Question

S.S is an 11 month old that was crawling when he "just stiffened. Collapsed on the floor on his tummy an then his tummy an then his arms and legs started to shaking for 2minutes. We tried to talk to him, "but he acted out of it". Parents report that S.S has been having a runny nose and today started to have a fever. No vomiting or diarrhea. VS 101.2 HR146 Resp 42 B/P 94/64. S.S appears drowsy but awaken when touched. All CN intact. On atrophy, on weakness or tremors.

A. Objective Data

B. Subjective Data

C. What is your analysis of this Patient?

D. What type of problem Focus Assessment would you do?

E. What type of Seizure did S.S have?

F. Give 3 Nursing Diagnosis

G. Give 3 Nursing Interventions

H. Critical thinking (Give 3 question outside the box)

I. Write a brief detail Nursing Note about this patient.

Answer 1

A. Objective data;

- Child had fever more than 101F, tachycardia and tachpnoea.

- Child had tremors for only 2 minutes

- No CNS related problems

- His developmental milestones were good, since he was crawling in 11 months, which is expected.

- CN are intact

- Baby was alright before the seizure episode.

B. Subjective data are;

- Parents said that child had fever,suddenly collspsed and tremors only for 2 minutes

- Baby awoke immediately after 1 episode of tremor

C. Analysis of patient

Patient is a baby of normal developmental stage and without any neurological deficit. Baby had a high fever and associated with seizures.

D. Problem focused assessment includes;

- Neurological assessment including reflexes, cranial nerve assessment.

- check the pupil

- monitor changes on BP.

- Assessment to check any physical injury.

E. Baby had a febrile seizure which is associated with high fever.

F. Nursing Diagnosis

1. Hyperthermia related to infection as evidenced by high temperature.

2. Impaired tissue perfusion related to hypoxia as evidence by tachcardia and tachpnoea, and weakness.

3. Risk for injury related to possible convulsion.

G. Nursing interventions

1. Provide tepid sponge

2. Administer supplemental oxygen.

3. Monitor temperature frequently to check any rise in temperature.

H. 1. Does the febrile seizures are preventable

2. Is there any possibility of neurological impairement

3. Does the child require any chronic antiepileptic therapy

I. The patient was admitted with debrile seizures as reported by parents. Patient had higg fever and tepid sponging and emergency management is done. Presently the patient is stable.