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Day of hospitalization:
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
Lumbar Puncture
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.
Why abnormal?
Medication, how is it
related to lab results
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
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
361.67mL/8hr=45.21mL/hr
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)
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
Safe
Y/N
Why is patient
receiving?
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.
Antipyretic,
antirheumatic,
nonopioid
analgesic, nonsteroidal antiinflammatory agent
Simethicone
Antiflatulent
D5W NSS
1000mL
Mineral and
electrolyte
replacement
Keppra
1,2
Anticonvulsant
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
PERRLA
Swallow
Treatment of seizures.
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
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
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
GI
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
Ct. Initials
Age:
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
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
A Dysfunction family processes R/T history of abuse
Basic Structure/Central
Normal
line of defense
Core
Lines ofline
Flexible
line
Resistance
ofdefense
defense
Normal
of
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:
Mother verbalized
understanding of fall
safety and read over the
material given to her.
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:
Complete a neurologic
check on the patient every 4
hours.
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:
Mother agreed on
starting the patient in
swimming class.
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:
Regular attendance at a group can provide support; help client see how others
Are dealing with similar problems; and
learn new skills.
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.