WESLEYAN UNIVERSITY PHILIPPINES

Mabini Ext. Cabanatuan City, Nueva Ecija

College Of Nursing SY: 2012-2013

AFFILIATION IN National Center for mental Health

CASE STUDY
Presented By: BJ Adette J. Hilario BSN III-Blk. 3; Group 3

Presented To: Mrs. Marjorie Trinidad RN, MAN Clinical Instructor A. PATIENTS PROFILE

Name Age Gender Status Permanent Address No., St. Town/City Brgy. Province Birthdate Birthplace Nationality Citizenship Religion Educational Attainment Occupation Fathers Name Mothers Name Spouse Informant Date and Time of Admission Hospital No. Pavilion/Ward Re-Admission Physician Admitting Diagnosis

Amy Belga Latino 16 years old Female Single c/o Bahay Kalinga R. Jacinto St. City of Valenzuela Canumay NCR 3rd district July 21, 1996 Valenzuela City Filipino Filipino Roman Catholic None None Victor DK Latino Emily DK Belga N/A Arnel V. De Leon Valenzuela City 445-6136/09327796932 4/28/2013 09:06pm 000000000039897 Pavilion 7; Infirmary-Female 4/30/2013 Pavilion 12; Zonta Dr. Mapa Dr. Tuazon F06.8 Other specified mental d/o due to brain damage and dysfunction and to physical disease (seizure d/o) t/c: status epilepticus

Introduction Few experiences match the drama of a convulsive seizure. A person having a severe seizure may cry out, fall to the floor unconscious, twitch or move uncontrollably, drool, or even lose bladder control. Within minutes, the attack is over, and the person regains consciousness but is exhausted and dazed. This is the image most people have when they hear the word epilepsy. However, this type of seizure a generalized tonic-clonic seizure -- is only one kind of epilepsy. There are many other kinds, each with a different set of symptoms.

Epilepsy was one of the first brain disorders to be described. It was mentioned in ancient Babylon more than 3,000 years ago. The strange behavior caused by some seizures has contributed through the ages to many superstitions and prejudices. The word epilepsy is derived from the Greek word for "attack." People once thought that those with epilepsy were being visited by demons or gods. However, in 400 B.C., the early physician Hippocrates suggested that epilepsy was a disorder of the brain -- and we now know that he was right. What Is Epilepsy? Epilepsy is a brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormally. Neurons normally generate electrochemical impulses that act on other neurons, glands, and muscles to produce human thoughts, feelings, and actions. In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss of consciousness. During a seizure, neurons may fire as many as 500 times a second, much faster than normal. In some people, this happens only occasionally; for others, it may happen up to hundreds of times a day. More than 2 million people in the United States -- about 1 in 100 -- have experienced an unprovoked seizure or been diagnosed with epilepsy. For about 80 percent of those diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical techniques. However, about 25 to 30 percent of people with epilepsy will continue to experience seizures even with the best available treatment. Doctors call this situation intractable epilepsy. Having a seizure does not necessarily mean that a person has epilepsy. Only when a person has had two or more seizures is he or she considered to have epilepsy. Epilepsy is not contagious and is not caused by mental illness or mental retardation. Some people with mental retardation may experience seizures, but seizures do not necessarily mean the person has or will develop mental impairment. Many people with epilepsy have normal or above-average intelligence. Famous people who are known or rumored to have had epilepsy include the Russian writer Dostoyevsky, the philosopher Socrates, the military general Napoleon, and the inventor of dynamite, Alfred Nobel, who established the Nobel Prize. Several Olympic medalists and other athletes also have had epilepsy. Seizures sometimes do cause brain damage, particularly if they are severe. However, most seizures do not seem to have a detrimental effect on the brain. Any changes that do occur are usually subtle, and it is often unclear whether these changes are caused by the seizures themselves or by the underlying problem that caused the seizures. While epilepsy cannot currently be cured, for some people it does eventually go away. One study found that children with idiopathic epilepsy, or epilepsy with an unknown cause, had a 68 to 92 percent chance of becoming seizure-free by 20 years after their diagnosis. The odds of becoming seizure-free are not as good for adults or for children with severe

epilepsy syndromes, but it is nonetheless possible that seizures may decrease or even stop over time. This is more likely if the epilepsy has been well-controlled by medication or if the person has had epilepsy surgery. What Causes Epilepsy? Epilepsy is a disorder with many possible causes. Anything that disturbs the normal pattern of neuron activity -- from illness to brain damage to abnormal brain development -can lead to seizures. Epilepsy may develop because of an abnormality in brain wiring, an imbalance of nerve signaling chemicals called neurotransmitters, or some combination of these factors. Researchers believe that some people with epilepsy have an abnormally high level of excitatory neurotransmitters that increase neuronal activity, while others have an abnormally low level of inhibitory neurotransmitters that decrease neuronal activity in the brain. Either situation can result in too much neuronal activity and cause epilepsy. One of the most-studied neurotransmitters that play a role in epilepsy is GABA, or gammaaminobutyric acid, which is an inhibitory neurotransmitter. Research on GABA has led to drugs that alter the amount of this neurotransmitter in the brain or change how the brain responds to it. Researchers also are studying excitatory neurotransmitters such as glutamate. In some cases, the brain's attempts to repair itself after a head injury, stroke, or other problem may inadvertently generate abnormal nerve connections that lead to epilepsy. Abnormalities in brain wiring that occur during brain development also may disturb neuronal activity and lead to epilepsy. Research has shown that the cell membrane that surrounds each neuron plays an important role in epilepsy. Cell membranes are crucial for a neuron to generate electrical impulses. For this reason, researchers are studying details of the membrane structure, how molecules move in and out of membranes, and how the cell nourishes and repairs the membrane. A disruption in any of these processes may lead to epilepsy. Studies in animals have shown that, because the brain continually adapts to changes in stimuli, a small change in neuronal activity, if repeated, may eventually lead to full-blown epilepsy. Researchers are investigating whether this phenomenon, called kindling, may also occur in humans. In some cases, epilepsy may result from changes in non-neuronal brain cells called glia. These cells regulate concentrations of chemicals in the brain that can affect neuronal signaling. About half of all seizures have no known cause. However, in other cases, the seizures are clearly linked to infection, trauma, or other identifiable problems.

Genetic Factors Research suggests that genetic abnormalities may be some of the most important factors contributing to epilepsy. Some types of epilepsy have been traced to an abnormality in a specific gene. Many other types of epilepsy tend to run in families, which suggests that genes influence epilepsy. Some researchers estimate that more than 500 genes could play a role in this disorder. However, it is increasingly clear that, for many forms of epilepsy, genetic abnormalities play only a partial role, perhaps by increasing a person's susceptibility to seizures that are triggered by an environmental factor. Several types of epilepsy have now been linked to defective genes for ion channels, the "gates" that control the flow of ions in and out of cells and regulate neuron signaling. Another gene, which is missing in people with progressive myoclonus epilepsy, codes for a protein called cystatin B. This protein regulates enzymes that break down other proteins. Another gene, which is altered in a severe form of epilepsy called LaFora's disease, has been linked to a gene that helps to break down carbohydrates. While abnormal genes sometimes cause epilepsy, they also may influence the disorder in subtler ways. For example, one study showed that many people with epilepsy have an abnormally active version of a gene that increases resistance to drugs. This may help explain why anticonvulsant drugs do not work for some people. Genes also may control other aspects of the body's response to medications and each person's susceptibility to seizures, or seizure threshold. Abnormalities in the genes that control neuronal migration - a critical step in brain development -- can lead to areas of misplaced or abnormally formed neurons, or dysplasia, in the brain that can cause epilepsy. In some cases, genes may contribute to development of epilepsy even in people with no family history of the disorder. These people may have a newly developed abnormality, or mutation, in an epilepsy-related gene. Status Epilepticus (SE) Status Epilepticus is a life-threatening condition in which the brain is in a state of persistent seizure. Definitions vary, but traditionally it is defined as one continuous, unremitting seizure lasting longer than 5 minutes, or recurrent seizures without regaining consciousness between seizures for greater than 5 minutes. Treatment is, however, generally started after the seizure has lasted five minutes. It is always considered a medical emergency. There is some evidence that five minutes is sufficient to damage neurons and that seizures are unlikely to self-terminate by that time. First aid guidelines for seizures state that, as a rule, an ambulance should be called for seizures lasting longer than five minutes (or sooner if this is the patient's first seizure episode and no precipitating factors are known, or if SE happens to a person with epilepsy whose seizures were previously absent or well controlled for a considerable time period).

The mortality rate of status epilepticus has the potential to be quite high (at least 20%), especially if treatment is not initiated quickly. However, with optimal neurological care, adherence to the medication regimen, and a good prognosis (no other underlying uncontrolled brain or other organic disease), the patient- even people who have been diagnosed with epilepsy- in otherwise good health can survive with minimal or no brain damage, and can decrease their risk of death and even avoid future seizures.

B. PATIENTS IDENTIFICATION
Hair: Black Eyes: Black Complexion: Fair Built: Medium Mustache: none Identifying Marks: (scars, tattoos, moles, etc.) With moles on the nose, right lower eye, inner back. With dark pigmentations on both upper extremities Physical Peculiarities: With healed wounds on both knees

C. ADMISSION NOTES
This is the case of Amy Latino, 16 years old, female, born on July 21, 1996, Roman Catholic, Filipino render by shift from Bahay Kalinga. NPI: The patient was turned over by the Brgy. after a care of physical abuse of her was filed. Last week, she was brought to the center for 4 days due to her suicidal tendencies, as she slashed her wrist. She was behaved but referred intake of medication. A month PTA, she had episode of epileptic attacks. Then she was brought to this center for further observation and management.

D. PATIENTS HISTORY
Past Medical History ------------- Unknown PMx ------------- Unknown Obstetric History ------------- Unknown

E. LABORATORY EXAMS

Physical Exam Vital Signs BP: 110/80 mmHg RR: 22 cpm PR: 83 bpm BT: 37 C

General: Conscious, coherent, with Oxygen cannula inserted. HEENT: Pink palpebral conjunctivae, anicteric sclerae, no naso-oral discharge, no tonsillopharyngeal congestion. Neck: Supple, no neck vein engorgement, no cervicolymphadenopathy.

Chest: Symmetrical chest expansion, no retraction, no wheezes, no nodules. Neurologic Exam Cerebrum: Conscious, coherent, with a GCS score of 15/15. Cerebellum: No nystagmus Cranial Nerves: I II III, IV, VI V VII VIII IX, X XI XII Motor Systems: Limbs N/A Pupils reactive to light EOM is intact Equal sensation of the face No facial asymmetry Normal gross hearing Uvula is midline, can swallow Can shrug shoulder against resistance, no sign of meningeal irritation Tongue is in midline

 Reflexes: Sensational:

Trunks Stance Gait Rombergo

5/5 | 5/5 5/5 | 5/5

J.J B.J S.J T.J Plaster

H| H H |H

Pain and Touch Temperature Vibration J.P.S. Two Point Discrimination

N/A

F. DRUG STUDY
1. CARBAMAZEPINE 200mg/tablet 2x a day P.O Generic Name Brand Name Preparation Classification Action Indication/Uses Side Effects CARBAMAZEPINE Tegretol, Tegretol XR , Equetro, Carbatrol Tablets: 200 mg. Chewable tablets; 100 mg. Extended release tablets; 100, 200, and 400 mg. Suspension; 100 mg/5 ml. Equetro is available in 100, 200, and 300 mg extended release tablets Anticonvulstant Decreases synaptic transmission in the CNS by affecting sodium channels in neurons Prevention of seizures Reduces anxiety, irritability, elation Impulse control behavior CNS: headache, tremors, confusion, restlessness, memory loss, seizures, slurred speech, muscle weakness, lack of coordination, lethargy, stupor CV: bradycardia, ECG changes, arrhythmias, hypotension, peripheral circulatory collapse EENT: blurred vision, tinnitus

 GI: anorexia, nausea, vomiting, abdominal cramps or pain, diarrhea, dry mouth, extreme thirst, metallic taste, weight gain GU: polyuria, glycosuria, proteinuria, incontinence, edema, hyponatremia Hematologic: leukocytosis Skin: rash, pruritus, alopecia, sweating, dryness or thinning of hair Contraindication Hypersensitivity Kidney disease Cardiovascular disease Seizure disorder, myasthenia gravis Dehydration Hypothyroidism Nursing Administer medication with food to minimize gastric irritation. Responsibilities Tablets may be crushed if patient has difficulty swallowing. Do not crush or chew extended-release tablets. Instruct patient to take carbamazepine around the clock, exactly as directed. If a dose is missed, take as soon as possible but not just before next dose; do not double doses. Medication should be gradually discontinued to prevent seizures. May cause dizziness or drowsiness. Instruct patients that fever, sore throat, mouth ulcers, easy bruising, petechiae, unusual bleeding, abdominal pain, chills, rash, pale stools, dark urine or jaundice should be reported. Advise patient not to take alcohol or other CNS depressant concurrently with this medication. Caution patients to use sunscreen and protecting clothing to prevent photosensitivity reactions. Inform patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may help reduce dry mouth. Saliva substitute may be used. 2. May give PHENYTOIN 1amp IV Generic Name Brand Name Classification Dosage and Route PHENYTOIN (diphenylhydantoin, phenytoin sodium) Dilantin-125, Dilantin Infatab, Dilantin Injection, Dilantin Kapseals, Phenytek Antiepileptic, Antiarrhythmic, group 1b, Hydantoin Pregnancy

Category D

Available forms :Chewable tablets50 mg; oral suspension 125 mg/5 mL; capsules100 mg; ER capsules30, 100, 200, 300 mg; injection50 mg/mL ADULTS

Phenytoin sodium, parenteral

Status epilepticus: 1015 mg/kg by slow IV. For maintenance, 100 mg PO or IV q 68 hr. Higher doses may be required. Do not exceed an infusion rate of 50 mg/min. Follow each IV injection with an injection of sterile saline through the same needle or IV catheter to avoid local venous irritation by the alkaline solution. Continuous IV infusion is not recommended. Neurosurgery (prophylaxis): 100200 mg IM q 4 hr during surgery and the postoperative period (IM route is not recommended because of erratic absorption, pain and muscle damage at the injection site). IM therapy in a patient previously stabilized on oral dosage: Increase dosage by 50% over oral dosage. When returning to oral dosage, decrease dose by 50% of the original oral dose for 1 wk to prevent excessive plasma levels due to continued absorption from IM tissue sites. Avoid IM route of administration if possible due to erratic absorption and pain and muscle damage at injection site.

Phenytoin and phenytoin sodium, oral

Individualize dosage. Determine serum levels for optimal dosage adjustments. The clinically effective serum level is usually between 10 and 20 mcg/mL.

Loading dose (hospitalized patients without renal or liver disease): Initially, 1 g of phenytoin capsules (phenytoin sodium, prompt) is divided into three doses (400 mg, 300 mg, 300 mg) and given q 2 hr. Normal maintenance dosage is then instituted 24 hr after the loading dose with frequent serum determinations. No previous treatment: Start with 100 mg tid PO. Satisfactory maintenance dosage is usually 300400 mg/day. An increase to 600 mg/day may be needed. Single daily dosage (phenytoin sodium, extended): If seizure control is established with divided doses of three 100-mg extended phenytoin sodium capsules per day, once-a-day dosage with 300 mg PO may be considered.

PEDIATRIC PATIENTS

Phenytoin sodium, parenteral

Status epilepticus: Administer phenytoin IV. Determine dosage according to weight in proportion to dose for a 150-lb (70-kg) adult (see adult dosage above; see Appendix Calculating Pediatric Doses). Pediatric dosage may be calculated on the basis of 250 mg/m2. Dosage for infants and children also may be calculated on the basis of 1015 mg/kg, given in divided doses of 510 mg/kg. For neonates, 1520 mg/kg in divided doses of 510 mg/kg is recommended.

Phenytoin and phenytoin sodium, oral

Children not previously treated: Initially, 5 mg/kg/day in two to three equally divided doses. Subsequent dosage should be individualized to a maximum of 300 mg/day. Daily maintenance dosage is 48 mg/kg. Children > 6 yr may require the minimum adult dose of 300 mg/day.

GERIATRIC PATIENTS AND PATIENTS WITH HEPATIC IMPAIRMENT

Use caution and monitor for early signs of toxicity; phenytoin is metabolized in the liver. Phenytoin acts as an anticonvulsant by increasing efflux or decreasing influx of sodium ions across cell membranes in the motor cortex during generation of nerve impulses; thus stabilizing neuronal membranes and decreasing seizure activity. It acts as an antiarrhythmic by extending the effective refractory period and suppressing ventricular pacemaker automaticity, shortening action potential in the heart. Control of grand mal (tonic-clonic) and psychomotor seizures Prevention and treatment of seizures occurring during or following neurosurgery Parenteral administration: Control of status epilepticus of the grand mal type Unlabeled uses: Antiarrhythmic, particularly in digitalisinduced arrhythmias (IV preparations); treatment of trigeminal neuralgia (tic douloureux)

Action

Indication

Side Effects

Hypersensitivity, lack of appetite, headache, dizziness, tremor, transient nervousness, insomnia, GI disturbances (e.g. nausea, vomiting, constipation), tenderness and hyperplasia of the gums, acne, hirsutism, coarsening of the facial features, rashes, osteomalacia. Phenytoin toxicity as manifested as a syndrome of cerebellar, vestibular, ocular effects, notably nystagmus, diplopia, slurred speech, and ataxia; also with mental confusion, dyskinesias, exacerbations of seizure frequency, hyperglycaemia. Solutions for inj may cause local irritation or phlebitis. Prolonged use may produce subtle effects on mental function and cognition, especially in children. Potentially Fatal: Toxic epidermal necrolysis, StevensJohnson syndrome. Pregnancy. IV admin in sinus bradycardia, heart block, or Stokes-Adams syndrome.

Contraindication Nursing Responsibilities

Assessment

History: Hypersensitivity to hydantoins; sinus

bradycardia, AV heart block, Stokes-Adams syndrome, acute intermittent porphyria, hypotension, severe myocardial insufficiency, diabetes mellitus, hyperglycemia, pregnancy, lactation Physical: T; skin color, lesions; lymph node palpation; orientation, affect, reflexes, vision examination; P, BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; periodontal examination; LFTs, urinalysis, CBC and differential, blood proteins, blood and urine glucose, EEG and ECG

Interventions

Use only clear parenteral solutions; a faint yellow color may develop, but this has no effect on potency. If the solution is refrigerated or frozen, a precipitate might form, but this will dissolve if the solution is allowed to stand at room temperature. Do not use solutions that have haziness or a precipitate. WARNING: Administer IV slowly to prevent severe hypotension; the margin of safety between full

therapeutic and toxic doses is small. Continually monitor patient's cardiac rhythm and check BP frequently and regularly during IV infusion. Suggest use of fosphenytoin sodium if IV route is needed. Monitor injection sites carefully; drug solutions are very alkaline and irritating. WARNING: Monitor for therapeutic serum levels of 10 20 mcg/mL. Give oral drug with or without food in a consistent manner. Give with food if patient complains of GI upset. Recommend that the oral phenytoin prescription be filled with the same brand each time; differences in bioavailability have been documented. Suggest that adult patients who are controlled with 300mg extended phenytoin capsules try once-a-day dosage to increase compliance and convenience. WARNING: Reduce dosage, discontinue phenytoin, or substitute other antiepileptic medication gradually; abrupt discontinuation may precipitate status epilepticus. Phenytoin is ineffective in controlling absence (petit mal) seizures. Patients with combined seizures will need other medication for their absence seizures. WARNING: Discontinue drug if rash, depression of blood count, enlarged lymph nodes, hypersensitivity reaction, signs of liver damage, or Peyronie's disease (induration of the corpora cavernosa of the penis) occurs. Institute another antiepileptic drug promptly. Monitor hepatic function periodically during long-term therapy; monitor blood counts and urinalysis monthly. Monitor blood or urine sugar of patients with diabetes mellitus regularly. Adjustment of dosage of hypoglycemic drug may be needed because antiepileptic may inhibit insulin release and induce hyperglycemia. WARNING: Have lymph node enlargement occurring during therapy evaluated carefully. Lymphadenopathy that simulates Hodgkin's lymphoma has occurred. Lymph node hyperplasia may progress to lymphoma. Monitor blood proteins to detect early malfunction of the immune system (eg, multiple myeloma). Arrange instruction in proper oral hygiene technique for long-term patients to prevent development of gum hyperplasia.

Teaching points

Take this drug exactly as prescribed, with food to reduce GI upset, or without foodbut maintain consistency in the manner in which you take it. Be especially careful not to miss a dose if you are on once-a-day therapy. Do not discontinue this drug abruptly or change dosage, except on the advice of your health care provider. Maintain good oral hygiene (regular brushing and flossing) to prevent gum disease; arrange frequent dental checkups to prevent serious gum disease. Arrange for frequent checkups to monitor your response to this drug. Monitor your blood or urine sugar regularly, and report any abnormality to your health care provider if you have diabetes. This drug is not recommended for use during pregnancy. It is advisable to use some form of contraception other than hormonal contraceptives. Wear a medical alert tag so that any emergency medical personnel will know that you have epilepsy and are taking antiepileptic medication. You may experience these side effects: Drowsiness, dizziness, confusion, blurred vision (avoid driving or performing other tasks requiring alertness or visual acuity; alcohol may intensify these effects); GI upset (take drug with food, eat frequent small meals). Report rash, severe nausea or vomiting, drowsiness, slurred speech, impaired coordination (ataxia), swollen glands, bleeding, swollen or tender gums, yellowish discoloration of the skin or eyes, joint pain, unexplained fever, sore throat, unusual bleeding or bruising, persistent headache, malaise, any indication of an infection or bleeding tendency, abnormal erection, pregnancy.

3. FERROUS SULFATE 1 tablet 2x a day P.O Generic Name Classification Action FERROUS SULFATE Hematinics Provides elemental iron component in the formation of hemoglobin.

Indication Side Effects

Iron deficiency Common: nausea, constipation, black stools Uncommon: epigastric pain, vomiting, diarrhea, anorexia; liquid forms may temporarily stain teeth

Nursing Responsibilities

Use cautiously on long-term basis Keep in mind that GI upset may be related to dose. Between-meal doses are preferable, but can be given with some foods, although absorption may be decreased. Enteric-coated products reduce GI upset but also reduce amount of iron absorbed Be aware that oral iron may turn stools black. Although this unabsorbed iron is harmless, it could mask melenas. Monitor hemoglobin and hematocrit levels and reticulocyte count during therapy, as ordered