Professional Documents
Culture Documents
In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING
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
ii
LIST OF TABLES
TABLE PAGE
iii
LIST OF FIGURES
FIGURE PAGE
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
DEFINITION OF TERMS
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)
POTT’S DISEASE - is a form of tuberculosis that occurs outside the lungs whereby disease is
seen in the vertebrae. (Hinkle & Cheever, 2018)
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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.
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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
GENDER: Male
RACE: Asian
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
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.
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
Early in 2018, Mr. Peach was hospitalized due to abdominal pain because of binge
drinking.
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GENOGRAM
Figure 1
MATERNAL PATERNAL
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.”
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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
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
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.
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DIAGNOSTIC TEST
ACTIVITY: 90%
INR: 1.11
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
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CONCEPT MAP
MODIFIABLE FACTORS: Figure 2 NON-MODIFIABLE FACTORS:
LEGENDS:
PATHOPHYSIOLOGY
MANIFESTATIONS
NURSING DIAGNOSIS
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DRUG STUDY
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.
6. Administer medication as
prescribed by the physician
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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
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NURSING CARE PLAN
Table 6
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.
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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.
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
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3. Treatments/Therapies (e.g., Chest physiotherapy, warm compress, steam inhalation,
hydrotherapy, nebulization, etc)
Chest Physiotherapy
Deep breathing exercises
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
Sexual Needs
( /) Marriage Counseling
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REFERENCES
1. Taylor (2008) Nursing Diagnosis Pocket Guide (2th ed.).Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
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.
8. https://www.scribd.com/doc/60612519/drug-study
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