Nursing care plan

On
Epilepsy

Submitted To : Ms. Sarita Lecturer College of Nursing ILBS

Submitted On : 10/06/2017
Submitted By : Divyanshi, Msc. Nursing 1st year

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HISTORY OF THE CLIENT

1. CLIENT PROFILE
Name : Ms. Gauri
Age : 16 years
Sex : Female
Education : None
Mother tongue : Hindi
Religion : Hindu
Address : Uttar pradesh
Ward : Neuro ICU
CR.NO : 383641
Diagnosis : Epilepsy
Date of admission : 23-05-2017
Surgery Proposed : No surgery

CHIEF COMPLAINTS AT THE TIME OF ADMISSION: Patient came to GB Panth emergency with Chief complaint of :

 vomiting since 1 day

 loss of consciousness since 1 day
 loss of speech since 1 day
 right side weakness since 1 day

PRESENT MEDICAL HISTORY: Patient came to emergency with chief complaint of seizure, vomiting loss of speech and
weakness of right side when doctor examined then then they found that patient had aspirated then they intubated the patient in
emergency and patient shifted to neurological ICU and patient is on medication diazepam, clonzepam.

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  Initially seizures was afebrile gernalized tonic clonic seizure. Seminolgy changed after few months head and eye deviation to
left side, dystonic position of left upper and lower limb and jerking of eye lasting for 30-40 second and then patient confused
for 2-4 hours.

PRESENT SURGICAL HISTORY: No past surgical history.

PAST MEDICAL HISTORY

Patient diagnosed with epilepsy in 2007 for that he took treatment in Lok Nayak hospital and patient took continuous medication and
patient recover.

PAST SURGICAL HISTORY : There is no past surgical history.

SOCIO ECONOMIC HISTORY

 Mr. Pankaj is the bread winner of the family. Mr. Pankaj is farmer.
 Patient is having nuclear family. Patient belong to middle class family. Patient monthly income is 5,000/ month. Patient is
having his own house, located in the rural area.

Primary facilities like

 Water : municipality
 Electricity : available
 Ventilation : satisfactory
 Latrine : well
 Method of waste disposal : Municipality

FAMILY HISTORY
a. Family Tree:

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 Mr. Pankaj 40 years healthy Ms. Rubi 38 years healthy

Shruti 11years healthy Versa 14 years Epilepsy Rajat 7 years healthy

8th class No formal education 2nd class

PERSONAL HISTORY

 The patient did not have any habits of alcohol, smoking, tobacco, drugs, caffeine, any other.
 Patient has normal sleep patterns. He sleeps for 6 to 8 hours.
 Patient is a non-vegetarian.
 Patient has regular bowel and bladder patterns.

BIRTH HISTORY

 Patient’s mother had a normal Vaginal delivery .

 Patient is completely immunized and vaccinated but patient is having delayed milestone.
 History of illness and hospitalization in the childhhod.

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 PHYSICAL EXAMINATION

1. GENERAL APPEARANCE
 Body Built : Moderate
 Posture : Erect
 Gait : Not able to seen.

2. MENTAL STATUS
 Consciousness : Unconscious.
 Orientation : Not Oriented to time, place, person
 Speech : Patient is having ET tube
 Level of Co-operation : Patient is unconscious.
3. ANTHROPOMETRIC MEASUREMENT
 Height : 140.5cm
 Weight : 42 kg
 BMI : 21.66

VITAL SIGNS

S.no. Vitals 6-06-17

1 Temperature 98.6F
2 Pulse 98/min
3 Blood pressure 131/60mmhg
4 Respiration 18b/min

SKIN

 Color : Fair

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  Turgor : Poor
 Moisture : Dryness
 Temperature : Warm
 Texture : Soft
 Lesion : No lesion
 Edema : No edema
 Vascularity : Red

HEAD

 Hair color : White

 Distribution : Equal
 Texture : Dry
 Scalp : Clean

EYES

 Conjunctiva : Clear
 Sclera : Pale
 Cornea : Clear
 Lens : Brown lens
 Eye Lids :Symmetrical
 Eye Balls :Normal
 Eye Brows :Symmetric
 Reaction to Light :PERRLA
 Reflexes : Normal

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 EARS
 Position : Symmetrical
 Lesions : Absent
 Patency : Patent
 Sinuses : Normal
 Sense of Smell : Normal

MOUTH

Odor : Dryness

Lips:

 Color : pink

Teeth:

 Number of teeth : 30
 Color : White
 Dental Caries : Absent
 Dentures : Absent

Gums:

 Color : Pink
 Lesion : Absent

Tongue:

 Color : Pink

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  Moisture : Moist
 Tongue Tie : Absent
 Tongue Sensation : Present

Oral Cavity

 Color : Pink
 Lesion : Absent
 Infection : Absent

THROAT

 Signs of Infection : Absent

 Tenderness : Absent
 Sore Throat : Absent
 Tonsils : Absent

 Gag Reflex : Absent

 Phonation : Clear

NECK

 Lymph Nodes : Normal

 ROM : Normal
 Trachea : Midline
 Thyroid : Non-palpable

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CHEST

BREAST
 Symmetry : Symmetrical
 Color : Normal skin color
 Lesions : Not present
 Areola : Size equal
 Nipple : Normal
 Discharge : Not present
 Abnormalities : No lump/No mass

AXILLA

 Redness : Absent
 Lumps : Absent
 Rash :Absent
 Lymph Nodes Enlarged : Absent

4. RESPIRATORY SYSTEM
 Inspection : Symmetrical
 Barrel Chest : Absent
 Kyphoscoliosis : Absent
 Breathing Pattern : 18 breaths/min
 Palpation : No tenderness/No mass
 Tactile Fremitus : Normal
 Percussion : Dull
 Air Entry : Equal and Normal

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CARDIOVASCULAR SYSTEM

 Inspection & Palpation : Vibratory sensation present

 Auscultation : S1, S2 Normal
 Heart Rate : 118 betas / min
 Pain : Absent

ABDOMEN

Inspection

Contour : rounded

Colour and lusture : normal

Umbilicus : center

Visible pulsation :Absent

Fullness of flanks : absent

Hernias : present

Lesion : absent

Abdominal pain : present

Auscultation

Bowel sounds : present

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 Percussion : tympanic

Palpation :

Mass : no any mass

Tenderness : present

Aorotic pulsation : Absent

Organs : hard

Enlargement of organs : no enlargement

On examination of eye there is paleness present in sclera and patient is having poor skin turgor and and ET tube present in mouth.

Medication :

DRUG NAME DOSE/ ACTION INDICATION CONTRAI SIDE NURSING

ROUTE S NDICATIO EFFECTS RESPONSIBILI
FREQUEN NS TIES
CY

Tablet lemotrigime Intravenous It enhances  Seizure Hypersensitivit Neuromuscular Monitor infection

100mg oral GABA  Epilepsy y to drug disorder and site frequently for
 Lennox- Use cautionary ototoxicity phlebitis (pain,
Gastaut with impaired redness, swelling).
syndrome. renal or Change sites every
neuromuscular 48- 72 hr to
disorder prevent phlebitis.

Advise patient to

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 report signs of
superinfections
and allergy.

Evaluate patient’s
hearing beforeand
during therapy
Notify prescriber if
patients has
tinnitus, vertigo, or
hearing loss
Injection metrogyl Intravenous Hinder Ameobic hepatic Hyper Dizziness assess pts.
Generic name 100ml IV TDS growth of abscess sensitivity headache Infection
Metronidazole selected Intestinal first trimester Abdominal pain >watch carefully
microorganis ameobasis of pregnancy vomiting diarrhea for edema because
m including To prevent Give Leukopenia itmay cause
anaerobic postoperative precautionary Phlebitis at the sodium retention
bacteria and infection in in pregnancy local site >assess skin for
antibiotic colorectal and children periphery severity areas of
surgeries neuropathy localadverse
Pelvic reactions
inflammatory >record number
disease and character
In my patient of stools
To prevent >assess pt’s and
postoperative family’s
infection knowledge of drug
therapy
Tablet Levra 750mg 1 tablet Blocks Partial seizure Uncompensate fatigue, weakness,  Instruct patient to
stimulation d HF anxiety dizziness, take medication as
of beta drowsiness, directed.
adrenergic Pulmonary insomnia, memory
receptors. edema loss nervousness,  Teach

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 Therapeutic blurred vision, patient and family
Effects: Decr Cardiogenic stuffy how to check pulse
eased BP and shock nose.bronchospas daily and BP
heart rate. m, biweekly and to
Decreased Bradycardia wheezing,BRADY report significant
frequency of CARDIA, HF, PU changes to health
attacks of heart block or LMONARY care professional.
angina sick sinus EDEMA, diarrhea,
pectoris. syndrome drug-induced
Decreased hepatitis, Advise patient to
rate of Cautious use heartburn, urinary change positions
cardiovascul in Renal frequency, slowly to minimize
ar mortality impairment hyperglycemia, orthostatic
and Hepatic hypoglycemia, hypotension.
hospitalizatio impairment arthralgia, back
n in patients Increased pain. Caution patient
with heart sensitivity to that this
failure. beta blockers medication may
initial dose increase sensitivity
reduction to cold.
recommended
Pulmonary
disease
Pantoprazole 40mg IV BD Binds to an Erosive Hypersensitivit headache,abdomin Monitor
enzyme in esophagitis y to al pain, diarrhea, bowel function.
the presence associated with rabeprazole or eructation, Diarrhea,
of acidic GERD. related drugs flatulence, abdominal
gastric pH, Maintenance of (benzimidazol hyperglycemia, cramping, fever,
preventing healing of erosive es) hypomagnesemia, and bloody stools
the final esophagitis acute interstitial should be reported
transport of Pathologic gastric nephritis, vitamin to health care
hydrogen hypersecretory B12deficiency, professional
ions into the conditions. bone fracture. promptly as a sign

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gastric of Clostridium
lumen. difficile-associated
diarrhea (CDAD).
Therapeutic May begin up to
Effects: Dimi several weeks
nished following
accumulation cessation of
of acid in the therapy.
gastric
lumen, with
lessened acid  Instruct patient
reflux. to take medication
Healing of as directed for the
duodenal full course of
ulcers and therapy, even if
esophagitis. feeling better.
Decreased  Advise patient
acid to avoid alcohol,
secretion in products
hypersecreto containing aspirin
ry or NSAIDs, and
conditions. foods that may
cause an increase
in GI irritation.
 Advise patient
to report onset of
black, tarry stools;
diarrhea; or
abdominal pain to
health care
professional
promptly. Instruct
patient to notify

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 health care
professional
immediately if
rash, diarrhea,
abdominal
cramping, fever, or
bloody stools
occur and not to
treat with
antidiarrheal
without consulting
health care
professional.
Tab Shelcal Orally 1 tab Neutralizing Bones weakening, Hypercalcemia Headache,Loss of Monitor
BD acids thus Dietary kidney appetite,Nausea,Vo vitals,watch for
relieving supplement, disease, kidney miting,Stomach side
acid reflux; Vitamin D stones, little or ache effects,Encorage
increasing deficiency, Better no stomach patient to take
absorption of absorption, acid \ calcium and
calcium and Acidity, (achlorhydria),  vitamin D rich diet
phosphorus Heartburn and heart disease,
required for other conditions. disease of the
strong bones in my patient pancreas, a
Dietary certain lung
supplement, disease
Calcium (sarcoidosis),
supplement difficulty
absorbing nutri
tion from food
(malabsorption
syndrome).So
me sugar-free
formulations

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 of calcium
may
contain asparta
me. If you
have phenylket
onuria (PKU)
or any other
condition that
requires you to
restrict your
intake of
aspartame (or
phenylalanine)
,
Injection Perfalgan 500mg IV Analgesic- Mild-to-moderate  Severe a]Bloody or black,  Monitor
TDS antipyretic. It pain and hepatic tarry stools vital sign
has moderate-to- impairm b]bloody or of the
analgesic, severe pain with ent or cloudy urine patient
antipyretic adjunctive opioid severe c]fever with or  Monitors
and weak analgesics active without chills (not side effects
anti- indicated for liver present before like cloudy
inflammator reduction of fever disease: treatment and not urine.
y action. The Contrain caused by the
mechanism dicated. condition being
of action is Mild-to- treated)
associated moderate pain in the lower
with hepatic back and/or side
inhibition of impairment (severe and/or
prostaglandi or active sharp)
n synthesis, liver disease: pinpoint red spots
the Use caution; on the skin
predominant a reduced skin rash, hives, or
influence on total daily itching

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 the dose may be
thermoregula warranted
tion center in
the
hypothalamu
s, enhances
heat transfer.
LABORATORY INVESTIGATIONS

S. Investigation 7/6/17
Normal Remarks
No. value
1 Hb 6.8 13-17gm/dl anemia
2 TLC 18,400 5-10thusand Infection
3 Neutrophill 75.2 40-75% Normal
4 Lymphocyte 24 20-45% Normal
5 Monocyte 04 02-10% Normal
6 Eosinophil 1 01-06% Normal
7 Platelet 6,32000 150-400 Thrombocytopenia
8 BU 16 15-40mg/dl Normal
9 S.Cr. 0.2 0.2-1.0mg/dl Normal
10 Na+ 132 135- Hyponateremia
145meqv/l
11 K+ 3.6 3.5- Normal
4.5meqv/l
12 T.Bilurbin 0.3 0.3-1.2mg/dl Normal
13 ALP 230 30-115u/l Normal
14 T.Protein 6.1 6-8gm/dl Normal
15 Albumin 2.6 3.5-5.2gm/dl Hypoalbunemia
RADIOLOGICAL INVESTIGATIONS:

MRI : T2 hyperintense signals B/l basal ganglia likely encepalomaledia with signal alteration in right medial temporal lobe.

ENTERAL AND PARENTERAL ADMINISTRATION:

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The patient is having ryles tube , as patient is on ventilator.

Theory application :

THEORY APPLICATION –Dorothea E. Orem’s Theory

OBJECTIVES

 To assess the patient condition by the various methods explained by the nursing theory
 To identify the needs of the patient
 To demonstrate an effective communication and interaction with the patient.
 To select a theory for the application according to the need of the patient
 To apply the theory to solve the identified problems of the patient
 To evaluate the extent to which the process was fruitful.

Reason for choosing this theory : Dorthea orems had explained the three basic theory : self care theory

Self care deficit theory

Nursing system theory.

This theory explains that some individuals are capable to perform their activities individually and some need guidance or
assistance to perform them on the otherhand some people are totally dependent on others to perform their activities.My
patient comes under wholly compensatory.

Concept used in the theory

Dorthea orems gives gernal theory nursing. Under this theory she gave three sub theories.

1. Self care theory: Under self care theory she describes four major component.

 Self care

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  Self care agency

 Self care requiste or self care need

 Therapeutic self care demands

2. Self care deficit theory : Under self care deficit theory she describes five major component :

 Acting or doing

 Guiding

 Teaching

 Supportive

 Provide conducive environment for current and future element

3. Nursing system : under this she describes three nursing system:

 Wholly compensated

 Partially compensated

 Supportive and educative

Application of theory to the patient scenario :

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 Accomplishes patient’s therapeutic self care
Monitored vitals
Administered IV fluids
Administer medications
Provide ryles tube feeding
Other theories that can be applied Change position every second hourly
Care of endotracheal tube
 King’s goal attainment theory Oral care given
 Henderson’s need theory Suction done
 Interpersonal theory Eye care and skin care given
Nursing care plan Ensured the ventilator tubings are insitu
Assess Diagnosi Plan Intervention Implementa Evaluati
ment s tion on
Ineffectiv To Nurse  Monitor  Monitore Patient
OD: e airway clear action respiratory rate, d airway
Patient Clearenc the depth, and respirato cleared.
is e related airway Compensates for patient’s inability to engage in
effort. ry rate
having to of self-care
 Keep head of continuo
excessiv excessive patient.  Provide bed bath
bed elevated. usly
e secrectio  Provide mouth care
Position on  Provided
secretio n.  Do all self care activities
sides. ventilato
n.  Catheterization done and care given
 Encourage r support
frequent  Kept bed Care given to prevent pressure
repositioning.. of head
Monitor serial elevated
ABGs, pulse  Monitore Supports and protects patient
oximetry, vital d ABG  Prevent injury
capacity every 6th  Keep side rails up
measurements, hourly  Provide psychological support to the
chest x-rays.  Chest patient
 Do Suctioning physioth
Include family members in the patient care

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 of patient. erapy done .
 Suctioning of
patient done.
OD: Imbalanced Maintain  Assess nutritional status and  Nutritionist Nutrition status
Imbalances in nutrition less nutritional weight of the patient. assessed the of patient
nutritional than body status.  Give small, frequent feeds. nutritional status maintained.
studies requirements  Refer to dietitian to provide of the patient
related to diet high in calories and  Inserted Ryles
inability to take simple carbohydrates, low in tube
feed orally. fat, and moderate to high in  Kitchen feed
protein; limit sodium and fluid administered
as necessary. Provide liquid every 2nd hourly.
supplements as indicated.  Provided mouth
care every 6th
hourly.
 Dietitian
prescribed diet
high in calories
and low in fats.
OD: Poor skin Risk for Maintain  Inspect pressure points and  Assessed the skin Skin integrity of
turgor impaired skin skin skin surfaces closely and every 2nd hourly patient
integrity related integrity. routinely.  Changed position maintained.
to poor skin  Gently massage bony every 2nd hourly
turgor as prominences or areas of  Kept linen free
evidenced by continued stress and free of
patient is  Use of emollient lotions and wrinkles
immobile. limiting use of soap for  Provided alpha
bathing may help bed
 reposition on a regular  Provided skin care
schedule. with oil

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  active and passive ROM
exercises as appropriate.
 Recommend elevating lower
extremities
 Keep linens dry and free of
wrinkles.
 Suggest clipping fingernails
short; provide gloves if
indicated.
 Provide perineal care
following urination and bowel
movement
 Use alternating pressure
mattress, egg-crate mattress,
waterbed, sheepskins, as
indicated
OD: Patient is High risk for Prevent  Monitor vital signs.  Assessed the skin Patient prevent
having infection related infection.  Assess skin color and every 2nd hourly from infection.
invasive lines to invasive lines temperature.  Monitored WBC
and tubing. and tubing.  Monitor WBC, Hct and count.
other pertinent laboratory  Adequates feed
records. ... provided to the
 Provide adequate foods patient.
and fluids. ...  Intake and output
 Measure Intake and of patient
Output. measured.
 Maintain aseptic  Aspectic
technique. technique
 Provide catheter care. maintained.
 give antibiotic as  Catheter care
prescribed. given to the
patient.

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  Antibiotic given
as prescribed.

OD: Statement Deficient Provide  Review disease process and  Assess the disease Family member
of knowledge knowledge prognosis and future condition and is able to
misconception related to to family expectations. prognosis. participate in
from family unfamiliarity members.  Refer to dietitian or  Encouraged care
members. with information nutritionist. patient to
resources as  Inform patient of altered verbalize the
manifested by effects of medications and doubt.
continuously importance of using only  Clarified doubt.
asking questions drugs prescribed or cleared by  Encouraged
a healthcare provider who is scheduling
familiar with patient’s history. activities with
 Assist family members adequate rest
identifying support person. period.
 Emphasize the importance of  Promote
good nutrition. diversional
 Recommend avoidance of activities.
high-protein/salty foods,  Provided spiritual,
onions, and strong cheeses. Psychological
 Provide written dietary support.
instructions.  Educated the
 Stress necessity of follow-up family member
care and adherence to and relative about
therapeutic regimen. the area they lack
 Discuss sodium and salt in knowledge
substitute restrictions and
necessity of reading labels on
food and drugs.
 Encourage scheduling
activities with adequate rest

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 periods.
 Promote diversional activities
that are enjoyable to patient.
 Recommend avoidance of
persons with infections,
especially URI.
 Identify environmental
dangers: exposure to hepatitis.
 Instruct patient’s signs and
symptoms that warrant
notification of health care
provider: increased abdominal
girth; rapid weight loss/gain;
increased peripheral edema;
increased dyspnea, fever,
blood in stool or urine; excess
bleeding of any kind and
jaundice
Instruct health care providers to
notify any confusion, untidiness,
night wandering, tremors, or
personality change.

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