrical discharges in a group of brain cells.
Different parts of the brain can be the site of such discharges. Seizures can vary from the briefest
lapses of attention or muscle jerks to severe and prolonged convulsions. Seizures can also vary in
frequency, from less than 1 per year to several per day.

One seizure does not signify epilepsy (up to 10% of people worldwide have one seizure
during their lifetime). Epilepsy is defined as having two or more unprovoked seizures. Epilepsy
is one of the world’s oldest recognized conditions, with written records dating back to 4000 BC.
Fear, misunderstanding, discrimination and social stigma have surrounded epilepsy for centuries.
This stigma continues in many countries today and can impact on the quality of life for people
with the disease and their families.

3
Epilepsy continues to be one of the leading causes of neurological consultations and
admissions in the Philippines. With a population of 83 million and an estimated prevalence of
0.9%, there is an estimated 750,000 people with epilepsy in the country, majority in the
productive years of their life.

Epilepsy is a chronic non-communicable disease of the brain that affects people of all
ages. More than 50 million people worldwide have epilepsy, making it one of the most common
neurological diseases globally. Nearly 80% of people with epilepsy live in low- and middle-
income countries. It is estimated that 70% of people living with epilepsy could live seizure- free
if properly diagnosed and treated.

About three quarters of people with epilepsy living in low- and middle- income countries do not
get the treatment they need.

In many parts of the world, people with epilepsy and their families suffer from stigma and
discrimination.

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VITAL INFORMATION

CODE NAME: Mr. Peach

AGE: 64 years old

GENDER: Male

CIVIL STATUS: Married

DATE OF BIRTH: May 24, 1955

PLACE OR BIRTH: Manticao, Misamis Oriental

RACE: Asian

CULTURAL OR ETHNIC BACKGROUND: Iliganon

PRIMARY LANGUAGE: Bisaya

SECONDARY LANGUAGE: Tagalog

RELIGION: Seventh Day Adventist

HIGHEST EDUCATIONAL ATTAINTMENT: High school Graduate

OCCUPATION: Retired Security Guard

USUAL HEALTH CARE PROVIDER: Health Center, Clinic

DATE OF ADMISSION: February 08, 2019 3:50 PM

SOURCES OF HISTORY: 40% chart, 60% S.O

REASON/S FOR SEEKING HEALTH CARE: Seizure

PRIMARY ATTENDING PHYSICIAN: Rowena Delorino, M.D

INITIAL IMPRESSION/ DIAGNOSIS: SEIZURE DISORDER

RULE OUT BRAIN TUMOR

LUMBAR TUMOR

FINAL DIAGNOSIS:

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PRESENT HEALTH CONCERN

One month before admission Mr. Peach experienced severe back pain associated with

limitation of movement because of pain, sleeplessness and lumbar back pain that cause him to

visit the hospital but according to the S.O the laboratory findings were not significant. 1 hour

before admission Mr. Peach had a seizure 3 times lasting about 30-60seconds and reoccurred

when they arrived at the Emergency Room.

PAST HEALTH HISTORY

Mr. Peach was born via Normal spontaneous vaginal delivery, and has completed his

immunizations. He has undergone childhood illnesses such as measles, chicken pox, and mumps.

He has no allergies to any food and drugs.

Last 2008, Mr. Peach had a rupture on his Left Testicle and on the same year he had

undergone I & D on his Right Testicle. On 2010, he was diagnosed with Pulmonary Tuberculosis

and was cured.

Early in 2018, Mr. Peach was hospitalized due to abdominal pain because of binge

drinking.

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GENOGRAM
Figure 1

MATERNAL PATERNAL

75 y.o 72 y.o 70 y.o 64 y.o 60 y.o

LEGENDS:
- MALE - TUBERCULOSIS OR - DECEASED

- FEMALE - HYPERTENSION
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- CLIENT - SEIZURE 9
PYSICAL EXAMINATION AND REVIEW OF SYSTEMS
Table 1

OBJECTIVE PROBLEM
AREAS ASSESSED
FINDINGS IDENTIFIED
General Health Survey Weight: 48 kgs
Height: 156 cm
Temp: 36.2 Celsius
RR: 20 bpm Impaired Activity
PR: 73 bpm Tolerance
BP: 120/70 mmHg
O2sat: 97%
Risk for Injury
 Unconscious
 Scar at the left lower extremity
INEFFECTIVE
 Edema at both hands
AIRWAY CLEARANCE
 Ambu bag attached
 Decorticated hands
Integumentary System OBJECTIVE FINDINGS:
 Skin is dry
 Pale nail beds
 Warm to touch
 Skin warm to touch IMPAIRED SKIN
 Temp of 36.2‫ﹾ‬c INTEGRITY
 Scar at the left lower extremities
 Edema of both hands
SUBJECTIVE FINDINGS:
“ kanang naa sa iyahang bagtak mao mana
iyahang samad atong nahagbong siya sa
duyan pag takig niya.”
HEENT OBJECTIVE FINDINGS:
a. Head and face  Head is bald
b. Eyes  Head is normally hard and smooth w/o
c. Ears lesions ALTERED SENSORY
d. Nose PERCEPTION
 Face is symmetric
e. Oral Cavity
 Eyes are closed, with discharges around
eyelids.
 NGT and mouthguard attached and
 Dry lips with secretions RISK FOR INFECTION
SUBJECTIVE FINDINGS:
“pagkahuman niya ug takig wala na ming buka
iyahang mata sukad, ayha ra pag mo takig nasad
siya ug balik.”

Neck OBJECIVE FINDINGS:


 Neck is symmetric with head centered NO PROBLEM
 No lymphadenopathy IDENTIFIED
 No distended carotid veins
 No lesions or lumps noted

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INEFFECTIVE
Respiratory System OBJECTIVE FINDINGS: AIRWAY CLEARANCE
 O2sat: 97%
 RR: 27 RISK FOR
 Client has Ambu-bag ASPIRATION
 Nasal flaring is not observed.
 Crackles INEFFECTIVE
 With yellowish secretions BREATHING
PATTERN
Cardiovascular System OBJECTIVE FINDINGS:
 No shortness of breath noted
 Heart rate: 73 bpm
 Blood pressure: 120/70
 No edema noted
NO PROBLEM
 Pulsations or vibrations are palpated in the
IDENTIFIED
areas of the apex, left sternal border or base
 The radial and apical pulse rates are
identical
 No murmurs are heard
Breast and Axilla OBJECTIVE FINDINGS:
 Breast are symmetrical with no signs of
dimpling or retraction
 areolas dark, brown and round
 Nipples are equal bilaterally in size and are NO PROBLEM
the same location on each breast IDENTIFIED
 No lumps or swelling in the underarm area
 No masses palpated
Gastrointestinal System OBJECTIVE FINDINGS:
and the Abdomen  Stool is yellow in color and watery in
texture
NO PROBLEM
SUBJECTIVE FINGDINGS: IDENTIFIED
“Basa nga murag orange nga yellow ang
iyahang color sa tae”
Genitourinary/Reprodu OBJECTIVE FINDINGS:
ctive System  Diaper attached DISTURBED BODY
IMAGE
 Ruptured Left and Right testicles
Musculoskeletal System OBJECTIVE FINDINGS: IMPAIRED PHYSICAL
 Unconscious MOBILITY
 Decorticated hand
IMPAIRED ACTIVITY
 Body weakness
INTOLERANCE
 Lumbar pain and swelling
 Pain in moving ACUTE PAIN
Lymphatic/Hematologic OBJECTIVE FINDINGS:
System  RBC: 3.486
 Hematocrit: 0.30
 Hemoglobin:105.0 ANEMIA
 Segmenters: 0.94
 Lymphocytes: 0.04
OBJECTIVE FINDINGS:
NO PROBLEM  Patient has no sweating
IDENTIFIED  Weight: 48 kgs

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GORDON’S FUNCTIONAL HEALTH ASSESSMENT
Table 2

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

NUTRITIONAL/ METABOLIC PATTERN


 Mr. Peach does not eat his meals but drinks
 NGT Attached
liquor early in the morning every day.

ELIMINATON PATTERN
 Client is on diaper and changes 2x a day.
 The client defecates once a day and urinate 6x
 Defecates once a day with yellowish
a day or more depending on his fluid intake.
watery stool

EXERCISE AND ACTIVITY PATTERN


 He was a farmer. And farming is his way of
 Unconscious
exercising.

SLEEP AND REST PATTERN


 He usually sleeps around 11 pm in the
 GCS of 3, unconscious.
evening and wakes up 6 am in the morning.

ALCOHOL AND STREET DRUGS


 He was a chronic drinker for 45 years now.
Mr. Peach can consume 3-4 bottle of tanduay  N/A
per day.
 He quitted smoking 5 years ago

ENVIRONMENTAL HAZARDS
 They live in San Roque, Iligan City. With a  Confine to bed
congested type of community.

OCCUPATIONAL HEALTH
 Mr. Peach was a high school graduate. And
he worked at Petron Tibanga as a Security  Confine to bed
Guard before and he was a farmer.

ROLE AND RELATIONSHIP PATTERN


 He’s living with his daughter and grandchild
together. He is separated with his wife.

COPING STRESS MANAGEMENT


 Drink liquor as a stress reliever every day.

VALUES AND BELIEFS


 Mr. Peach is a Seventh Day Adventist and
goes to Church often.

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DIAGNOSTIC TEST

CBC & PLATELET COUNT


FEBRUARY 08, 2019
Diagnostic test Normal Test Result Interpretation Nursing responsibilities
Red blood cell 4-6x10 12/L 3.48 Normal  Inform the patient that the test is used to evaluate anemia and disorders affecting the number
of circulating RBCs.
 Positively identify the patient using at least two unique identifiers before providing care,
treatment, or services.
 Obtain a list of the patient’s current medications, including herbs, nutritional supplements,
and nutraceuticals.
Hematocrit 0.40-0.54 0.30 Decreased  Inform the patient that the test is used to evaluate anemia, polycythemia, and hydration status
and to monitor therapy.
 Obtain a history of the patient’s cardiovascular, gastrointestinal, hematopoietic, hepatobiliary,
immune, musculoskeletal, and respiratory systems, symptoms, and results of previously
performed laboratory tests and diagnostic and surgical procedures.
 Note any recent procedures that can interfere with test results.
Hemoglobin 130-160g/L 105.0 Decreased  Inform the patient that the test is used to evaluate anemia, polycythemia, and hydration status
and to monitor therapy.
 Obtain a history of the patient’s complaints, including a list of known allergens, especially
allergies or sensitivities to latex.
 Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe
normally and to avoid unnecessary movement.
WBC 5-10x10 9/L 25.34 Normal  Inform the patient that the test is primarily used to evaluate viral and bacterial infections and
to diagnose and monitor leukemic disorders.
 Obtain a history of the patient’s hematopoietic, immune, and respiratory systems, symptoms,
and results of previously performed laboratory tests and diagnostic and surgical procedures.
 Review the procedure with the patient. Inform the patient that specimen collection takes
approximately 5 to 10 min. Address concerns about pain and explain that there may be some
discomfort during the venipuncture.
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Segmenters 0.50-0.65 0.94 Increased  If the patient has a history of allergic reaction to latex, avoid the use of equipment containing
latex.
 Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe
normally and to avoid unnecessary movement.
Lymphocytes 0.25-0.65 0.04 Decreased  Positively identify the patient using at least two unique identifiers before providing care,
treatment, or services.
 Obtain a history of the patient’s complaints, including a list of known allergy, especially
allergies or sensitivities to latex.
Stabs 0.05-0.10 0 Decreased  Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe
venipuncture site for bleeding or hematoma formation and secure gauze with adhesive
bandage.
 Promptly transport the specimen to the laboratory for processing and analysis.
Monocytes 0.03-0.07 0.02 Decreased  Depending on the results of this procedure, voadditional testing may be performed to evaluate
or monitor progression of the disease process and determine the need for a change in therapy.
Evaluate test result in related to the patient’s symptoms and other tests performed.
 Obtain a list of the patients current medications, including herbs, nutritional supplements, and
nutraceuticals.
Eosinophil’s 0.01-0.03 0 Decreased  Inform the patient that the test is used to assist in the diagnosis of conditions related to
immune response, such as allergy or parasitic infection.
 Instruct the patient with an elevated eosinophil count to report any signs or symptoms of
infection, such as fever.
 Obtain a history of the patient’s hematopoietic, immune, and respiratory systems, symptoms,
and results of previously performed laboratory tests and diagnostic and surgical procedures.
Basophils 0-0.01 0 Normal  A report of the results will be sent to the requesting HCP, who will discuss the results with
tha patient.
 Reinforce information given by the patients HCP regarding furthertesting, treatment, or
referral to another HCP
Platelet count 146-450x10 438 Normal  Inform the patient that the test is used to evaluate, diagnose, and monitor bleeding disorders.
9/L  Obtain a history of the patient’s hematopoietic and immune systems, especially any bleeding
disorders and other symptoms, as well as results of previously performed laboratory tests and
diagnostic and surgical procedures.
 Instruct the patient to report bleeding from any areas of the skin or mucous membranes.
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PROTIME (PROTHROMBIN TIME)
FEBRUARY 08, 2019

PATIENT: 15.0 SECONDS

CONTROL: 13.5 SECONDS

ACTIVITY: 90%

INR: 1.11

EXAMINATION RESULT NORMAL VALUES

HGT – (HEMOGLUCOTEST) 171 70-110mg%

SGPT – (ALANINE AMINO TRASNFERASE) 13.93 5-35 U/L

CREATININE 59.84 71-115 umol/L

POTASSIUM 2.69 3.5-5.3 mmol/L

SODIUM 130.6 135-148 mmol/L


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EXAMINATION: X-RAY OF THE CHEST AP, AND LUMBO-SACRAL, SPINE, APL, VIEWS
CC: LOWER BACK PAIN

CHEST X-RAY: AP VIEW:


Fibroreticular densities are noted in both lungs, with hazy component densities in both paracardiac area.
Heart is not enlarged. Tortuous aorta.
The diaphragm and both costophrenic sulci are distinct.
The included osseous structures are not remarkable.

IMPRESSION: BILATERAL PTB


No interval progression compared with the previous study doe last December 2017. Sable lesion.

SACRAL SPINE X-RAY APL VIEWS:


Minimal bone rarefaction. Bone spurs seen at the articular edges of the lumbar vertebrae.
Erosion of the bodies and the adjacent enplattes of L3 and L4 vertebrae, with resultant kyphosis.
No demonstrable para-verterbral masses. Negative for para-vertebral calcification.

IMPRESSION: LUMBAR SPONDYLOSIS


EROSION OF L3 AND L4 INCLUDING WITH OBLITERATION OF THE DIC SPACCE
The primary consideration is tubercular spondylitis (Pott’s disease).
However, suggest MRI if clinically warranted.
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CT SCAN OF THE HEAD (NON- CONTRAST)

Clinical data: Seizure


Technique: plain CT images of the head were obtained.
Comparison: None.

FINDINGS:
An extraaxial, crescentic hyperdense collection is noted in the left frontal convexity with maximal thickness of 0.5cm. Sulcal hyperdensities are also seen in
the superior left frontal region.

Tiny fairly, defined hypodense foci are noted in the periventricular white matter of the left frontal lobe. Gray-white matter interface is maintained.
The ventricles, cisterns, and sulci are prominent. No suggestive mass effect or midline shift noted.
The midbrain and pons show no abnormality. The cerebellar interfolial spaces are slightly widened.
The bilateral internal carotid and vertebral arteries are calcified.
The sella is intact. The visualized paranasal are clear. The orbits, petromastoids and visualized osseous structures are unremarkable.

IMPRESSION:
1. Acute subdural hematoma in the left frontal convexity.
2. Subarachnoid hemorrhage in the left superior frontal region.
3. Consider small infarcts of indeterminate age in the periventricular left frontal lobe.
4. Age-related cerebro-cerebellar atrophy.
5. Atherosclerotic internal carotid and vertebral arteries.
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NORMAL ANATOMY AND PHYSIOLOGY
Table 3

ANATOMICAL STRUCTURE FUNCTION

Controls all functions of the body, interprets information


from the outside world, and embodies the essence of the
BRAIN
mind and soul. Intelligence, creativity, emotion, and memory
are a few of the many things governed by the brain
Is the largest part of the brain and is composed of right and
left hemispheres. It performs higher functions like
CEREBRUM interpreting touch, vision and hearing, as well as speech,
reasoning, emotions, learning, and fine control of movement.
Is located under the cerebrum. Its function is to coordinate
CEREBELLUM muscle movements, maintain posture, and balance.
Acts as a relay center connecting the cerebrum and
cerebellum to the spinal cord. It performs many automatic
BRAIN STEM functions such as breathing, heart rate, body temperature,
wake and sleep cycles, digestion, sneezing, coughing,
vomiting, and swallowing

LEFT HEMISPHERE Controls speech, comprehension, arithmetic, and writing.

Controls creativity, spatial ability, artistic, and musical


RIGHT HEMISPHERE
skills.
The largest lobe, located in the front of the brain. The major
functions of this lobe are concentration, abstract thought,
FRONTAL LOBE information storage or memory, and motor function. It is also
responsible for a person’s affect, judgment, personality and
inhibitions. (Hickey, 2014)
This lobe analyzes sensory information and relays the
interpretation of this information to other cortical areas and
PARIETAL LOBE is essential to a person’s awareness of body position in
space, size and shape discrimination, and right-left
orientation. (Hickey, 2014)
This lobe contains the auditory receptive areas and plays a
TEMPORAL LOBE role in memory of sound and understanding of language and
music. (Hinkle & Cheever, 2018)
This lobe is responsible for visual interpretation and
OCCIPITAL LOBE
memory. (Hinkle & Cheever, 2018)

is continuous with the medulla, extending from the cerebral


SPINAL CORD hemispheres and serving as the connection between the brain
and the periphery. (Hinkle & Cheever, 2018)

Positioned in the middle of the lumbar spine, plays an important


role in supporting the weight of the torso. The nerves, muscles,
L3- L4 SPINE
and other soft tissues also aid with such processes as knee
extension and foot motion.

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CONCEPT MAP
MODIFIABLE FACTORS: Figure 2 NON-MODIFIABLE FACTORS:

- Life style (heavy alcohol use) - Age (64 years old)


- Diet - Gender
- Sleep deprivation
- Stress

Altered integrity of neuron In the


TONIC PHASE
epileptogenic focus
Alteration in the activity in the
midbrain (connects brain to Loss of consciousness
spinal nerves) Spreads to both
Hyperexcitability state of neurons in
hemisphere
the epileptogic focus
Risk for Injury related to decreased
level of consciousness and seizure
activity Hyperexcitability of neurons in the Partial depolarization
brainstem causing disruption in the (high voltage electrical discharges)
functions of the medulla, pons and
Alteration in the activity of the Musculature stiffening midbrain.
pons (extremities pulled toward
body) Imbalanced release in excitatory and
Abnormal spontaneous spread of
inhibitory neurotransmitters
electrical discharges
Disturbed sensory perception
related to neurologic impairment
Activated by precipitating factors Lowered seizure threshold

Disruption in medullary activity


Cessation of cardiovascular
thus alteration in function of CLONIC PHASE
and respiratory activity Inhibitory impulse starts from the
respiratory and cardiovascular - Muscles will contract and relax
causing apnea and cyanosis thalamus and interrupts the tonic
system rapidly
phase into continuous bursts of
- Violent, jerking movements
electrical activity
- Upward rolling of the eyeballs
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PHARMACOLOGIC THERAPY NURSING DIAGNOSIS
DIAGNOSTIC TESTS NURSING MANAGEMENT
- Keppra - Ineffective Airway Clearance
- CT scan of head 1. Initiate seizure precautions for
- Dilantin related to Altered Level of
- Lumbo-sacral spine x-ray Consciousness patients at risk for seizures:
- Valproic acid
- Chest x-ray Suction set up and working,
- Mannitol - Risk for injury related to seizure
- CBC & Platelet count activity Ambu-bag in room, padding
- Ceftriaxone
- Omepron - Risk for Impaired Skin Integrity side rails and all side rails up.
- Dexamethasone related to Prolonged Immobility 2. Maintain safety during any
- Azithromycin - Self-care Deficit related to seizure activity: Turn patient
unconscious state to side, nothing in mouth. Do
not restrain.
3. Assess, monitor and document
seizure activity.
4. Administer antiepileptics
medications per orders.
5. Provide emotional support.

LEGENDS:

PATHOPHYSIOLOGY

MANIFESTATIONS

NURSING DIAGNOSIS
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DRUG STUDY

DOSAGE,FREQUENC MECHANISM OF ADVERSE NURSING


GENERIC NAME CLASSIFICATION INDICATION
Y, ROUTE ACTION REACTION CONSIDERATION
CO AMOXICLAV Penicillin 1.2 gm IVTT  An antibiotic that  Treatment of  Diarrhea,  Assess bowel pattern
(BACTIV) combines infections caused  pseudomembranous before and during
amoxicillin and by susceptible gm colitis, treatment as
clavulanic acid. It + ve & gm -ve  indigestion, pseudomembranous
destroys bacteria by microorganisms.  vomiting, colitis may occur.
disrupting their  mucocutaneous  Assess respiratory
ability to form cell  candidiasis, status.
walls.  nausea,  Observe for
 hepatitis, anaphylaxis.
 cholestatic  Ensure that the
 Jaundice. patient has adequate
fluid intake during
any diarrhea attack
MANNITOL Osmotic Diuretic 75 cc IV  Acute oliguric renal  Test dose for  CNS: dizziness,  Monitor vital signs
failure. marked oliguria headache, seizures  Intake and output
 Toxic overdose or suspected  CV: chest pain,  Central venous
 Edema inadequate renal hypotension, pressure
 Increased function, prevent hypertension,  Pulmonary artery
intracranial acute renal failure tachycardia, thrombo pressure
pressure(ICP) during phlebitis, heart  Signs and symptoms
 Intraocular pressure cardiovascular failure, vascular of dehydration (e.g.
(IOP) and other overload poor skin turgor, dry
surgeries, acute  EENT: blurred skin, fever, thirst)
renal failure, to vision, rhinitis  Signs of electrolyte
reduce  GI: nausea, vomiting, imbalance/deficit
intracranial diarrhea, dry mouth (e.g. muscular
pressure and brain  GU: polyuria, urinary
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mass, reduce retention, osmotic weakness, paresthesia
intraocular nephrosis , numbness,
pressure, to  Metabolic: confusion, tingling
promote dieresis dehydration, water sensation of extremity
in drug toxicity, intoxication and excessive thirst)
irrigation during  (for increase ICP)
trans urethral Neurologic status and
resection of intracranial pressure
prostate. readings.
 (for increase IOP)
Elevating eye pain or
decreased visual
acuity.
POTASSIUM Electrolytes 2 tablets TID  Replace potassium  To prevent  Arrhythmias,  Make sure the powder
CHLORIDE and maintain hypokalemia, pro  Heart block, are completely
(KALIUM) potassium level phylaxis during  Hypotension dissolve before
treatment w/  Cardiac arrest giving.
diuretics  Hyperkalemia
 Respiratory paralysis
LEVETIRACETA Anticonvulsants 500mg 1 tablet BID  Appears to  Partial onset  Coordination  Assess duration,
M (KEPPRA) inhibiting burst seizures. Primary difficulties location, and
finding firing generalized tonic-  Weakness characteristics of
without affecting clonic seizures  Dizziness seizure activity.
normal neuronal  Behavioral  May administer
excitability and abnormalities medication without
may selectively regard to meals.
prevent  Observe patient’s
hypersnchronizatio behaviour closely for
n of epileptiform atleast 15-30 minutes
burst firing and after administration.
20
propagation of
seizure activity.
OMEPRAZOLE Proton Pump 20mg 1 capsule BID  Gastric acid pump  Treatment of  Constipation,  Take the drug before
(OMEPRON) Inhibitor inhibitor suppresses heartburn or  diarrhea, meals. Swallow the
gastric acid symptoms or  flatulence, capsules whole; do
GERD  nausea & vomiting not chew, open,
 acid regurgitation. or crush them.
 Abdominal pain,  Report if severe head
 asthenia, ache, fever,
 headache, worsening of the
symptoms.
 dizziness,
 rash
CEFTRIAXONE 3rd generation 3gms IV OD  Works by inhibiting the  Lower respi tract  Pain, induration,  Assess patient’s
(XTENDA) cephalosporin mucopeptide synthesis infections, acute tenderness & inj site Previous sensitivity reaction to
in the bacterial cell bacterial otitis reaction after IM penicillin or other
wall. media, skin & administration. cephalosphorins.
skin structure  Rash;
infections, UTI, thrombocytosis,  Assess patient for signs
uncomplicated leukopenia; diarrhea, and symptoms
gonorrhea, pelvic  Elevations of SGOT, of infection before and
inflammatory SGPT & BUN. during the treatment
disease, bacterial  Headache or
septicemia, bone dizziness;
& joint infections,  diaphoresis &
intra-abdominal flushing.
infections,
meningitis,
surgical
prophylaxis.
21
PHENYTOIN Central nervous 500mg 1 tablet TID  A hydantoin  Control of tonic-  Bradycardia  Stop drugs if rash
(DILANTIN) system agent, derivative that clonic seizures,  Dizziness appears.
anticonvulsant, probably stabilizes  Prevention and  Constipation  Use cautiously in
hydantoin neuronal treatment of  Vomiting patients with hepatic
membranes and seizures occurring  Decreased dysfunction,
limits seizure during coordination hypotension,
activity by either neurosurgery myocardial infarction,
increasing reflux
SODIUM Oral electrolytes 1 tablet QID  Replaces and  Treatment for  Overdoses may cause  Obtain baseline
CHLORIDE NaCl maintains sodium hyponatremia pulmonary edema sodium chloride
and chloride levels  Headache levels before starting
which are essential  Tinnitus therapy and reassess
ions necessary in  Sensation of warmth regularly thereafter to
normal cellular lips monitor drug
metabolism.  Back pain effectiveness.
 Diarrhea  Monitor electrolyte
 Muscle twitching levels.
 Assess patient’s fluid
status.
 Assess patient’s and
family’s knowledge
on drug therapy.
 Instruct patient to
report occurrence of
drug induced adverse
reactions.
VALPROIC ACID Anticonvulsant, 500 mg 1 tablet BID  Increase level of  Complex partial  Confusion  Take vital signs prior
mood stabilizer gamma- seizures  Dizziness to administration.
aminobutyric acid  Simplex or  Blurred vision  Give drug with food
in brain, reducing complex absence  Nausea & vomiting if GI upset occurs.
22
seizure activity. seizures  Abdominal pain  Don’t give syrup in
carbonated beverages
PIRACETAM Neuromuscular 800mg 1 tablet TID  acts selectively  Cerebral  Hyperkinesia  Monitor heart rate, ECG
(NOOTROPIL) Agent upon telencephalon insufficiency and  Weight gain and BP periodically
by improving its chronic  Nervousness throughout the therapy.
associative function. It manifestation of  Agitation  Drug has strong taste.
increases the energy CVA, post  Irritability Mixing oral form with
output of the brain cell traumatic  Anxiety orange juice mask the
and activates its syndromes,  Sleep disturbances taste.
neurophysiological severe mental  Fatigue  Assess patient to clear
potentialities, cloudiness and airway
 Drowsiness
especially in deficit vascular coma of
 GI disturbances.  Provide support
conditions. a traumatic of ventilation, if it is
toxic involutional needed.
syndromes related to  Assess and support
aging, cortical cardiac function
myoclonus
AZITHROMYCI Anti- infective 500mg 1 tablet OD  Inhibits cell- wall  Injectable form is  Fatigue  Culture site of
N (ZITHROMAX) synthesis, used for treatment  Vertigo infection before
promoting osmotic of serious  Dizziness therapy
instability, usually infections of the  Headache  Administer on an
bactericidal lower respiratory empty stomach 1 hour
racts before or 2-3 hours
after meals
 It should never be
taken with food.
DEXAMETHASO Anti-inflammatory 5mg IVTT  To decreases  Adjunctive  Insomnia  Instruct patient to
NE Glucocorticoid inflammation, treatment in  Headache take drug with food
mainly by bacterial  Seizures and milk.
stabilizing meningitis  GI irritation  Determine whether
23
leukocyte  Cerebral edema  Muscle weakness patient is sensitive to
lysosomal allergic and  Nausea & vomiting other corticosteroids
membranes; inflammatory  Give oral dose with
suppresses immune conditions food when possible.
response;  Shock Patient may need
stimulates bone  Tuberculosis drugs to prevent GI
marrow; and meningitis irritation.
influences protein,
fat and
carbohydrate
metabolism
24
NURSING CARE PLAN
Table 4

NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVE: Ineffective STO: 1. Assess airway for patency.  Maintaining patent airway is After the short term and long
 Use of Ambu- Airway After 2 hours of nursing always the first priority, term nsing interventions, the
bagging Clearance intervention, client will be especially in cases like patient was able to:
 Yellowish related to able to: trauma, acute neurological
secretion has Altered Level of decompensation, or cardiac 1. Maintain patent airway and
seen upon Consciousness  To maintain a patent arrest ensured ventilation.
suctioning airway and ensure
 Crackles were ventilation.
2. Suctioning, oral Hygiene,  To prevent from any kinds 2. Showed no signs of
heard upon and chest physiotherapy of obstruction in the lungs aspiration.
auscultating LTO: and airway.
 Respiratory rate
of 27bpm After 8 hours of nursing 3. Reduce his congested
intervention, the patient airway with clear breath
3. Provide mouth care to  Provide meticulous mouth
will be: care consists of brushing sounds
patient
 The patient will show teeth. To avoid mouth ulcer
no signs of aspiration and lesions
 Have reduced his
congestion in the 4. Reposition client every 2  To prevent bed sores and to
airway with clear hours pool down the secretion
breath sounds. which is preventing or
clogging the secretion in the
airway.

5. Provide supplemental  A variety of medications


humidification like may be used to decrease
nebulization and mucus and to improve
respiration.

6. Administer medication as
prescribed by the physician
25
NURSING CARE PLAN
Table 5

NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for Injury After 2 hours of nursing 1. Explore with the patient the  Lack of sleep, flashing After 2 hours of nursing
“pag takig niya related to seizure interventions, the client various stimuli that may lights, and prolonged interventions, the clients
nahagbong siya sa activity will be able to: precipitate seizure activity. television viewing may was able to:
duyan” increase brain activity
1. Monitor its seizure that may cause potential 1. Monitor its seizure
activities. seizure activity. activity status.
2. Check and monitor 2. Discuss seizure warning signs  Enables the patient to 2. Checked and
and usual seizure pattern. protect self from injury.
patient’s condition. monitored its
3. Understand the safety condition and health.
3. Keep padded side rails up with  Minimizes injury when
precautions for bed in lowest position. seizure occurs while 3. Understood the safety
seizure. patient on bed. precautions for
Objective: seizures.
- seizure 4. Perform neurological and vital  Document postictal state
- Weakness signs check post seizure: 3 time and completeness
- Loss of LOC, orientation, ability to of recovery to normal
consciousness comply with simple state. May identify
- GCS of 3 commands, ability to speak, additional safety
- V/S taken as memory of incident, weakness concerns to be addressed.
follows: or motor deficits, BP, PR and
BP: 120/70 RR.
P: 78
R: 27 5. Reorient patient following  Patient may be confused,
T: 36 ºc seizure activity. disoriented, and possibly
amnesic after seizure and
need help to regain
control and alleviate
anxiety
26
NURSING CARE PLAN
Table 6

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION


Subjective: Risk for impaired skin Short-term: 1. Inspect all skin areas, noting  Skin especially prone to After 2 hours of nursing
integrity related to capillary blanching/refill, breakdown because of interventions, the client
“Dili kaayo namo siya immobility. After 2 hours of nursing redness, and swelling. Pay changes in peripheral was able to:
malihok-lihok kay interventions, the client particular attention to back of circulation, inability to 1. Identify individual
maglisod mi ug lihok will able to: head and folds where skin sense pressure, risk factors.
niya.: as verbalized by 1. Identify individual continuously touches. immobility, altered 2. Verbalize
the client’s daughter. risk factors temperature regulation. understanding or
2. Verbalize treatment needs.
understanding of 2. Elevate lower extremities  Enhances venous return. 3. Participate to level of
treatment needs. periodically, if tolerated. Reduces edema ability to prevent skin
3. Participate to level of formation. breakdown.
ability to prevent skin
breakdown. 3. Provide gentle massage  Improves blood flow,
Objective: around reddened or blanched minimizing tissue Long-term:
- Weak Long term: areas. hypoxia. Note: Direct
- On complete bed massage of compromised No signs of bedsores
rest The patient will not area may cause tissue
- unconscious exhibit signs of bedsores. injury.
- immobile
4. Encourage frequent position  Reduces pressure on
changes in bed and chair. tissues, improving
Assist with active or passive circulation and reducing
range of motion (ROM) time any one area is
exercises. deprived of full blood
flow.

5. Provide frequent skin care;  Excessive dryness or


minimize contact with moisture damages skin
moisture or excretions. and hastens breakdown.
27
NURSING CARE PLAN
Table 7

NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
 GCS OF 3 Disturbed sensory Short-term: 1. Evaluate and continually  To obtain an overview of After 8 hours of nursing
 UNRESPONSIVE perception monitor changes in orientation, client’s mental and cognitive intervention, the patient
related to ability to speak, mood and status and ability to interpret was able to compensate
neurologic affect, sensorium, and thought stimuli. for sensory
impairment processes.
impairments.
Long-term: 2. Assess sensory awareness,  To assess degree of
After 8 hours of including response to touch, impairment.
nursing intervention, hot/cold, dull/sharp, and
the patient will be able awareness of motion and
to compensate for location of body parts. Note
sensory impairments. problems with vision and other
senses.  To note whether response is
3. Determine response to painful appropriate to stimulus,
stimuli. immediate or delayed.
 Reduces anxiety, exaggerated
4. Eliminate extraneous noise and emotional responses, and
stimuli, as necessary. confusion associated with
sensory overload.
 Agitation, impaired judgment,
5. Provide for client’s safety, such poor balance, and sensory
as padded side rails or bed deficits increase risk of client
enclosed with safety netting, injury.
assistance with ambulation, and  Interdisciplinary approach can
protection from hot or sharp create an integrated treatment
objects. plan based on the individual’s
unique combination of abilities
and disabilities with focus on
COLLABORATIVE: evaluation and functional
6. Refer to physical, occupational, improvement in physical,
speech, and cognitive therapists cognitive, and perceptual
skills.
28
NURSING CARE PLAN
Table 8

NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Self-care Deficit Short-term 1. Assess self-care needs; self-  Provides baseline data to After 4 hours of nursing
related to : care deficits of the client, plan care. interventions, the client
“Dili na kaayo namo unconscious state After 4 hours of nursing availability of care given to was able to:
siya maligo kay naa interventions, the client perform self-care activities.
naman gud siya daani, will be bathe with 1. Bathe with
magpatabang rami assistance of the nurse and 2. Perform bed bath daily and as  Clean skin prevents assistance of the
usahay sa nurse. Unya significant others. required. bacterial growth. Promotes nurse and
laktaw ug adlaw ang overall well-being. significant others.
iyang ligo maam.”
As verbalized by the
Long-term: 3. Provide oral hygiene 4 hourly.  Unconscious client suffer 2. Be free of body
client’s daughter. odor and have a
from problems of neglected
At the end of the shift, the mouth such as well hygiene.
client will be able to: inflammation. Oral and
Objective:
- Mouth discharges 1. Be free of body odor nasal mucosa dryness,
- Secretion on the and have a well halitosis, spread of
eyelids hygiene. infection to adjacent
- Toenails are dirty structures.
- Foul body odor
4. Teach the significant others  To maintain proper
how to maintain hygiene on the hygiene.
patient.

5. Bathe the client at least every 2  It provides comfort and


days and change hospital gown relaxation to the client.
into new clean clothes.
29
DISCHARGE PLAN

A. OBJECTIVES

At the end of an hour of health teaching/education, the client and his SO will be able to:
1. Summarize a simple and productive health education plan;
2. Adhere prescribed medications for health maintenance and resistance;
3. Promote a healthy lifestyle, maximize the level of health ;
4. Gain knowledge in managing the condition; and
5. Maintain and ensure adequate intake for nourishment
B. METHODS
1. Medications
Dosage
Name of Drug
Preparation Curative
(Generic and Route Side Effects Instructions
Frequency Effects
Trade Name)
Duration
Azithromycin 500 mg 1 tablet oral Anti-infective - Fatigue - Culture site of
(Zithromax) OD - Vertigo infection before
- Dizziness therapy.
- Headache - Administer on an
empty stomach 1
hour before or 2-3
hours after meals.
- It should never be
taken with food.
Valproic Acid 500 mg 1 tablet NGT Anticonvulsant - Confusion - Take vital signs prior
BID - Dizziness to administration.
- Blurred - Give drug with food
vision if GI upset occurs.
- Nausea and - Don’t give syrup in
vomiting carbonated beverages
- Abdomen
pain

2. Exercise/Activity and Home Environment


Type of Activity Allowed/To be continued:
 Depending on the status of the patient.
 Walking at least 30 minutes every day.
 Deep breathing exercise
Use of Equipment (if any): wheel chair
Restrictions:
 Avoid strenuous activities, wherein heavy exercise is also prohibited.

30
3. Treatments/Therapies (e.g., Chest physiotherapy, warm compress, steam inhalation,
hydrotherapy, nebulization, etc)

 Chest Physiotherapy
 Deep breathing exercises

4. Health Teaching/Education (e.g., asthma)


Health Prevention/Promotion
 Avoid lifting heavy objects.
 Avoid alcoholic beverages and smoking
 Taught the client some of the stress-coping strategies such as seeking help
from others, expressing his feelings assertively, to think positive and always
seek God for help.
 If seizure reoccur, document time and duration of seizure
 Put patient in a side lying position during attack
 Put hard edges of the tables and other furniture
 Install a rubber mat or non-skid strips on the tub or shower floor

5. OPD Visit
Clinic Appointment Schedule: 1 week after discharge

6. Diet
a. Prescribed Diet:
 High-fat foods such as:
- Bacon, eggs, mayonnaise, butter, hamburgers and heavy cream, with
certain fruits,
 Vegetables,
 Nuts,
 Avocados,
 Cheeses
 Fish

b. Diet Restrictions:
 Smoking
 Alcohol beverages

7. Spiritual Care and Psychological or Sexual


(/) Spiritual Counseling
(/) Family Therapy
(/) Supportive Counseling
(/) Join Church Organizations/Activities
(/) Prayer
(/) Meditation, Reflection, and Spiritual Devotion
(/) Religious Rituals

Sexual Needs
( /) Marriage Counseling

31
REFERENCES

1. Taylor (2008) Nursing Diagnosis Pocket Guide (2th ed.).Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.

2. Lewis, Heitkemper ,Dirksen ,O'Brien,Bucher (2007): Assessment and Management of


Clinical Problems, liver, Pancreas and Biliary Tract problems, Medical Surgical Nursing,
MOSBY.1st Edition, 1101:15.

3. Ignatavicius & Workman (2006) Medical Surgical Nursing: Critical Thinking for
Collaborative Care. USA. Elsevier.

4. Brunner & Suddarth’s (2018). Medical Surgical Nursing 14th edition. Philadelphia:
Wolters Kluwer Health/ Lippincott Williams & Wilkins.

5. Tortora (2011). Principles of Anatomy and Physiology , 14th Edition John Wiley & Sons,
2008.

6. Weber & Kelley (2014). Health Assessment In Nursing. Philadelphia. Lippincott


Williams & Wilkins.

7. Goldman and Schafer (2016).Goldman-Cecil Medicine. 25th ed. Philadelphia, PA:


Elsevier Saunders

8. https://www.scribd.com/doc/60612519/drug-study

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