Professional Documents
Culture Documents
COLLEGE OF NURSING
La Paz, Iloilo City
Vision: WVSU as one of the TOP TEN universities in Southeast Asia by 2015.
Mission: To produce globally competitive individuals who are life-long learners.
Core Values: S - Service H – Harmony E – Excellence
I. VITAL INFORMATION
Name of Child: K.L.C. Name of Informant: R.C.
Sex: Female Relationship with the child:
Mother
Date of Birth: 08/04/95
Age: 13 years old
Address: Brgy. Malugsod, Dueñas, Iloilo
Date and Time Admitted: 08/09/08 @ 4:00 pm
Chief Complaints: “Gin-convulsion siya nga naglawig mga pulo ka minutos.”
Ward: PSW-B
Religious Affiliation: Roman Catholic
Name of Mother: R.C.
Educational Attainment: 3rd year high school Age: 48 years old
Occupation: none
Name of Father: N.C.
Educational Attainment: 3rd year high school Age: 49 years old
Occupation: Farmer,
carpenting
Approximate Monthly Income of the Family:
a.) Mother – N/A
b.) Father – Php 9000-9500
c.) Others – Php 2000 ( Patient’s uncle)
TOTAL Php 11000-11500
Physician: Dr. G.
Impression/Diagnosis: Status Epilepticus
Pre-op Diagnosis: N/A
Post-op Diagnosis: N/A
I. CLINICAL ASSESSMENT
A. Nursing History
“Halin sang gamay siya, sang 3 years old pa lang, gina-convulsion na siya
nga da-an. Ga turong gid na iya mata pero mga segundo man lang ang kalawigon.
Sang nagadako siya, daw gasige-sige na, halos kada adlaw na gani ang atake niya.
Kun mabug-atan, makulba-an kag kun grabe iya hulag, amu gid na siya atakihun.
Gamay ni siya dayon pakan-on kay medyo pisli-an. Kun masobrahan gani ka gutom,
gina atake man siya. Ginapapahuway man lang siya namun tapos ginahilot-hilot ang
likod sang iya li-og.” As verbalized by patient’s mother.
Chronologic story
When K.L.C. was 2 years old, a small vase fell in her head (exact location
unrecalled). K.L.C. then lost consciousness. She regained her consciousness a few
minutes later. No medical check-up made after the incident. 9 years prior to
admission, 1998, K.L.C. experienced episodes of seizure attack characterized by
crying, upper rolling of eyeballs and involuntary muscle jerking which lasted for
about 30-40 seconds. Parents did not seek any medical help. Episodes of seizure
attack of same symptoms continued with approximately 5-6 days interval. Still,
parents did not seek medical help. Instead, they just massage the lower portion of
the neck and let the patient rest.
In year 2000, patient had a seizure attack characterized by change in lost of
consciousness, stiffening of the body and upper rolling of eyeballs which lasted for
almost 3 minutes. “Daw nag grabe iya atake tapos medyo mas dugay siya
komparar sa mga na una ya nga convulsion. Amo ‘to gindali-dali dala sa Western.”
As verbalized by the mother. An EEG was done and the mother claimed that the
result showed an impinged vessel. Unrecalled anticonvulsant meds were given and
monthly check-up was advised. K.L.C. complied with the prescribed meds and
medical check-up for 4 months only. There was a noticeable decreased in frequency
of seizure attacks with 3-4 weeks interval. The mother stated “ Daw kamahal na gid
ya galing sang bulong, amo ‘to gin-untatan na lang namun.” Thus, the seizure
attacks recurred with 5-6-day interval.
If the patient would feel hungry or tired, a seizure attack would occur which
would last for seconds. The patient would complain of dizziness thereafter. Rest and
massage in the neck were again the management of folks after the attack.
1 month prior to admission, July 2008, there was an increase in frequency of
seizure attacks (4x weekly).
2 days prior to admission, K.L.C. experienced episodes of seizure attack
which lasted for 5 hours within 5-minute interval with no febrile episodes or
difficulty of breathing.
A day prior to admission, seizure attacks continued which lasted for 10
minutes with seconds interval and K.L.C. was admitted in Iloilo Provincial Hospital.
K.L.C. was then referred to WVSU-MC for further treatment. Thus, last August 9,
2008, K.L.C. was admitted in WVSU-MC, PSW-B.
Parasitism____________ Tuberculosis____________
Anemia____________
AGE____________ Measles 8 years old Seizure since 3
years old
AGN____________ BPN____________ Emotional
Disorder____________
Allergy none Accidents (specify) ______ Others:
Family History
Spontaneous /
Caesarian Section/Forceps (specify
reasons)
Food likes:
Cheeze Curls, fried chicken, “lumpia”
Allergies: None
Problems related to nutrition: none
Elimination Patterns
Toilet Training
Sleeping Patterns
Immunization Status
Peer interaction:
“Palahampang ni siya sa mga kilala ya lang galing nga ka-edad ya.Indi man
siya pala-away pero amo lang na eh, kun indi ya makwa gusto ya,
masinuplada na siya.” As verbalized by the mother.
Improved flexibility
and coordination;
plays musical
instrument.
Spiritual Individuating-
13 y.o. reflexive:
Adolescents become
more skeptical and
begin to compare
the religious
standards of their
parents with those
of others. They
attempt to
determine which to
adopt and
incorporate to their
own set of values.
They also begin to
compare religious
standards with
scientific viewpoint.
It is a time of
searching than
reaching.
Adolescents are
uncertain about
many religious ideas
but will not achieve
profound insights
until late
adolescence or early
adulthood.
Cognitive Formal operations:
13 y.o. formal operational
thought is
characterized by
adaptability and
flexibility.
Adolescents can
think in abstract
terms, use abstract
symbols, and draw
logical conclusions
from a set of
observations. They
can consider
abstract, theoretic,
and philosophic
matters. Although
they may confuse
the ideal with the
practical, most
contraindications in
the world can be
dealt with and
resolved.
A. Measurements:
B. Clinical Inspection
Vital Signs:
Temperature: _37.2˚C per axilla__________ Pulse Rate: _76 beats per
minute______
Respiratory Rate: _21 breaths per minute__ Blood Pressure: _110/70
mmHg_______
VI. PHYSICAL ASSESSMENT
General Appearance:
Appears restless, irritable, and disheveled. Easily cries when
approached. Has strong tenseness and rigid movement. Does not follow through
with directives. Does not observe eye contact.
Presence of four point restraints on right and left hands and right and
left feet, attached to bed frame.
A. Integumentary System
Skin is brown in color. It is soft and warm to touch. When pinched at
the abdomen, it returned in one second, which indicated good turgor. Reddish,
dry, scattered lesions on right forearm, approximately 2 cm. in diameter. Wound
with pus draining on right ankle of 2 cm. in diameter and 1 mm. in depth.
Moderate dandruff noted on hair, as well as lice and nit infestations.
Nails are not well-trimmed and cleaned. Nail beds are pink and firm. No
clubbing or beau lines.
B. Respiratory System
Respiratory patterns are even and unlabored. No use of accessory
muscles upon respiration. Deep inhalation and shallow expiration. Usual
respiratory rate is 20 breaths per minute. Clear breath sounds ascultated on all
lung fields.
E. Gastrointestinal System
Canker sore of approximately 2 cm. on lower lip. Buccal mucosa is pink
and dry. Pinkish gums. Papillae present on tongue and midline fissure present.
Abdomen is flat. Umbilicus is midline.
F. Reproductive System
Breasts are bilaterally symmetrical. Areolae are light brown. No
discharges on both nipples.
G. Endocrine System
No swelling and tenderness of thyroid gland. No excessive sweating.
Equal body hair distribution.
H. Musculoskeletal System
Full ROM of the arms and legs. Hand grip is strong. Brief voluntary
muscular jerking of both extremities. Generalized tensed movements.
I. Lymphatic System
Thyroid and cervical lymph nodes are not assessed. No presence of
swelling. Neck is symmetrical and can rotate freely.
J. Hematopoietic System
Capillary refill of 1 second. No bruising.
1. CLINICAL CHEMISTRY
• Definition:
Sodium is the most abundant cation (90% of the electrolyte fluid) and the
chief base of the blood. Its primary functions in the body are to maintain osmotic
pressure and acid-base balance chemically and to transmit nerve impulses.
Potassium is the principal electrolyte (cation) of the intercellular fluid and the
primary buffer within the cell itself. 90% of potassium is the blood by damaged
cells.
• Purpose
o It is used to indicate acid-base balance and hydration status.
• Preparation
o Inform the client about the reason why the specimen was ordered, how
is to be collected, the equipments needed and the stinging sensation
that may be felt.
o Foods and fluid are usually not restricted before the collection of the
specimen.
• Specimen
o Venous blood collected in a collecting tube or syringe.
146.4 139.9
Serum Sodium 135-148 mmol/L Within normal range
mmol/L mmol/L
2.62
Serum Calcium 2.18-2.68 mmol/L Within normal range
mmol/L -
Serum 72.48
20-40 µmol/L Increased. UTI
Creatinine µmol/L -
2. HEMATOLOGY
Red blood cells are produced by erthyroid elements in the bone marrow.
Under the stimulation of erythropoietin, RBC production is increased. Within each
RBC are molecules of hemoglobin that permits the transport and exchange of
oxygen to the tissues and carbon dioxide in tissues.
Hemoglobin is the main component of red blood cells. Its main function is to
carry oxygen from the lungs to the body tissues and to transport carbon dioxide,
the product of cellular metabolism, back to the lungs. Another function of
hemoglobin is to act as a buffer to help maintain acid-base balance.
White blood cells (WBC) are produced in red bone marrow and lymphatic
tissue. After they are formed they enter the blood, which transport them to the
parts of the body where they are needed to defend against invading organisms
through phagocytosis and produce or antibodies to help maintain immunity.
• Preparation
o Inform the client about the reason why the specimen was ordered, how
is to be collected, the equipments needed and the stinging sensation
that may be felt.
o Foods and fluid are usually not restricted before the collection of the
specimen.
o Instruct the patient to remain still and to hold the arm extended either
resting flat on bed on supported firmly during specimen extraction.
• Specimen
o 5-10 mL sample of venous blood collected in a tube or syringe.
Results Significance
Normal Values
8/9 8/13 8/22 Abnormal Results
erythrocyte
number 3.81 4.82 3.96 3.7-5.3 x 1012/L Within normal range
concentration
leukocyte
6.2-17.0 x
number 12.4 9.0 10.8 Within normal range
109/L
concentration
200,000-
Platelets 232 220 281 473,000/cu Within normal range
mm
APTT 28.7 - -
3. URINALYSIS
• Definition:
A urinalysis involves multiple routine test of urine specimen. It includes
remarks about the color, appearance, and odor of the urine. The pH is also
determined. The urine is tested for the presence of proteins, glucose, ketones,
blood and leukocytes esterase.
Urine specimens that have been left standing may contain lysed red blood
cells, disintegrated casts, and rapidly multiplying bacteria.
Casts are molds of the distal nephron lumen. A gel like substance called tam-
horsfall mucoprotein, which is formed in the tubular epithelium, is the major protein
constituent of urinary casts. These develops when protein concentration of the urine
is high, urine osmolality is high. And urine pH is low.
• Purpose
o It is used to evaluate the patient’s urine for renal or urinary tract
disease. It is also to help detect
metabolic or systemic disease on related to renal disorders and to
detect substance use.
• Preparation
o Instruct the patient about the type of specimen needed and the best
time to collect it.
(early morning urine)
o Inform client to collect the midstream urine about 30cc.
o The container should be labeled with the patient’s name, date, and the
type of the specimen.
• Specimen
o 30cc of midstream urine collected in a specimen container.
Physical Properties
Pale Straw Straw Clear - Straw Within normal range
Color
Slightly Clear-Slightly
Transparency Hazy Within normal range
Hazy Hazy
Acidic Acidic
Reaction (pH) 4.6-8.0 Within normal range
(6.0) (6.5)
Chemical Tests
negative
Sugar negative Trace - None Within normal range
Increased. Any
distruption in the
blood-urine barrier,
whether at the
RBC 2-7 0-2 0-1/hpf
glomerular, tubular
or bladder level, will
cause RBC’s to enter
the urine.
Crystals
Urates-
Amorphous - Trace - None Within normal range
Few
Squamous Epithelial
Few Occasional Trace - None Within normal range
Cells
Round Epithelial Cells Few Few Trace - None Within normal range
Yeast Cells - Occasional Trace - None Within normal range
4. Blood Culture and Sensitivity
• Definition
A blood culture and sensitivity test is used to identify the microorganisms
causing the infection. The culture is then subjected into antibiotics to identify which
one is the most effective treatment and which one is not.
• Preparation
o Blood culture should ideally be obtained before any antibiotic therapy.
o Cleanse skin first before obtaining specimen
o NPO status not required.
Amikacin 30 *
Ampicillin 10 *
Amoxicillin 25 *
Augmentin 30 *
Cefaclor 30 *
Cefamandole 30 *
Ceftazidime 30 *
Cefotaxime 30 *
Ceftriaxone 30 *
Cefuroxime 30 *
Cephalexin 30 *
Chloramphenico *
30
l
Ciprofloxacin 5 *
Cotrimoxazole 25 *
Erythromycin 15 *
Gentamycin 30 *
Imepenem 10 *
Nalidixic Acid 30 *
Netilmicin 30 *
Nitrofurantoin 300 *
Norfloxacin 10 *
Piperacillin *
10/75
Tazobactam
Meropenem
Tetracycline 30 *
Interpretation
Of the drugs the bacteria Klebsiella was subjected to, only chloramphenicol,
cotrimoxazole, ceftazedime, and piperacillin tazobactam were considered effective
in treating it. Out of these drugs, Chloramphenicol was chosen over the others
because it was the cheapest of the group.
Definition:
PO2 – this is an indirect measure of the oxygen content of arterial blood. PO2 is a
measure of the tension
(pressure) of oxygen dissolved in plasma.
Preparation:
Specimen: Arterial blood obtained from any area of the body where strong pulses
are palpable. Usually
from the radial, brachial, or femoral artery.
Compon
Result Normal Values Significance
ent
pH 7.409 7.35-7.45 Normal
PCO2 32.4mmHg 35-45 mmHg Decreased due to
20.3meq/L 21-28meq/L Decreased due to lactic acidosis,
a form of metabolic acidosis
HCO3 experienced by status epilepticus
patients
Definition:
Preparation:
• Lessen patient anxiety by showing him/her the machine first and encouraging
to verbalize concerns.
• NPO status for 4 hours before the study if oral contrast medium is used.
• Remove hairpins, wigs, or any other hair clips and paraphernalia in the head.
• Tumors
• Inflammation
• Diaphragmatic hernia
• Heart size
Preparation:
• No fasting is required
• Instruct patient that he or she will have to take a deep breath and hold it
while the x-ray films are being taken.
• Instruct men to cover their testicles and women to cover their ovaries using
lead shield to prevent radiation-induced abnormalities.
Result:
• No evident peritubular densities
• Trachea is at midline
8/28/08 @830AM
S–
“Kung kaisa hindi ma-igo sang mga Doctor ang ugat, te hala
saylo e. Kag daan grabe siya pa hulagon, budlayan gid guro mga
doctor sa iya,” as verbalized by the mother.
“Hala saylo eh, kung kaisa ginahukas niya ukon mag-dinugo na,”
referred
IV tubing accidentally being pulled out by patient herself.
“Hulagan siya abi, sadto nga may banig kami di, siguro nag-sag-
id hala ka nusnus eh te nagkapilas sya.”
O–
Guarding behavior
P/I –
E–
A. Definition
A seizure is a sudden, abnormal electrical discharge from the brain that results
in changes sensation, behavior, movements, perception or consciousness.
Seizure disorders have numerous and varied causes. Most are idiopathic.
Genetic factors may in some way alter the seizure threshold to influence neuronal
discharge. It can also be acquired as a result of brain injury during prenatal,
perinatal or postnatal periods.This injury may be caused by trauma, hypoxia,
infections. Biochemical events and nutritional deficiencies produce seizure activity
Status epilepticus is a tonic clonic or absence seizures that follow one another
without restoration of consciousness. Common precipitating factors include abrupt
cessation of anticonvulsant medications and alcohol withdrawal. This disorder is life
threatening and produces greatly accelerated neuronal metabolic rate, hypoxia,
acidosis, hyperthermia, and alterations in cerebral blood flow. Damage occurs to the
cerebral cortex, hippocampus, and cerebellum, along with other metabolic
derangements.
Tonic-Clonic Seizures are the most common major motor seizure. The tonic
phase is followed by the clonic phase, which involves rhythmic bilateral contraction
and relaxation of the extremities.
Cyanosis (-)
Hypoxia (-)
C. Schematic Diagram
Head trauma
Cerebrovascular disease
Infection
Physiologic Stimuli
loss of consciousness,
jerking movements,
rigidness of body
Seizure
Status Epilepticus
D. Management
a. Nursing Management
During a seizure, the major goals are to maintain the airway, to prevent
injury, to observe seizure activity and to administer appropriate
anticonvulsant medications. Today, “seizure precautions” as identified in a
hospital setting refers to the availability of an oral airway, and suction
equipment.
c. Surgical Management
REFERENCES: