JacksonWeberVSIMworksheetFINAL.pdf - CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS A

JacksonWeberVSIMworksheetFINAL.pdf - CONCEPT MAP WORKSHEET...

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Unformatted text preview: CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) A generalized tonic-clonic seizure, formerly known as grand mal seizure, is defined as a seizure that has a tonic phase followed by clonic muscle contractions. Among patients, families, and observers, they are most feared of seizure types. They are usually associated with impaired awareness or complete loss of consciousness. According to the recent classification from the International League Against Epilepsy (ILAE), they are categorized under seizures belonging to generalized in onset. Generalized onset seizures are further categorized into motor and non-motor (absence) seizures. A generalized tonic-clonic seizure is a motor seizure and the most common type seen in patients with epilepsy. Generalized tonic-clonic seizures arise within and rapidly involve bilateral cortical, subcortical, and brainstem networks of the brain.A focal seizure-originating from either left or right hemisphere - can rapidly spread and evolve into a bilateral tonic-clonic seizure (previously known as a secondary generalized seizure), which can be difficult to differentiate from a primary generalized tonic-clonic seizure. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) *EEG --> records electrical activity in order to identify the origin of the seizure *MRI --> to determine any brain abnormalities that may have caused the seizure CT scan --> detects brain malformation that may have caused the seizure; can determine extent of trauma if trauma occurred with the seizure General labs and chemistry panel --> will determine if an infection is the underlying cause of the seizure PATIENT INFORMATION Jackson Weber is a 5 year old Caucasian male. He was diagnosed with generalized tonic-clonic seizures 2 years ago. He has been taking oral phenobarbital as prescribed by his neurologist since he was diagnosed. Due to his seizure diagnosis today, my initial assessment focused on his neurological status, including his eye movements, pupil reaction, and orientation. These were all normal upon assessment. ANTICIPATED PHYSICAL FINDINGS The first sign of a tonic-clonic seizure is that a child cries out or groans loudly, then falls down. The child may lose consciousness at this point or later in the seizure. In the tonic phase of the seizure, the child becomes rigid, their teeth clench, they may stop breathing and turn blue, and saliva or foam may drip from their mouth. Their heart rate and blood pressure rise and they may sweat or tremble. In the clonic phase of the seizure, the child’s arms and legs jerk quickly and ANTICIPATED NURSING INTERVENTIONSrhythmically; their pupils contract and dilate. At the end of this phase, the child relaxes and may lose control of their bowel or bladder. Before the seizure even occurs, the patient should be placed on seizure precautions. This would include padded side rails, having the bed in the lowest position, removing restrictive clothing, and help with activities as walking going to the Aftersuch the seizure, the or child regains bathroom. Once the seizure begins, the nurse should immediately record the time and start of the seizure. The They nurse may should then consciousness slowly. seem call for help, lower the patient to the ground and prevent any physical injury, and then place theconfused, patient onanxious his sideortodepressed. prevent sleepy, any airway complications. Next steps would include placing the patient on the appropriate of oxygen, liters of Thislevel post-ictal phasewhether may last2 for nasal cannula or 10 liters on a non-rebreather mask. The nurse can then expect to administer medications to prevent future several hours. seizures such as phenoarbital like in this scenario. Finally, once the seizure has ended, call the provider reporting the findings in an SBAR format, follow any orders from the provider, and then monitor for any more seiures. vSim ISBAR ACTIVITY INTRODUCTION Your name, position (RN), unit you are working on SITUATION Patient’s name, age, specific reason for visit BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs STUDENT WORKSHEET Peter Rantz RN Pediatric Unit/ER Jackson Weber 5 year old Caucasian male 3 minute tonic-clonic seizure last night Generalized tonic-clonic seizure 5/26/2020 (today) Current orders are cardiac apnea monitor, continuous pulse oximetry, titrate O2 per nasal cannula to keep SpO2 > 93% while awake Phenobarbital 300mg IV loading dose Phenobarbital level x 1 after loading dose Oral 15 mg of Phenobarbital to be taken every 12 hours Basic metabolic panel x 1 Vital signs every two hours Neuro checks every two hours NPO, D5 1/2NS +alert 20 mEq @58 Patient is initially and KCl/L oriented. NomL/hr obvious airway obstruction. Chest moving equally. Normal elasticity of the skin. Color is normal, not sweating. Breath sounds are clear and equal bilaterally. Regular heart sounds without murmurs. Normal neurological findings, including PERRLA and good eye movment. Post-seizure vital signs --> Child status - ECG: Sinus rhythm. Heart rate: 117. Pulse: Present. Blood pressure: 130/88 mmHg. Respiration: 4. Conscious state: Unconscious. SpO2: 89%. Temp: 36.7 C RECOMMENDATION Any orders or recommendations you mayhave for this patient Continue to keep the patient on seizure precautions and continue to monitor vital signs and neurological status. Administer any seizure medications in appropriate doses and time frame. Educate the patient and the parents appropriately. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Phenoarbital CLASSIFICATION: 1. Barbiturate; anticonvulsant; sedative-hypnotic PROTOTYPE: 1.Phenobarbital SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1. 3 to 5 mg/kg/day in 1 to 2 divided doses. PURPOSE FOR TAKING THIS MEDICATION Phenobarbital is a barbiturate, nonselective central nervous system depressant which is primarily used as a sedative hypnotic and also as an anticonvulsant in subhypnotic doses. Phenobarbital Tablets and Elixir are administered orally and are contained in DEA Schedule IV. Barbiturates are substituted pyrimidine derivatives in which the basic structure common to these drugs is barbituric acid, a substance which has no central nervous system (CNS) activity. CNS activity is obtained by substituting alkyl, alkenyl, or aryl groups on the pyrimidine ring. Phenobarbital is used to control seizures. Phenobarbital is also used to relieve anxiety. It is also used to prevent withdrawal symptoms in people who are dependent ('addicted'; feel a need to continue taking the medication) on another barbiturate medication and are going to stop taking the medication. Phenobarbital is in a class of medications called barbiturates. It works by slowing activity in the brain. PATIENT EDUCATION WHILE TAKING THIS MEDICATION Phenobarbital may be habit-forming. Never share phenobarbital with another person, especially someone with a history of drug abuse or addiction. Keep the medication in a place where others cannot get to it. Selling or giving away this medicine is against the law. Do not change your phenobarbital dose without your doctor's advice. Tell your doctor if the medicine does not seem to work as well in treating your condition. If you are taking phenobarbital to treat seizures, keep taking the medicine even if you feel fine. Do not stop using suddenly after long-term use, or you could have unpleasant withdrawal symptoms. Ask your doctor how to safely stop using phenobarbital. Store at room temperature away from moisture, heat, and light. Keep track of the amount of medicine used from each new bottle. Phenobarbital is a drug of abuse and you should be aware if anyone is using your medicine improperly or without a prescription. What happens if I miss a dose? Take the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not take extra medicine to make up the missed dose. Date: 5/26/2020 Initials: JW Age: 5 years old M/F: Male Code Status: Full code Student Name: Peter Rantz Diagnosis: General tonic-clonic seizure HCP: PCP Length of Stay: today Consults: N/A Allergies: NKA Clinical Worksheet Assigned vSim: Isolation: None Fall Risk: Yes Transfer: N/A Jackson Weber IV Type: Location: Left arm Fluid/Rate: Potassium Chloride in 5% dextrose/58 mL/hr Critical Labs: Hemoglobin: 12.2g/dL Hematocrit: 35% Clorine : 97mEq/L HCO3: 28mEq/L Other Services: Neurologist Consults Needed: Neurologist Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Patient was admitted after suffering from a 3 minute tonic-clonic seizure last night. Patient had another seizure episode while in the hospital today. Health History/Comorbities (that relate to this hospitalization): History of tonic-clonic seizures Shift Goals/ Patient Education Needs: 1. Administer phenoarbital when Jackson is alert and able to swallow to manage seizures during hospital visit 2. Monitor patient's neurological status and vital signs for any recurring seizures 3. Educate Jackson and his mother about seizures, in regards to medication regimen, maintain neurologist appointments, and what to do during seizures going forward 4. Establish another appointment with Jackson's neurologist or provide resources so he can see one after being discharged Path to Discharge: Jackson is stable and neurological status remains normal. He has not had any more seizures. His mother and him are now well educated on the importance of his medication regimen and the interventions for during a seizure, and will reconnect with Jackson's neurologist after being discharged. Path to Death or Injury: Jackson continues to have tonic-clonic seizures and may suffer some form of physical head trauma. Also, recurring seizures can result in status epileptics which has life-threatening complications. Alerts: What are you on alert for with this patient? (Signs & Symptoms) Clinical Worksheet Management of Care: What needs to be done for this Patient Today? 1. 1. 2. 2. 3. 3. 4. What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 5. 1. 6. 2. Priorities for Managing the Patient’s Care Today 1. 3. 2. 3. List Complications may occur related to dx, procedure, comorbidities: 4. 1. 2. 3. What nursing or medical interventions may prevent the above Alert or complications? 1. 2. 3. 4. What aspects of the patient care can be Delegated and who can do it? ...
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