MINI CASE STUDY

Demographic profile:
Name of patient: Ybanez, Chloe Eloise PasajeYbañez, Chloe Rose
Gender: Female
Age: 8 months old
Address: Tacurong City, Sultan Kudarat
Date of Admission: June 24, 2023

Medical History:
Chief complaint: Seizures
Present Illness:
- One day prior to admission, noted onset of runny nose with 1 episode of
generalized tonic seizures. Morning prior to noted recurrence of seizure x 1
episode thus this consult.
- (+) history of head trauma- March 2023
Past health History: (Present illness or operation)
- (-) previous hospitalization
- (-) Bronchial Asthma
- (-) previous history of seizure
Family History
- Unremarkable

Diagnosis:
Admission diagnosis- Seizure disorder
Principal Diagnosis- Seizure disorder, Urinary Tract Infection
 AMPICILLIN
Brand Name: Ampicin (CAN), Apo-Ampi Indication: Nursing Consideration/
(CAN), Novo-Ampicillin (CAN), Nu-Ampi -Infections caused by strain of Intervention
(CAN), Penbritin (CAN), Principen shigella, salmonella, e. choli, 1. Check IV site
h. influenzae, proteus carefully for signs of
Generic Name: Ampicillin, Ampicillin mirabilis, Neisseria gonorrhea, thrombosis or drug
Sodium enterococci, gram-positive reaction.
organisms. 2. Culture infected area
Classification: Antibiotic, Penicillin - Meningitis caused by before treatment; re-
Neisseria meningitis culture area if
- Unlabeled use: prophylaxis in response is not as
cesarean section in HR expected.
patients 3. Do not give IM
injections in the
Action: Bactericidal action against Contraindication: same site; atrophy
sensitive organisms; inhibits synthesis of - Hypersensitivity to drug can occur. Monitor
bacterial wall, causing cell death. - Use cautiously in renal injection sites.
disorders 4. Administer oral drug
Rout on an empty
Onset Peak Duration stomach, 1 hour
e Side Effects: Lethargy,
hallucinations, seizures, CHF, before or after meals
NAV, black hairy tongue, with a full glass of
abdominal pain, bloody water; do not give
diarrhea, Nephritis, Anemia, with fruit juice or soft
prolonged bleeding, rash, drinks.
fever, pain, phlebitis.
Drug Study

DIAZEPAM
Brand Name: Apo-Diazepam (CAN), Diastat, Indication: Nursing Consideration/
Diazemuls (CAN), Diazepam Intensol, Valium -Anxiety disorders; alcohol Intervention
Generic Name: Diazepam withdrawal; muscle relaxant 1. Do not administer
(skeletal muscle spasms); intra-arterially, may
Classification: Benzodiazepine, Anxiolytic, treatment of tetanus; status produce
Antiepileptic, Skeletal muscle relaxant epilepticus; seizure disorders; arteriospasm,
(centrally acting) treatment of panic attacks. gangrene.
2. Change from IV
Action: a long-acting benzodiazepine with Contraindication: therapy to oral
anticonvulsant, anxiolytic, sedative, muscle - Hypersensitivity to ASAP.
relaxant and amnestic properties. It increases drug; Existig CNS 3. Do not use small
neuronal membrane permeability to chloride depression/coma, veins for IV
ions by binding to stereospecific respiratory injection.
benzodiazepine receptors on the depression, acute 4. Carefully, monitor
postsynaptic GABA neuron within the CNS pulmonary VS; BP, TEMP, RR,
and enhancing the GABA inhibitory effects insufficiency, or sleep HR, & SPO2
resulting in hyperpolarization and apnea; hepatic 5. WARNING:
stabilization. impairment; acute maintain pts
narrow glaucoma; receiving parenteral
pregnancy & lactation. benzodiazepines in
Rout bed for 3 hrs; do
Onset Peak Duration
e Side Effects: fatigue, not permit
drowsiness, sedation, ataxia, ambulatory
vertigo, confusion, 6. Monitor EEG in pts
PO 15-60min 30-90min up to 24hr
depression, GI disturbances, treated for status
changes in salivation, epilepticus;
amnesia, jaundice, seizures may recur
I.V. 1-5min 15-30min 15-60min paradoxical excitation, after initial control,
elevated liver enzyme values; presumably bcoz od
muscle weakness, visual short duration of
within disturbances, headache, drug effect.
I.M. 0-5-1.5hr unknown
20min slurring of speech and
dysarthria; mental changes;
incontinence, constipation;
hypotension, tachycardia;
changes in libido; pain and
thrombophlebitis at Inj site
(IV).

CEFTRIAXONE
Brand Name: Rocephin Indication: Nursing Consideration/
-Infections caused by Intervention
Generic Name: Ceftriaxone susceptible organisms in 1. Assess oral
lower respiratory tract, skin cavity for white
Classification: Anti-infective; Antibiotic; Third and skin structures, urinary patches on
generation cephalosporins tract, bones, and joints; also, mucous
intra-abdominal infections, membranes,
pelvic inflammatory disease, tongue (trush).
uncomplicated gonorrhea, 2. Monitor daily
meningitis, and surgical pattern of
prophylaxis bowel activity,
stool
Action: Semisynthetic third generation Contraindication: consistency.
cephalosporin antibiotic. Preferentially binds to - Hypersensitivity to Mild GI effects
one or more of the penicillin-binding proteins drug may be
(PBP) located on cell walls of susceptible tolerable
organisms. This inhibits third and final stage of (increasing
bacterial cell wall synthesis, thus killing the severitymay
bacterium. indicate onset
Rout of antibiotic-
Onset Peak Duration
e Side Effects: oral associated
candidiasis (thrush), mild colitis)
diarrhea, mild abdominal 3. Monitor I&O,
cramping, vaginal renal function,
Immediat candidiasis. Occasional: vomiting,
IV Immediate unknown
e Nausea, serum sickness– diarrhea,
like reaction (fever, joint anal/genital
pain; usually occurs after pruritus, oral
second course of therapy mucosal
and resolves after drug is changes,
discontinued). Rare: Allergic (ulceration,
IM unknown 2-3hr unknown reaction (rash, pruritus, pain,
urticaria), thrombophlebitis erythema).
(pain, redness, swelling at
injection site).

FOCUS/DATA/ACTION/RESPONSE
(FDAR)
DATE & TIME FOCUS DATA/ACTION/RESPONSE

D- Patient started crying

June 26, 2023 Promote Comfort upon interaction with
student nurse. With IVF of
D50.3NaCl to run for
30cc/hour. With history of 2
seizure activity prior to
admission. Patient agitated
and irritable.
A- Nursing rounds done.
Introducing oneself done.
Giving explanation before
any procedures. IVF
checked and regulated. Vital
signs taken and recorded.
Due medications given.
R- Patient Afebrile.
(seizure). Vital signs within
normal limits.

DATE & TIME FOCUS DATA/ACTION/RESPONSE

 D- Patient with IVF of
D50.3NaCl to run for
June 27, 2023 Risk for fall 30cc/hr. Afebrile. (-) seizure.
Seen and evaluated by Dr.
Ontulan.
A- Nursing rounds done.
Due meds given. IVF
checked and regulated. Vital
signs taken. Needs
attended to. Ensured
Bedside rails are raised.
R- patient free from fall and
injury. Vital signs within
normal limits. Endorsed.

DATE & TIME FOCUS DATA/ACTION/RESPONSE

D- Patient’s admitting
diagnosis was seizure
disorder. With history of
head trauma last two
months ago. Vital signs are
within normal limits. Temp:
36.4, HR: 140, RR: 50,
SPO2: 98. (-) seizure noted
on endorsement. With IV of
D50.3 NaCl to run for
Safety 30cc/hour.
June 28, 2023
A- Patency of IV site and
8:00 am
fluid checked and regulated.
Vital signs taken. Due
medications given. Safety
precautions ensured.
R- (-) seizure, (-) fall,
afebrile, patient’s vitals
within normal limits. An
order of may go home was
indicated in the client’s
chart.
 NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING/GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Within 4-8 hours
Date: June 26, of nursing 1. Establish rapport 1. The easiest way and After 4-8 hours of
2023 Comfort intervention the and trust by being foremost action the nursing intervention the
Subjective: impaired client will be able kind and gentle, nurse can take with goal was PARTIALLY
“nahadlok ni siya related to the to: introducing patients is to be kind MET as evidenced by:
ma’am, sa inyo, presence of 1. Appear oneself. and do introductions. 1. Minimal crying
parehas man sa a healthcare calm and 2. Explain Smiling, using a during vital sign
nauna sa inyo, mu provider relaxed with procedures and warm gentle tone. taking.
gd ni siya”, as (student vital signs care before Patients need to feel
verbalized by the nurse) as within implementing. safe to feel 2. Vital signs are
mother of the evidenced by normal comfortable. still within
infant. persistent limits. 3. Suggest parents 2. Patients are often at normal limits.
- Child began crying. 2. Participate be present during the mercy of others Temp: 36.2
crying in desirable procedures. and can feel RR: 40
loudly as and health vulnerable when sick HR: 137
soon as I seeking 4. Provide age- and hospitalized. The SPO2: 98
approached behavior appropriate nurse should always
. with help of comfort measures explain everything
the (presence of they do before they
Objective: significant gentle touch, do it. Explain the
- Persistent other/paren change of position, steps of starting an
crying t offering distraction, IV, obtaining vital
- Irritable etc.) signs, or how a
- Sweaty medication might
- Clingy to 5. Offer relaxation make them feel. This
the mother and calming drastically decreases
Vital Signs techniques to the fear and discomfort
Temp: 36.4 significant other. when a patient knows
HR: 140 what to expect.
RR: 50 6. Administer 3. The presence of
 medications to parents gives the
ease comfort. child a sense of
assurance and
comfort.
4. To provide non-
pharmacological pain
management.
5. A patient feeling
irritated and
overwhelmed or
SPO2: 98
anxious needs a
calming voice to
remind them they are
safe.
6. Pain medications,
antiemetics, and
antianxiety
medications are
necessary to
increase comfort and
improve rest and
healing.

ASSESSMENT NURSING PLANNING/GOAL INTERVENTION RATIONALE EVALUATION

 DIAGNOSIS

Date: June 27, Risk for fall After 4 -8 hours of  Note child’s  Acute/short Within 4-8 hours
2023 related to history nursing current term situations of nursing
Subjective: of seizure. intervention the disorder/conditio can affect any intervention the
“naga convulsion client will be able n that could child. These goal was FULLY
abi ni siya ma’am, to: increase potential can include MET, as
tung before siya for falls. cognitive issues evidenced by the
na admit ka duha 1. Be free and others not child being free
gd siya nag from fall. limited to critical from fall and injury
convulsion”, as 2. Be free illness or injury as noted.
verbalized by the from injury. or chronic
Childs’ mother. diseases.
 Assess the  Determining
Objective: child’s needs and
- Patient environment for deficits could
irritable structural provide
- Minimal concerns or the opportunities for
crying presence of environmental
equipment that redesign and
Vital Signs: could potentiate instruction.
Temp: 37.0 a fall.  To improve the
HR: 140  Collaborate in child’s overall
RR: 55 treatment of health thereby
SPO2: 98 disease or reduce potential
condition (acute for falls.
illness,
neurological or
musculoskeletal
conditions, etc.)
 Teach parents or  These
family about measures are
safety and how to necessary to
 prevent accidents keep a child in
by raising the a confirmed
bedside rails, area and
never leaving the prevent falls
child unattended and accidents.
and safe lifts the
child etc.
 Avoid use of  To prevent
restraints excessive
agitation and
struggling.

NURSING
ASSESSMENT DIAGNOSI PLANNING/GOAL INTERVENTION RATIONALE EVALUATION
S

Date: June 28, Within 4-8 hours  Assess and record seizure  Documentation of After 4-8 hours of
2023 Risk for of nursing activity and location. Note the information is nursing intervention
Injury intervention the duration of seizures, parts of essential for the the goal was
Subjective: related to a client will be free the body involved, and site of prevention of injury FULLY MET as
Objective: diagnosis of from injury when onset and progression of or complications evidenced by the
- Irritable seizure seizure episode seizure. because of a patient being free
behavior disorder. reoccurs.  Assess skin for pallor, seizure. from any injury and
- Bedside flushing, or cyanosis; Monitor vital signs within
rails not respiratory rate, depth, and normal limits thus
raised. signs of respiratory distress. (-) seizure.
 Once seizures are
Vital Signs:  Maintain side-lying position; prolonged and
Temp: 36.8 Keep padded side rails up respiration is
RR: 48 with the bed in the lowest compromised, this
HR: 140 position and removed any will provide
SPO2: 97 clutter from the child. information on
possible signs of
 aspiration of
 Instruct parents to avoid secretion.
restraining the child or putting  Side-lying position
anything in his/her mouth; facilitates drainage
provide gentle support to the of secretions and
head and arms if harm might maintain airway
result. patency. Padding
protects a child
 Stay with the child during the from injury during a
phase of seizures, reorient seizure.
when awake, and allow to rest  Restraining a child
or sleep after an episode. can result in
trauma due to the
amount of force
exerted; inserting
an object in the
mouth increases
stimuli; Padding the
area helps to
protect the head
from injury.
 Provides support
and prevents any
injury to the child.