Patient Nursing Round in English at IMC 2D Ward
September17, 2014 at 14.30 -15.30 pm.
Today I am going to present a case: A Thai boy 1 year old. He was admitted on August 8, 2014. His
diagnosis was Lennox-Gastaut Syndrome.
Chief complaint: Increased seizures 3 days before admission
Present illness : Known case Lennox-Gastaut syndrome diagnosed in June 2014 from EEG results
showed as generalized slow-spike wave, 1-2Hz frequency , brief tonic + myoclonic + absence,
and
increased seizures.
Before admission , he had seizures which presented with closed left eye, atilt neck, muscle
rigidity lasting 5 seconds to 2 minutes then listless. He had more than 10 seizures per day. Parents took
him to the hospital.
At AE, he had 4 seizures and he was got Valium 3mg IV once to control seizures. He was then
admitted to 2D ward. He still had uncontrolled seizures and was found to be RSV (Respiratory syncytial
virus) positive. Therefore the pediatrician considered moving him to IMC for isolation.
At IMC2D, he has received oxygen by cannula at 2 LPM . His RR was 34- 42 /min, O2 sat 95100 % BT 36.5 – 37.6oC, retained NG for feeding IF 180 x 6 feedings . If he had a seizure for more
than 5 minutes, Valium and Midasolam would be given to the patient IV push.
It was difficult to open veins so the pediatricians had performed central line on September 10.
He still has some problems, and we have set the nursing diagnoses and interventions, as follows;
Nursing Diagnoses
1. Risk for hypoxia related to seizures
2. Risk for injury related to uncontrolled seizure activity
3. Risk for Infection related to having central line
4. Parent are anxious related to patient’s illness.
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Nursing Diagnoses
1. Risk for hypoxia related to seizures
S: O: U/D Lennox-Gastaut syndrome Diagnosis in
June 2014 (EEG: Generalized slow-spike
wave,1-2Hz frequency , Brief tonic + myoclonic
+ absence, increase seizure )
- Uncontrolled seizures
- The latest seizure was more than 5 minutes ,
Valium 3 mg / Midazolam 1 mg IV push were
given.
Expected Outcome
- SpO2 ≥ 92%
- Regular respiratory rate/pattern
Intervention
1. Health assessment frame work (head to feet);
A= Airway (check breath sounds, movements of chest)
B= Breathing (observe chest movements, color;
peripheral cyanosis. central cyanosis)
C= Circulation (vital signs; rate, rhythm, intensity)
D= Disability/consciousness (alert, drowsy, stupor,
semiconscious & coma)
E= Exposure; check environment and equipment.
2. Observe vital signs such as respiratory rate, heart
rate, blood pressure & SpO2 Pediatric Glasgow Coma
Scale (GCS ) such as consciousness, pupil, and motor
power every 2 hr.
( C= Circulation)
3. Clear airway suction prn. (B= Breathing)
4. Maintain clean and comfortable environment and
equipment for rest. (E= Exposure)
5. Observe clinical signs of hypoxia , such as
- Cyanosis (skin appearing bluish due to
insufficient oxygen)
- Cheyne-Stokes respirations (irregular pattern
of breathing)
- Elevated blood pressure
- Apnea (temporary cessation of breathing)
- Tachycardia (increased heart rate, more than
100 per minute)
- Hypotension (abnormally low blood pressure )
- Coma
6. Notify of any signs of changes in patient’s
neurological condition to doctor.
7. If he has seizures for more than 5 minutes, give
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Valium 3 mg / Midazolam 1 mg IV push.
8. Consult respiratory therapist for chest
physiotherapy.
9 .Provide anti-convulsive as order, such as;
Lamictal (100) 125 mg oral bid pc
Topamax (50 )1 tab oral bid pc
Dilantin 4o mg oral bid pc
Phenobarb 25 mg oral bid pc
Keppra <500> 400 mg oral bid pc
10. Observe side effects from seizure medicines :
dizziness, somnolence, headache, double vision,
blurred vision, nausea, vomiting and rash etc.
2. Risk for injury related to uncontrolled
seizure activity
S: O: Reduced level of consciousness
Expected Outcome
- no physical injury to the patients
- patients is in a safe condition,
- no bruises
-no falls
- no aspiration
1.Identification of environmental factors that
allow risk of injury
2. Monitor neurological status every 2 hours
3. Keep objects that could cause injury to the
patient during a seizure.
4. Install a barrier on the patient's bed.
5. Place the patient in a low and flat position.
6. Provide anti-convulsive per your doctor's
orders.
Lamictal (100) 125 mg oral bid pc
Topamax (50 )1 tab oral bid pc
Dilantin 40 mg oral bid pc
Phenobarb 25 mg oral bid pc
Keppra (500) 400 mg oral bid pc.
7. Observe side effects from seizure medicines :
dizziness, somnolence, headache, double vision,
blurred vision, nausea, vomiting and rash etc.
8. Ask parents to report any prodromal sign of
seizures, any unusual activity or if the child feels
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uncomfortable.
9. Provide information to the family about what to
do during the patient's seizures.
10.Aspirate precautions
- Check placement of NG / residuals before
feeding.
- Position with head of bed elevated 30 to 45°.
- Maintain upright position for 30 to 45 minutes
after feeding.
11. When a seizure occurs, observe and document
the following:
- date
- time of onset
- duration
- activity at time of onset
- level of consciousness (confused, dazed,
excited, unconscious)
- movements, type of motor activity
- respirations (impaired/absent, rhythm and
rate)
- heart rate and rhythm
- skin changes
- pupil size, symmetry, and reaction to light
12. Provide oxygen and suctioning as needed
3. Risk for Infection related to having
central line
S: O: Pediatricians has performed central line on
September 10.
- He had a fever BT 38.5 °C on September 11,
2014.
1. Demonstrate/ encourage good hand washing
technique.
2. Observe vital signs every 2 hr. especially
temperature.
3. Maintain clean environment and equipment.
4. Use separate devices for each patient.
5. Observe clinical signs of infection, such as;
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Expected Outcomes
- Patient remains free of infection, as evidenced
by normal vital signs ,normal skin around the
exit site
- Infection is recognized early to allow for
prompt treatment.
- Hyperthermia (temperature >37.5 C); flushed
skin, agitation, sweating, crying etc.
- Hypothermia (temperature < 36.5 C); cold
extremities, cyanosis, drowsiness, apnea etc.
6. Dressing central line follow Preventing Central
Line-Associated Bloodstream Infections Guidelines.
7. Observe skin around the exit site.
4. Parent are anxious related to patient’s
illness.
S: Mother said that she has only one child and
she is too old to have another child. She is
anxious about the baby’s illness.
O: Expected Outcomes
- Able to recognize signs of anxiety.
- Demonstrates positive coping mechanisms.
- Parents may describe a reduction in the level of
anxiety experienced.
- Verbalizes or manifests a reduction or absence
of anxiety.
1. Assess level of anxiety and determine how parents
cope with anxiety.
2. Provide friendly and professional care.
3. Encourage verbalization of concerns.
4. Make appointments for doctor to speak with family
to give information.
5. Express empathy.
6. Encourage parents to participate in caring.
Are there any questions or any suggestions? Please
Thank you very much.