Day of care: 3/16/15

Day of hospitalization:

Student Name: Jenna Spotts

Clinical site: LHV-CC
Age: 19 mos
Allergies: Grape TylenolHives

Pt initials:

Admitting Medical Diagnosis and Explanation: Status Epilepticusa prolonged seizure lasting more than 5 minutes or repeated seizures over the
course of 30 minutes. Status Epilepticus is a potential complication of all types of seizures. Seizures lasting longer than 10 minutes can cause death.
Common causes of status epilepticus are: sudden withdrawal from antiepileptic medication, infections, acute alcohol or drug withdrawal, head
trauma, cerebral edema, and metabolic disturbances.
Additional Diagnosis: None.
Pertinent Past Medical History: First seizure occurred at six months with a temperature of 101; febrile seizure (shaking limbs and rolling of the
eyes). The second seizure occurred at 16 months with generalized tonic clonic convulsion with a temperature of 101. In 10/2014 the patient fell off
of the bed and had a small subdural bleed with no further complications.
Likes/Dislikes/Comfort Measures Individualized to Your Patient: (Ask nurse or patient/family): The patient loves Minnie Mouse, Jack and
the Neverland Pirates, and the color pink. The patient is comforted by the mother and mothers boyfriend. The patient dislikes being examined but
likes to play with the stethoscope.
Current Treatment/Complementary Health Practices: Lumbar Puncture, Brain MRI with sedation, Pediatric Neurology
Nursing Assessments Related to Diagnosis and Treatments (G-Tubes, Chest Tubes, IVs, Dressing & Wound Care, Teaching Goals)
Tubes, lines, drains or
treatments:
Right antecubital IV 22 g

Purpose

Brain MRI with Sedation

To check for injury to the brain, and for a

diagnosis of epilepsy.
To check for infections such as meningitis.

Lumbar Puncture

To provide fluids to the patient

Nursing
assessment/documentation
Clean, patent, and intact. Check for
infiltration or crimped tubing. Check for any
pain, redness, or swelling.
Assess oxygenation status while sedated and
monitor vital signs.
Obtain vital signs, neurologic checks, keep
patient on bedrest and to stay flat, increase
fluid intake unless contraindicated, monitor
for complications (increased intracranial
pressure {headaches, nausea, photophobia,
change in level of consciousness}), observes
site for leakage, provide medication for
headache.

Neurological Checks every 4 hours

To check for further progression, injury, or

another seizure.

Lab and Diagnostic Data:

Interpretation of Lab
Why was it ordered?
Results
Glucose: High (119)
To check if the blood
sugar caused a seizure.

Total Alkaline Phosphate:

High (393)
Creatinine: Low (0.17)

Cerebrospinal Fluid Cell

CountLymphocytes:
High (83)
Cerebrospinal Fluid Red
Blood Cells: High (1)

Why abnormal?

Normal: 65-99. Patient is

on Keppra which
increases blood sugar.
Patient is taking D5W
NSS which has sugar in
the solution, this increases
blood sugar.
Comprehensive Metabolic Normal: 156-369. Patient
Panel; to check the overall was under stress from a
metabolic status of the
seizure.
patient.
Comprehensive Metabolic Normal: 0.39-0.55 Patient
Panel; to check the overall was under stress from a
metabolic status of the
seizure.
patient.
To check for a spinal
Normal: 40-80
infection and hemorrhage
of the brain.
To check for a spinal
Normal: 0
infection and hemorrhage
of the brain.

Assess level of consciousness, Glasgow

coma scale, motor function, sensation,
reflexes, and vital signs.

How are they being

corrected?
Nothing was being done
to correct the patients
high blood sugar.

Medication, how is it
related to lab results
No medication was being
prescribed.

Nothing was being done

to correct this.

No medication was being

prescribed.

Nothing was being done

to correct this.

No medication was being

prescribed.

Nothing was being done

to correct this.

No medication was being

prescribed.

Nothing was being done

to correct this.

No medication was being

prescribed.

VITAL SIGNS
VITAL SIGNS
Temperature
HR
Respiration
Blood Pressure
Pain

0800

YOUR SHIFT
1200

97.3
120
18
Unable to obtain
0

97.5
124
17
90/47
0

HOSPITAL STAY
LOWEST
97.3
114
18
71/45
0

HOSPITAL STAY
HIGHEST
98.5
150
36
115/73
3

NORMAL VALUES
97.5-98.0
120-150
20-30
80/45-85/45
0-3

O2/Pulse OX
IV sol, rate, site
Diet
Activity Order
PT
Respirator settings
Intake
Output

99%
99%
D5W NSS, 45 mL/hr, right
antecubital
NPO after midnight
As tolerated
No order
None

96%

100%

97-99%

286 mL
39/188/58

SHOW YOUR MATH

Weight

Calculated for patient

11.7kgX2.2lbs=25.74lbs
25.74 lbs

Actual for patient

11.7 kg

INTAKE / OUTPUT
24 Hour Fluid Requirement:
100ml x first 10kg
50ml x next 10kg
20ml x remainder of weight in kg
SHOW YOUR MATH
Shift Fluid Requirement:
_ 8 hour

100mLX10kg=1000mL
50mLX1.7 kg=85mL
1000mL+85 mL=1085 mL/day

1085mL/3=361.67mL/8 hr shift

286mL (after NPO status)

Hourly Fluid Requirement:

IV Fluid: D5W NSS
@ 45 cc/hour
IV Tubing Change Due: 3/17/15
Medication Tubing Change Due:
3/17/15

361.67mL/8hr=45.21mL/hr

Patient was made NPO on 3/16/15 for a

procedure and had a Heplock IV Heplock ___
No IV

24 Hour Output Requirement:

0.5 2ml/kg/hour

0.5mLX11.7kg=5.85mL/hour (minimum)
5.85mLX24=140.4mL/day (minimum)
2mLX11.7kg=23.4mL/hour (maximum)
23.4mLX24=561.6mL/day (maximum)

Shift Output Requirement:

_ 8 hour

285 mL for the shift

140.4mL/3=46.77mL/8 hours (minimum)

561.6mL/3=187.2mL/8 hours (maximum)

Notes: Pt was NPO on 3/16/15 for a Brain MRI with sedation, after procedure patient was able to eat and drink as tolerated. IV fluids were
Heplocked because the patient was drinking fluids.
MEDICATIONS
(Include PRNs)
Patient Wt. 11.7 kg
Medication
+
Classification

Nursin
g
Diagno
sis
numbe
r

Ordered
Dosage
& Route

Recommended Wt Based Dosage

Dosage
Calculation (mg/dose)
(mg/kg/dose) SHOW MATH

Safe
Y/N

Why is patient
receiving?

Major side effects & nursing

implications

Ibuprofen

120 mg
PO q6
PRN

4-10 mg/kg/dose

4mgX11.7kg=46.8mg/dose
(minimum)
10mgX11.7kg=117 mg/dose
(maximum)

Treatment of mild to
moderate pain.

None

20 mg
QID PO
PRN

20 mg 4 times
daily (up to
240mg/day)

20mgX3=60mg/day

45 mL/hr
q22hr IV

N/A

N/A

N/A

Relief of painful
symptoms of excess
gas in the GI that may
occur postop or from
air swallowing,
dyspepsia, peptic
ulcer, or diverticulitis.
To replenish
electrolytes and fluid
in the body.

GI bleeding, hepatitis, exfoliative

dermatitis, Stevens-Johnson
syndrome, toxic epidermal necrolysis,
anaphylaxis.
Assess for s/s of GI bleeding (tarry
stools, lightheadedness, hypotension),
renal dysfunction (elevated BUN and
creatinine levels, and decreased urine
output), and hepatic impairment
(elevated liver enzymes and
jaundice). Assess for skin rash during
therapy. Assess pain prior and after
administration.
No significant side effects.
Assess for abdominal pain, distention,
and bowel sounds prior to and
periodically throughout treatment.

Antipyretic,
antirheumatic,
nonopioid
analgesic, nonsteroidal antiinflammatory agent

Simethicone
Antiflatulent

D5W NSS
1000mL
Mineral and
electrolyte
replacement

Allergic reaction to dextrose, severe

burning, pain, or swelling at IV site.
Assess IV site for warmth, redness,
oozing, or bleeding. Assess for fever
or ongoing cough.

Keppra

1,2

Anticonvulsant

Neuman Systems Variables

Psychological
Coping methods
Mood/Affect
Cognitive abilities
Attitudes
Values
Memory
Thought content
Hallucinations
Agitation
Developmental
Developmental stage (Erikson)
Maturational events
Significant life events
Transitions stressors
Role/Occupation
Sociocultural
Access to healthcare
Family resources
Economic status
Family structure
Ethnic-cultural
Language
Literacy
Marital status

120 mg
PO q12hr

10mg/kg daily,
increase by
20mg/kg/day at 2
week intervals to
recommended
dose of 30mg/kg
2 times daily.

Assessment

LOC
Wakefulness
Orientation
Speech
Follows commands

Can remember family and staff

Unable to assess on patient
None
Not being able to eat, while being
assessed.

PERRLA
Swallow

Autonomy vs Shame & Doubt

None
Seizures
Not being able to eat or rest
Child

Mother has insurance

Mother and boyfriend only
Not stated
DNA against biological father, mothers
boyfriend had a code orange against him
and wasnt allowed on the unit.
Caucasian
English
Patient spoke gibberish, not speaking full
sentences yet.
Single
Agnostic
None

Treatment of seizures.

Physiological (Systems Review)

NEURO

Reaches for mother.

Happy with mother.
Developmental delay
Happy, smiling
Unable to assess on patient

Spiritual
Religious beliefs
Spiritual values

Initial:
10mgX11.7kg=117mg/day
Increase:
20mgX11.7kg=234mg/day
Final:
30mgX11.7kg=351mg BID
351mg/2=175.5mg/dose

Suicidal thoughts, dizziness, and

weakness.
Assess location, duration, and
characteristics of seizure activity.
Monitor mood changes. Assess
patient for CNS adverse effects
throughout therapy (asthenia, ataxia,
abnormal gait, agitation).

Assessment
Alert
Awake
A&O x3
Patient spoke a few words, most were gibberish
Yes
Pupils are equal, round, reactive to light, and
accommodate
Patient can swallow

Musculo-Skeletal
Extremity Strength
Movement/ Sensation
ROM
Activity/Gait
Equipment/ CPM/Traction
CARDIO
Heart Sounds
Pulses
Edema
Capillary Refill
Jugular Vein Distention
SCDs Teds

Patient is able to grasp equally 5/5

Patient is able to move as tolerated 5/5
Patient has active ROM
Patient is able to ambulate
None
Clear S1/S2 Normal Sinus Rhythm
+2 on bilateral arms and knees, +1 on feet
Absent
<3 seconds
None
None

Pulmonary
O2 amt/mode
O2 saturation

Room Air
99%

Respiratory effort
Lung sounds
Cough/Secretions
Chest Tubes

Effortless
Clear and even throughout all lobes
None
None

Hopefulness
Sacrament of the Sick
Physiological (start systems review)
Skin
Color/Temp
Turgor/Moisture
Mucous Membranes
IV site
Braden score/stage

Mother was hopeful

Mother denied

GI

Pink and warm

Immediate recoil and dry
Dry (NPO) and pink
R antecubital
24

Abdomen
Bowel sounds
Appetite/% eaten
Nausea/vomiting
Tube feeding: type/site
Other tubes/drains

Soft, non-tender
Active all 4 quadrants
NPO
None
None
None
GU

Urine description
Catheter
Bladder scan

Physiological Stressor # 2

Physiological Stressor # 1

S Mother stated She has fallen before from a seizure, they

Student Concept Map, p1

can happen so fast. Mother stated She was playing around

and fell off the bed, we brought her to the ER.

Life threatening stressors penetrate

Core

O Patient has a history of seizures, previous falls with a

S Mother stated She has fallen before from a seizure,

they can happen so fast. Mother stated She was playing
around and fell off the bed, we brought her to the ER.

O Previous falls, seizure disorder, tonic clonic seizure

small subdural bleed. Patient walks on her tiptoes.

Medication. Fall score of 19.

Abnormal Symptoms penetrate

normal line of defense

febrile seizure with shaking limbs and rolling of the eyes,

developmental delay

A Risk for falls R/T seizure disorder, history of falls, age,

Stressors penetrate flexible line of

defense & ^risk for penetration of
NLD

A Ineffective cerebral tissue perfusion R/T seizure

on Keppra medication, fall score of 19, and walking on

tiptoes.

P Patients mother will verbalize understanding of

Medical Diagnosis: Status
Epilepticus
CC: Seizing at home and upon
arrival to ER

Positive Variable Aiding

Defense

Ct. Initials
Age:

Positive Variable Aiding

Defense
Medication for seizures
S Mom statement
She doesnt speak a lot of words, just
MRI to see brain function
hi, bye, mommy, daddy, and grandma, she speaks a lot of
Drinking and eating after
babble Mother statement She doesnt have a hand
NPO status.
preference she uses both hands all the time.

HPI:

Ct. Initials:
AO
Age: 19 mos

Physiological Stressor # 3

O
A Delayed growth and development R/T multiple
caretakers, seizure disorder AEB patient having a small
vocabulary, using both hands, tiptoe walking, and not
imitating play.

A
P Patient will perform motor, social, and expressive
skills typical of age group within scope of present
capabilities
on the day of care.
P

normal range on the day of care.

Positive Variable
Aiding Resistance
Positive Variable
Aiding Resistance
Teaching to mother about

S Mother statement
Her
father her
was abusive and abused
medications,
bathing
drugs, I dont
need
him around
her with that attitude.
child,
mother
being there
S
for child.

O Do not announce
against
biological
Other
Stressor
# 4 dad, code orange

Physiological Stressor # 3

O Patient didnt want to imitate play, tiptoe walking

disorder and increased intracranial pressure AEB a tonic

clonic, febrile seizure, developmental delays, and a
previous fall with a small subdural hematoma.

P Patient will display neurological signs within patients

individual risk factors that contribute to the possibility of

falls for her daughter on the day of care.

Clear, yellow/straw, no odor

None
None

HPI: First seizure occurred at six months with a

temperature of 101; febrile seizure. The second seizure
occurred at 16 months with generalized tonic clonic
convulsion with a temperature of 101. In 10/2014 the
patient fell off of the bed and had a small subdural bleed
with no further complications.

called on mothers boyfriend the previous day, mothers

boyfriend calling approximately 30 times to get onto the
unit with a last warning,
filing with
Other Stressor
# 4children in youth

O
A Dysfunction family processes R/T history of abuse

Flexible line of defense

AEB mothers statement Her father was abusive and

abused drugs, I dont need him around her with that
attitude, DNA against biological father, code orange on
mothers boyfriend, and children in youth case filing.
A

Basic Structure/Central
Normal
line of defense
Core
Lines ofline
Flexible
line
Resistance
ofdefense
defense
Normal
of

P Patients mother will demonstrate and plan for

necessary lifestyle changes on the day of care.

J
E
N
N
A
S
P
O
T
T
S
4
/
2
5
/
1
5

Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jenna Spotts
Patient Initials: AO
Nursing Dx: Risk for falls R/T seizure disorder, history of falls, age, on Keppra medication, fall score of 19, and walking on tiptoes.
Behavioral Outcome: The patients mother will.will verbalize understanding of individual risk factors that contribute to the
possibility of falls for her daughter on the day of care.
Interventions:

Rationale:

Implementation:

Evaluation/ Pt. Responses:

Review patients general health status

Noting multiple factors that may affect

safety such as chronic/debilitating
use of more than 4 prescriptions, recent
trauma (especially a fall within the past
3-12 months, prolonged bedrest or
Immobility. (Doenges, Moorhouse, &
Murr, 2013).

Ask the patients mother about

her general health status and
look up the patients past medical history to obtain information.

Patients mother was

able to tell the student
about her daughters
seizures and past fall.

Note the clients age/ developmental

level, gender, decision making ability,
and level of competence.

Infants, young children (climbing, stairs)

young adults, and elderly, are at the
Greatest risk because of developmental
issues or impaired/lack of ability to selfprotect. (Doenges, Moorhouse, & Murr,
2013).

Ask the mother how the patient

interacts at home with stairs as
well climbing furniture.

The mother stated that

the patient likes to try to
climb stairs and tries to
climb furniture but slides
down to the ground.

Place bed in lowest possible position

use raised-edge mattress, pad floor at
side of bed, or place mattress on floor.

Helps to decrease the injury to the

patient if they were to fall out of bed.

Inform the patients mother

about keeping the bed low to
the ground to avoid injury.

The mother verbalized

that her daughters bed is
Low to the ground and
stated that she will place
a mat at the bedside.

Educate caregiver in fall prevention;

address the need for exercise balanced
with need for client/care provider
safety.

While fall prevention is necessary, the

the need to protect the client from harm
must be balanced with preserving
clients independence. (Doenges,
Moorhouse, & Murr, 2013).

Talked with the mother about

the importance of fall safety
and offered tips and reading
material on fall prevention.

Mother verbalized
understanding of fall
safety and read over the
material given to her.

Discuss importance of monitoring the

client and intervening in conditions.

Leaving a child unattended during play

time has been shown to contribute to
falls (Doenges, Moorhouse, & Murr,
2013).

Asked the mother how she

allows her daughter to play and
if anyone is there with her.

Mother stated that she

or another caregiver will
always be with her
while she plays.

Assessment of behavioral outcome: Outcome was fully met, patients mother was able to verbalize understanding of fall risk factors that
contribute to the risk for falls, patient was safe for the day and didnt have a fall.
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jenna Spotts
Patient Initials: AO
Nursing Dx: Ineffective cerebral tissue perfusion R/T seizure disorder and increased intracranial pressure AEB a tonic clonic, febrile seizure,
developmental delays, and a previous fall with a small subdural hematoma.
Behavioral Outcome: The client will. display neurological signs within patients normal range

Interventions:

Rationale:

Implementation:

On the day of care.

Evaluation/ Pt. Responses:

Note current situation or presence of

condition.

These conditions can affect all body

systems and systemic circulation.
(Doenges, Moorhouse, & Murr, 2013).

Ask the mother if the patient

has any conditions that could
affect all body systems.

The mother stated that

the only condition the
Patient has is status
epilepticus.

Assess level of consciousness, mental

status, speech, and behavior.

Clinical symptoms of decreased

cerebral perfusion include fluctuations
in consciousness and cognitive
functions. (Doenges, Moorhouse, &
Murr, 2013).

Complete a neurologic
check on the patient every 4
hours.

The patient was awake,

PERRLA, strong hand
grasp, follows commands
and is verbal.

Restore or maintain fluid balance.

To maximize cardiac output and prevent decreased cerebral perfusion

associated with hypovolemia.
(Doenges, Moorhouse, & Murr, 2013).

Ask the patients mother

to make sure the patient is
drinking enough fluids.

The mother stated she

keep encouraging fluids
and check for correct
amount of wet diapers.

Control fever, monitor hypothermia

therapy, and provide supplemental

Indicated to decrease cerebral metabolism and cerebral edema. (Doenges,

Moorhouse, & Murr, 2013).

Check the patients temperature and monitor vital signs.

The patients temperature stayed within

normal limits.

Discuss impact of unmodifiable risk

factors such as family history, race,
and age.

Understanding effects and interrelationships of all risk factors may

encourage client to address what can
changed to improve general well-being
And reduce individual risk. (Doenges,
Moorhouse, & Murr, 2013).

Ask the patients mother

if there is any family history of
seizures.

The patients mother

stated that she was
unsure of her family
history.

Assessment of behavioral outcome: The outcome was met, the patient was able to maintain normal neurologic function on the day of care.

Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jenna Spotts
Patient Initials: AO
Nursing Dx: Delayed growth and development R/T multiple caretakers, seizure disorder AEB patient having a small vocabulary, using both
hands, tiptoe walking, and not imitating play.

Behavioral Outcome: The client will. perform motor, social, and expressive skills typical of age group within scope of present
capabilities On the day of care.
Interventions:

Rationale:

Implementation:

Evaluation/ Pt. Responses:

Determine existing condition(s) (e.g.

chronic illness, violence, poverty).

These conditions contribute to, or are

evidence of a growth or developmental
deviation, necessitating specific evaluation and interventions depending on
the situation. (Doenges, Moorhouse, &
Murr, 2013).

Get an in-depth explanation

from the mother about any
chronic illness, violence, or
poverty in the home.

The mother was able to

explain the seizure disorder, and that the patient
wasnt abused or living
in poverty.

Collaborate with physician, nutritionist,

and other specialists in developing plan
of care.

Multidisciplinary team care increases

likelihood of developing a well-rounded
plan of care that meets the clients/
familys specialized and varied needs.
(Doenges, Moorhouse, & Murr, 2013).

Talk with the care team to

see if they could meet with the
patient to help minimize the
the growth deviations and
associated complications.

Care team came in to

meet with the patients
mother to set up a plan to
decrease growth deviations in the patient.

Recommend involvement in regular

exercise and sports program.

To enhance muscle tone and strength

and appropriate body building.
(Doenges, Moorhouse, & Murr, 2013).

Ask the mother what the

patient likes to do at home
activity wise, and to place her
in a group of her favorite.

Mother agreed on
starting the patient in
swimming class.

Communicate with client at appropriate

cognitive level of development. Give
patient tasks and responsibilities appropriate to age or functional level.

To model age and cognitively appropriate caregiver skills. (Doenges,

Moorhouse, & Murr, 2013).

Stack blocks for the patient,

and ask the patient to model
stacking the blocks. Teach the
patients mother about cognitive
testing.

Patient was smiling and

able to stack the blocks.
The patients mother was
able to verbalize understand the teaching.

Provide information about normal

growth and development process as
appropriate.

Individuals need to know about normal

process so deviations can be recognized
when necessary. (Doenges, Moorhouse,
Murr, 2013).

Assess the patients mothers

knowledge on growth and development milestones, and print out
any information needed.

Mother was unaware

of growth and development milestones. Inforwas given to patients
mother.

Assessment of behavioral outcome: Patient was able to perform some of the motor and social skills on the day of care, the patient wasnt able to
perform any expressive skills. The outcome was partially met on the day of care.
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jenna Spotts
Patient Initials: AO
Nursing Dx: Dysfunction family processes R/T history of abuse AEB mothers statement Her father was abusive and abused drugs, I dont
need him around her with that attitude, DNA against biological father, code orange on mothers boyfriend, and children in youth case filing.
Behavioral Outcome: The patients mother will.will demonstrate and plan for necessary lifestyle changes On the day of

care.
Interventions:

Rationale:

Implementation:

Evaluation/ Pt. Responses:

Assess current level of functioning of

of family members.

Information necessary for planning

Care determines areas for focus,
potential for change. (Doenges,
Moorhouse, & Murr, 2013).

Ask the mother and boyfriend

their functioning level of their
household.

The mother was able to

state that the family was
in a state of dysfunction
And wanted to change it.

Discuss current and past methods of

coping.

Family members have developed

coping skills to deal with behaviors of
of client, which may or may not be
useful to changing the situation.
(Doenges, Moorhouse, & Murr, 2013).

Ask the mother the coping

methods of the household.

The mother stated that

her and her boyfriend
fight and dont talk about
their fights. The mother
stated she would work on
their communication.

Determine family strengths, areas for

growth, individual/family success.

Family members may not realize they

they have strengths, and as they
indentify these areas, they can choose
to learn and develop new strategies for
A more effective family structure.
(Doenges, Moorhouse, & Murr, 2013).

Ask the mother about family

strengths, success, and where
she feels they need work.

The mother stated that

their strengths were
honesty and they need to
work on communication.

Discuss importance of restructuring

life activities, work, and leisure
relationships.

Previous lifestyle and relationships

supported substance abuse requiring
change to prevent relapse.
(Doenges, Moorhouse, & Murr, 2013).

Inform the mother about

ways to change her lifestyle.
Print out information on ways
to change a lifestyle.

The mother requested

information and verbalized
understanding of ways to
change her life for her child.

Encourage involvement with/refer

to self-help groups, such as a family
therapy groups.

Regular attendance at a group can provide support; help client see how others
Are dealing with similar problems; and
learn new skills.

Inform the mother about

self-help groups and the importance of joining a group.

The mother verbalized

understanding and asked
about different groups.

(Doenges, Moorhouse & Murr, 2013).

Assessment of behavioral outcome: The outcome was met, the patients mother was able to identify groups that she felt would be best for her
family and to have a plan to change her lifestyle.