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A febrile seizure is a convulsion in a child triggered by a fever. Such convulsions occur without any underlying brain or spinal cord infection or other neurological cause.  According to studies, about 3-5% of otherwise healthy children between the ages of 9 months and 5 years will have a seizure caused by a fever. Toddlers are most commonly affected. Most occur well within the first 24 hours of an illness, not necessarily when the fever is highest.

The first febrile seizure is one of life’s most frightening moments for parents. Most parents are afraid that their child will die or have brain damage. Thankfully, simple febrile seizures are harmless. There is no evidence that simple febrile seizures cause death, brain damage, mental retardation, a decrease in IQ, or learning difficulties. (www.nlm.com) However, a very small percentage of children go on to develop other seizure disorders such as epilepsy later in life.

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1 Hyperthermia

Benign Febrile Convulsion is a convulsion triggered by a rise in body temperature. Fever is not an illness and is an important part of the body’s defense against infection. Antigens or microorganisms cause inflammation and the release of pyrogens which is a substance that induces fever.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome
Subjective:

Ө

Objective:

the patient manifested:

> febrile temp = 39°C

>flushed skin and warm to touch

> convulsion

> RR = 34 bpm

the  patient may manifest:

> high fever

> weakness

 Hyperthermia Short term:

After 4 hours of nursing interventions, the patient’s temperature will decrease from 39°C to normal range of 36.5°C to 37°C.

Long Term:

After 2 days of nursing interventions, the patient will be able to be free of complications and maintain core temperature within normal range.

 >Assess underlying condition and body temperature.

>Monitor and recorded vital signs.

>Remove unnecessary clothing that could only aggravate heat.

>Promote adequate rest periods.

>Provide TSB

>Advise to increase fluid intake.

>Loosen clothing.

>Administer IV fluids at prescribed rate. Monitor regulation rate frequently.

>Administer antipyretics as ordered.

 >To obtain baseline date.

>To note for progress and evaluate effects of hyperthermia.

>To decrease or totally diminish pain.

>Reduces metabolic demands or oxygen.

>To promote surface cooling.

>To help decrease body temperature.

>To provide proper ventilation and promote release of heat through evaporation.

>To promote fluid management.

> Antipyretics lower core temperature.

 Short term:

The patient’s temperature shall have decreased from 39°C to normal range of 36.5°C to 37°C.

Long Term:

The patient shall have been able to be free of complications and maintain core temperature within normal range.

2 Imbalanced Nutrition

The nutritional requirements of the human body reflect the nutritional intake necessary to maintain optimal body function and to meet the body’s daily energy needs. Malnutrition (literally, “bad nutrition”) is defined as “inadequate nutrition,” and while most people interpret this as undernutrition, falling short of daily nutritional requirements. The etiology of malnutrition includes factors such as poor food availability and preparation, recurrent infections, and lack of nutritional education.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome
Subjective:

Ө

Objective:

the patient manifested:

> body weakness

> weight of 7.9kg

> loss of appetite

> poor muscle tone

the  patient may manifest:

> abnormal laboratory studies

> pallor

 Imbalance Nutrition: Less than the body requirement related to economical factors. Short term:

After 4 hours of nursing interventions, the patient’s will identify measures to promote nutrition and follow the treatment regimen

Long Term:

After 2 days of nursing interventions, the will demonstrate behaviours or lifestyle changes to regain appropriate weight.

 >Review patient’s records.

>Assess underlying condition.

>discuss eating habits and encourage diet for age.

> Note total daily intake includes patterns and time of eating.

>Consult physician for further assessment and recommendation regarding food preferences and nutritional support.

 >To obtain baseline data.

>To determine specific interventions.

>To achieve health needs of the patient with the proper food diet for his disease.

>To reveal change that should be made in the client’s dietary intake.

>For greater understanding and further assessment of specific food.

 Short term:

The patient shall have identified measures to promote nutrition and follow the treatment regimen.

Long Term:

The patient shall have demonstrated behaviours or lifestyle changes to regain appropriate weight.

3 Ineffective Tissue Perfusion

The circulation to the tissues is not getting enough oxygen or nourishment. Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome
Subjective:

Ө

Objective:

The patient manifested:

>Body temperature changes.

>Skin discoloration

The patient may manifest:

> Anemia

 Ineffective tissue perfusion realated to decreased Hgb concentration in blood as evidenced by low Hgb count in CBC result Short term:

After 4 hours of nursing intervention, the patient will demonstrate behaviour lifestyle changes to improve circulation.

Long term:

After 2 days of nursing intervention, the patient’s S.O. will verbalize understanding of the condition.

 > Establish rapport.

> Monitor VS.

> Determine factors related to individual situation.

> Evaluate for signs of infection especially when immune system is compromised.

> Discuss individual risk factors.

> Elevate head of bed at night.

> Discuss the importance of a healthy diet..

 > To gain patient and S.O.’s trust and promote cooperation.

> To monitor patients status.

> To gain information regarding the condition.

>To observe for possible risk factors.

> This information would be necessary for the client’s S.O.

> To increase gravitational blood flow.

>To promote a healthy diet to help increase RBC synthesis and Hgb count for faster recovery.

 Short term:

The patient shall have demonstrated behaviour lifestyle change.

Long term:

The patient’s S.O. shall have verbalized understanding of the condition.

4 Risk for Infection

The immune system is the body’s defense against bacteria, viruses, and other foreign organisms or harmful chemicals.  It is very complex and it has to work properly to protect us from the harmful bacteria and other organisms in the environment which may infect our body.  If the immune system is compromised, it can affect the normal production of WBC from the bone marrow.  If there is an increase in number of WBC, therefore it may increase the possibility to increase infection.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome

S = Ø

O = the patient manifested:

>body weakness

>fatigue

>poor muscle tone

=The patient may manifest:

>elevated body temperature

>Hgb = 112

>WBC = 22.9

>RBC = 3.97

>HCT = 0.34

>Platelet count = 234

Risk for (spread) of infection

Short Term:

After 3 hours of nursing interventions, the patient will verbalize understanding of ways on how to prevent spread of infection.

Long Term:

After 1week of nursing interventions, the patient will be free from infections and further complications

>Establish good working relationship with the client and S.O.

>Monitor and record vital signs

> Determine pt’s individual strength

>Provide peaceful environment

>Provide adequate rest and sleep.

>Emphasize importance of hand washing

>Provide safety measures

>Monitor I & O

>Check IV and Regulate IVF

>Advice pt to increase oral fluid intake when allowed

>To gain their trust and cooperation

>For comparative baseline data

>To know when to assist client

>To promote optimum level of functioning

>To prevent fatigue and conserve energy

>.to prevent occurrence of further infections

>To prevent falls and injuries

>To note for imbalances

>To ensure proper hydration

> To replace fluid electrolyte loss

Short Term:

After 3 hours of nursing interventions, the patient shall have verbalized understanding of ways on how to prevent spread of infection.

Long Term:

After 1week of nursing interventions, the patient shall have been free from infections and further complications.

5 Risk for Injury

A seizure or convulsion is the visible sign of a problem in the electrical system that controls your brain. A single seizure can have many causes, such as a high fever and lack of oxygen. Hemoglobin is a protein in red blood cells that carries oxygen. Therefore, Low levels of hemoglobin in the human body may reult to seizure. During episodes of convulsion, patients are prone to injuries since they may strike different objects due to uncontrollable muscle spasms.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome
Subjective:

Ө

Objective:

the patient may manifest the following:

>Fever

>Convulsion

>Low

>Low Hgb Level = 112

 Risk for injury related to possible convulsion. Short term:

After 4 hours of nursing interventions, the SO will modify environment as indicated to enhance safety.

Long term:

After 2 days of nursing interventions, the SO will verbalize understanding of individual factors that contribute to possibility of injury.

 >establish rapport

>monitor and record Vital Signs

> ascertain knwlge of safety needs/ injury prevention

> note clients gender, age, developmnt stage, decision makng ability, level of cognition/competence

>provide health care within a culture of safety

> identify interventions/safety devices

> discuss importance of self monitoring of conditions/ emotions

 > To gain patient’s trust

>To obtain baseline data

> to prevent injuries in home, community, and work setting

>affects client’s ability to protect self/others and influence choice of interventions/ teachings

>to prevent errors resulting in client injury, promote client safety and model  safety behaviors for client/SO

>to promote safe physical environment and individual safety

>it can contribute to occurence of injury

 Short term:

The SO shall have modified environment as indicated to enhance safety.

Long term:

The SO shall have verbalized understanding of individual factors that contribute to possibility of injury.

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