2NU08 Group 2 - RLE-OPD| MINI-CASE PRESENTATION

I. GROUP MINI-CASE PRESENTATION

CASE#5: Seizure

This is a case of H.T, a 1 year old female, Born Again Christian, from Pasig City , admitted
last May 25, 2018.

1 day PTC, Patient experienced fever with Tmax if 39.3 °C temporarily relieved by intake of
Paracetamol at 10mkd. Associated with one episode of non- projectile, non-bilous
vomiting, of previously ingested milk amounting to approx. ½ cup. No cough, colds, loose
bowel movement, ear discharge, rashes nor seizure noted.

Few hours PTC, Still with the same symptoms, but now accompanied by one seizure episode
described as upward rolling of the eyeballs, circumoral cyanosis and stiffening of
bilateral extremities lasting for less than 5 minutes and with no noted loss of consciousness;
hence consult to the ER department of this institution and subsequent admission.

PAST MEDICAL HISTORY:

- No history of seizure
- No known allergies to food nor medications

FAMILY MEDICAL HISTORY:

- (+) febrile seizure, maternal side

- (-) epilepsy

PERSONAL AND SOCIAL HISTORY:

- Lives in a bungalow house with parents and grandparents

- Garbage properly collected and disposed
- Well ventilated
- Water supply from water station
- No pets
IMMUNIZATION HISTORY:
Complete vaccination, until 15 months old at a local health center with no noted severe
reactions.

FEEDING/NUTRITION:
• Exclusively breastfed for 3 months
• Started complementary feeding at 6 months old of rice and mashed vegetables •
Consumes 7 8 oz bottles of formula milk with 1:1 ratio
REVIEW OF SYSTEMS: unremarkable

Prepared by Hanna H. Arcilla, RN, MD

RLE-OPD| MINI-CASE PRESENTATION

PHYSICAL EXAMINATION:

GENERAL SURVEY

Awake, crying, carried by the mother and not in cardiorespiratory distress

VITAL SIGNS

• Temp: 38.3 °C
• HR: 140
• RR: 40
• SPO2: 94% at room air

ANTHROPOMETRICS

HEAD CIRCUMFERENCE: 44 CM
CHEST CIRCUMFERENCE: 42 CM
ABDOMINAL CIRCUMFERENCE: 43 CM
LENGTH: 75 CM
WT: 9kg

SKIN
No lesions, rashes, scaling noted. Good skin turgor

HEENT
Anicteric sclerae, pink palpebral conjunctiva, PERRLA, no cervical lymphadenopathies.

CARDIOVASCULAR

Adynamic precordium, no heaves no thrills. PMI at 4th left ICS MCL. Distinct S1 and S2, with
normal rate and rhythm.

RESPIRATORY

No nasal flaring, use of accessory muscles, no chest wall deformities. Equal lung expansion
with clear breath sounds.

Prepared by Hanna H. Arcilla, RN, MD

RLE-OPD| MINI-CASE PRESENTATION

ABDOMEN

No lesions, globular and non-distended. Normoactive bowel sounds. Tympanitic in all

quadrants. No palpable mass nor tenderness. No organomegaly noted.

EXTREMITIES
No gross deformities, no edema noted. CRT <2 sec. Bilateral brachial pulses and dorsalis
pedis were full

GENITALIA
Grossly female, with no noted erythema or discharge.

NEUROLOGIC EXAM:

I- not assessed
II- 2-3 mm pupils equally reactive to light; fundoscopic examination not done III,
IV,VI- Intact EOMs, no nystagmus, no strabismus
V- not assessed
VII- No facial asymmetry
VIII- good gross hearing
IX,X- uvula midline, good suck and swallowing
XI- no difficulty in turning head from all sides
XII- tongue midline

• No Kernig’s and Brudzinski’s sign

• No bulging fontanel
• Good muscle tone
DIAGNOSIS: Benign Febrile Seizure Secondary to Pneumonia

LABORATORY RESULTS:
CHEST XRAY: Bilateral Pneumonia

COURSE IN THE WARD:

MAY 25,2019 (DAY 0)

S> Fever 39.3

• Fever 39.3
• Seizure episode described as upward rolling of the eyeballs, circumoral cyanosis and
stiffening of bilateral extremities
O>

• awake
• pink palpebral conjunctiva
• anicteric sclera
• symmetric lung expansion
• no retractions
• clear breath sounds
• full pulses
• CRT <25 sec

A> Benign Febrile Seizure Secondary to Pneumonia

P> Admitted and secured consent.
• Diet for age
• IVF: PNSS at fluid maintenance rate of 37.5cc/hr via soluset
Prepared by Hanna H. Arcilla, RN, MD
RLE-OPD| MINI-CASE PRESENTATION

• CBC w/ PC
• UA
• Na,K, Ca, Cl, Mg
• HGT
• CXR (APL)
• Ampicillin 100mkD
• Paracetamol at 16.6 mkd
• VS Q4h
• I&O Q shift

DAY 1: MAY 26,2019

S>
• Awake
• no seizure episode
• No LBM
• No cough/colds

O>
• afebrile
• Symmetric chest expansion
• no retractions
• (+) harsh breath sounds
• soft abdomen
• full pulses

A> Benign Febrile Seizure Secondary to Pneumonia P> IVF: PNSS

at fluid maintenance rate of 37.5cc/hr via soluset • for lumbar
puncture
• secure consent
• urine CS

DAY 2: MAY 27,2019

S>
• Awake
• no seizure episode
• No LBM
• No cough/colds

O>
• afebrile
• Symmetric chest expansion
 • no retractions
• (+) harsh breath sounds
• soft abdomen
• full pulses

Prepared by Hanna H. Arcilla, RN, MD

RLE-OPD| MINI-CASE PRESENTATION

A> Benign Febrile Seizure Secondary to Pneumonia

P>
• Shift to heplock
• For CRP
• Repeat urinalysis
• Continue medications
• Refer accordingly

DAY 2: MAY 28,2019

S>
• Awake
• no seizure episode
• No LBM
• No cough/colds

O>
• afebrile
• Symmetric chest expansion
• no retractions
• (+) harsh breath sounds
• soft abdomen
• full pulses

A> Benign Febrile Seizure Secondary to Pneumonia

P>
• May go home
• Take home medications
• Amoxicillin 100mg/ml drops; 1ml for 4days

GUIDE QUESTIONS:
1. What are the additional datas, you can ask the mother of the patient?

- Ask the mother if they travel recently, or any anyone in the family got
sick recently
- How is the child's appetite and what are her favorite foods (increase
intake)
- Is there other notable abnormalities that worries the mother

2. How do you do a proper neurological assessment?

Neurologic Assessment
Subjective Objective

History of Present Health Concern Cranial Nerves

● Headaches ● CN 1 - olfactory
● Seizures ● CN 2 - optic
● Dizziness ● CN 3, 4 and 6 - oculomotor,
● Numbness, Tingling/Prickling trochlear and abducens
(Paresthesias) ● CN 5 - trigeminal
● Senses ● CN 7 - facial
● Difficulty speaking ● CN 8 - acoustic/vestibulocochlear
● Muscle control ● CN 9 and 10 - glossopharyngeal
● Memory loss and vagus
● CN 11 - spinal accessory
Past Health History ● CN 12 - hypoglossal
● Head injury with/without loss of
consciousness Motor and Cerebellar Systems
● Meningitis, encephalitis, injury to the ● Condition and movement of
spinal cord or stroke muscles; size and symmetry of all
muscle groups
Family History ● Strength and tone of all muscle
● High BP, stroke, Alzheimer, groups
dementia, epilepsy, brain cancer or ● Unusual involuntary movements
Huntington chorea ● Gait and balance
● Romberg test
Lifestyle & Health Practices ● Coordination
● Medications, alcohol, recreational ● Rapid alternating movements
drugs
● Smoking Sensory System
● Seatbelt, protective headgear ● Light touch, pain and temperature
● Usual 24-hour diet sensations
● Exposure to lead, insecticides, ● Vibratory sensations
pollutants, other chemicals ● Sensitivity to position
● Lift heavy objects, repetitive motions ● Tactile discrimination
● Normal IADLs ● Point localization
● Neurologic problem changed your ● Graphesthesia
self-perception ● Extinction
● Neurologic problem caused stress
 Reflexes
● Deep tendon reflexes
● Biceps reflex
● Brachioradalis reflex
● Triceps reflex
● Patellar reflex
● Achilles reflex
● Ankle clonus
● Plantar reflex
● Abdominal reflex
● Cremasteric reflex

Meningeal Irritation or Inflammation

● Neck mobility
● Brudzinski sign
● Kernig sign

3. What is Benign febrile seizure?

Febrile seizures are seizures that happen in children between the ages of 6 months and 5
years, that is associated with high fever but with an absence of intracranial infection, metabolic
conditions, or previous history of febrile seizures. It is subdivided into 2 classifications: A simple
febrile seizure is brief, isolated, and generalized while a complex febrile seizure is prolonged
(duration of more than 15 minutes), focal (occurs in one part of the brain), or multiple (occurs
more than once within 24 hours). A febrile seizure is a convulsion in a child that's caused by a
fever. The fever is often from an infection. Febrile seizures occur in young, healthy children who
have normal development and haven't had any neurological symptoms before. It can be
frightening when your child has a febrile seizure. Fortunately, febrile seizures are usually
harmless, only last a few minutes, and typically don't indicate a serious health problem.

a. Risk factors

Factors that increase the risk of having a febrile seizure include:

● Young age. Most febrile seizures occur in children between 6 months and 5 years
of age, with the greatest risk between 12 and 18 months of age.
● Family history. Some children inherit a family's tendency to have seizures with a
fever. Additionally, researchers have linked several genes to a susceptibility to
febrile seizures.

b. Signs and symptoms

Usually, a child having a febrile seizure shakes all over and loses consciousness.
Sometimes, the child may get very stiff or twitch in just one area of the body.
 A child having a febrile seizure may:
● Have a fever higher than 100.4 F (38.0 C)
● Lose consciousness
● Eye rolling
● Involuntary moaning, crying, and passing of urine
● Shake or jerk the arms and legs
● Stiffening of Limbs
Febrile seizures most often occur within 24 hours of the onset of a fever and can
be the first sign that a child is ill.

4. Give at least 5 NCP for this patient.

1.
Assessment Nursing Planning Intervention Evaluation
Diagnosis

Objective: Impaired gas Short-term 1. Assess Goal Met.

-Circumoral exchange related Goal: respiratory rate,
cyanosis to airway After 2 hours of depth, and
-HR: 140 plugging as nursing effort, including
-RR: 40 evidenced by intervention, the the use of
-SPO2: 94% at circumoral patient will have accessory
room air cyanosis pulse oximetry muscles, nasal
-Respiratory: use on room air flaring, and
of accessory within normal abnormal
muscles parameters and breathing
there will be an patterns.
absence of
cyanosis. 2. Monitor skin and
mucous
Long-term membrane
Goal: color.
After 1 day of
nursing 3. Monitor oxygen
intervention, the saturation via
patient will have pulse oximetry.
continuous
adequate gas 4. Assess and
exchange monitor mental
status (lethargy,
restlessness,
combativeness)

5. Position the
child with the
head elevated,
in a semi -
Fowler’s position
 and assist to
assume
positions while
having a
seizure.

6. Suction as
necessary.

7. Provide frequent
contact and
support to the
child and family.

8. Administer
oxygen and/or
medications
(albuterol,
levalbuterol) as
ordered.

2.
Assessment Nursing Planning Intervention Evaluation
Diagnosis

Subjective: Risk for Short Term 1. Maintain side- Goal Met.

ineffective airway Goal: lying position
One seizure clearance related during seizure
episode to pneumonia After 8 hours of activity
described as nursing 2. Ensure mouth is
upward rolling of intervention, the empty of foreign
the eyeballs, client will display objects if aura
circumoral patent airway occurs or
cyanosis and and breath seizure occurs
stiffening of sounds clearing without warning
bilateral 3. Elevate head of
extremities Long Term bed and change
lasting for less Goal: position
than 5 minutes frequently
and with no After 1 day of 4. Supervise
noted loss of nursing supplemental
consciousness intervention, the oxygen as
client maintains indicated
Objective: normal airway 5. Suction as
clearance as indicated
(+) harsh breath evidenced by (adventitious
sounds on days normal breath breath sounds)
1-3 in the ward sounds 6. Maintain
adequate
 hydration by
providing fluids
3.
Assessment Nursing Planning Intervention Evaluation
Diagnosis

Subjective: Hyperthermia Short Term 1. Monitor the Goal Met.

Patient related to Goal: patient’s BP, HR
experienced infection After 4 hours of and especially
fever with Tmax nursing the patient’s
if 39.3 °C intervention the temperature.
child’s 2. Assess for
Objective: temperature will hydration status.
Physical decreased from 3. Eliminate
Examination: 38.3 to normal excess clothing.
Temp: 38.3 °C range of 36.5 to 4. Administer tepid
37.5 sponge bath.
Laboratory 5. Advise mother
Results: Long Term to avoid
CBC: WBC: 14.9 Goal: applying cold
After 1 day of water or alcohol
intervention, the to the child.
child will 6. Administer
maintain antipyretic as
temperature indicated.
within normal
range and will
not experience
complications.

4.
Assessment Nursing Planning Intervention Evaluation
Diagnosis

Subjective: Risk for Injury Short Term 1. Assess and Goal Met.
related to seizure Goal: record seizure
One seizure activity. activity and
episode After 4 hours of location. Note
described as nursing the duration of
upward rolling of intervention the seizures, parts
the eyeballs, patient’s of the body
circumoral environment will involved, site of
cyanosis and modify as onset and
stiffening of indicated to progression of
bilateral enhance safety. seizure.
extremities
lasting for less Long Term 2. Assess skin for
than 5 minutes Goal: pallor, flushed,
and with no or cyanosis;
noted loss of After 1 day of Monitor
consciousness Nursing respiratory rate,
intervention the depth, and signs
(+) febrile child will be free of respiratory
seizure, maternal from injury when distress.
side seizure occurs.
3. Maintain side-
lying position;
Objective: Keep padded
side rails up with
• awake the bed in
• pink palpebral lowest position
conjunctiva and remove any
• anicteric clutter from the
sclera child.
• symmetric
lung expansion 4. Avoid restraining
• no retractions the child or
• clear breath putting anything
sounds in his/her mouth;
• full pulses provide gentle
• CRT <25 sec support to head
and arms if
harm might
result.

5. Stay with the

child during the
phase of
seizures,
reorient when
awake, and
allow to rest or
sleep after an
episode.

6. Advice parents
to remain calm
during seizure
activity of the
child.

7. Educate the
parents
regarding
precautionary
measures during
a seizure.
 8. Administer
Medication as
Indicated.
5.
Assessment Nursing Planning Intervention Evaluation
Diagnosis

Subjective: Risk for deficient Short Term 1. Assess vital sign Goal Met.
One episode of fluid volume Goal: changes:
non- projectile, related to fever After 20-30 increasing
non-bilous minutes of temperature,
vomiting, of nursing prolonged fever,
previously intervention, lost tachycardia.
ingested milk body fluids will 2. Assess skin
be replenished. turgor
Objective: 3. Monitor I&O
Fever with Tmax 4. Investigate
if 39.3 °C Long Term reports of
Goal: nausea and
vomiting.
After 2-4 hours 5. Provide
of providing supplemental IV
nursing fluids as
intervention, the necessary.
child will 6. Administer
maintain medications as
adequate fluid indicated:
volume as antipyretics,
evidenced by antiemetics.
good skin turgor,
moist skin and
balanced intake
and output

5. Do a drug study on the drugs given above.

Drug Dosage Mechanism of Indication and Side Effects and Nursing

Action Contraindicatio Adverse Responsibility
ns Reactions

Generic 100mg/mL It interferes with Indication: SE: -Assess input and

Name: drops; 1 mL for cell wall -Bacterial - Abdomina output ratio; report
Amoxicillin 4 days replication of infection l or hematuria, oliguria
Brand Name: susceptible stomach since penicillin in
Clavulin organisms; the Contraindicatio cramps or high doses is
Functional cell wall, n: tendernes nephrotoxic.
Class: Broad rendered - Hypersensitivity s.
spectrum osmotically - Black, - Assist patient to
antibiotic unstable, swells, tarry eat small frequent
Chemical and bursts from stools. meals.
Class: osmotic - Diarrhea
Aminopenicillin pressure. - Make sure the
-B lactamase AE: patient will be taking
inhibitor the full course
CNS: Lethargy, therapy.
hallucinations,
seizures - Frequent mouth
care may help (if
GI: Nausea, patient experiences
vomiting, sore mouth)
Dysentery
Hematologic:
Anemia,
thrombocytopenia
, leukopenia,
neutropenia,
prolonged
bleeding time

Hypersensitivity:
Rash, fever,
wheezing,
anaphylaxis

Drug Dosage Mechanism of Indication and Side Effects and Nursing

Action Contraindicatio Adverse Responsibility
ns Reactions

Generic 16.6 mkd Inhibits the Indication: SE: - Make sure

Name: synthesis of -Reduce fever - Skin patient does
Paracetamol prostaglandins swelling not exceed
Brand Name: that may serve Contraindicatio - Disorienta recommende
Calpol as mediators of n: tion d dosage
Functional pain and fever, -Hypersensitivity - Dizziness - If patient
Class: primarily in the to the drug - Rash refuses
Analgesics CNS. - Cough medicine off
a spoon try
AE: using a
- Anaphylax medicine
is syringe to
- Liver squirt liquid
failure slowly into
- Kidney the side of
toxicity the child's
 - Stevens- mouth or use
Johnsons soluble
Syndrome paracetamol
mixed with a
drink.

6. Discharge plan
Discharge Plan

M-edications
- Teach caregiver on how to administer properly the prescribed home medication
(Amoxicillin 100 mg/ml drops; 1 ml for 4 days).
- Advice the mother not to administer medication unless prescribed by the physician.
- Inform the mother to give her child the medicine exactly as directed. Skipping doses can
alter blood levels of the medicine and may cause a seizure
E-nvironment
- Provide a safe environment by removing harmful objects near to the child.

H-ealth Teachings
- Teach the mother to determine and familiarize with warning signs and how to care for
her child during and after seizure attacks.
Protecting the child during a seizure:
● Stay calm, and stay with your child.
● Do what you can to prevent injury, but don't restrain movement, which can actually
cause injury to you or your child.
● Move sharp or hard objects away from your child.
● Place a flat, soft object under your child's head to cushion the head.
● Attempt to roll your child onto his or her side.
● Loosen tight clothing.
● Have someone call 911 if the seizure lasts longer than 5 minutes. Don’t leave your child
alone.
● Don’t put anything in your child's mouth and don't try to hold the tongue. It is impossible
to swallow the tongue.
● Don't give your child oral medicines or liquids during a seizure.
● Don’t panic. It is normal to turn slightly blue or pale during a seizure. And, in most cases,
seizures last fewer than 3 minutes. They usually just stop on their own.

After a seizure:
 ● Let your child sleep after a seizure. It’s normal for the child to be sleepy.
● Notify your child's healthcare provider when seizures have happened.

Get emergency medical care or call 911 if your child:

● Has a seizure lasting more than 5 minutes or is having repeated seizures

● Has trouble breathing
● Has a bluish color on the lips, tongue, or face
● Remains unconscious for more than a few minutes after a seizure
● Seems to be sick
● Has a seizure while in water
● Has any symptom that concerns you

O-utpatient Follow up
- Keep all scheduled appointments with your child’s healthcare provider even if seizures
are controlled. Regular visits will help to find any side effects your child may be having
from the medicine.

D-iet
- Eating and drinking may cause the child to become tired easily, so offer small amounts
of foods and liquids more often than usual.