Question

ohn Moore, a 22-year-old patient weighing in at 150 pounds, arrived at the emergency department (ED) after being thrown from his horse and passing out for a few minutes; later he regained consciousness. The friend who was also riding a horse called the squad. The patient presented with a GCS of 15, and the neuro exam was within normal limits (WNL). The ED physician wrote the orders for a CT scan without contrast of the head, CBC, renal and metabolic profile, PT, PTT, and INR. The nurse sent the labs and had the IV of NS at keep-open rate per ED protocol hanging. The nurse was awaiting radiology to call for the patient to go for the CT when the patient had an epileptic cry, became unconscious, stiffened his entire body, and then had violent muscle contractions. His respirations were very shallow, and his lips and nail beds turned blue. The patient lost control of his bladder and bowel. The patient bit his tongue and was bleeding from his mouth. The radiology department called and was now ready for the patient.

1. List the correct order of actions that should be taken by the nurse.
2. Explain what type of seizure the patient is having, and describe the three phases of the patient’s seizure, and the specific nursing care for each stage.
3. The ED physician orders the following: Valium (diazepam) 10 mg every 10 to 15 minutes prn for seizures (maximum dose of 30 mg). Once seizures stop, administer Dilantin (phenytoin) 10 mg/kg IVPB. ECG monitoring continuously, VS, GCS, neuro checks every 30 minutes. Explain what meds the nurse should provide, in what order, and how they should be administered.

Answer 1

1. Make the environment safe

2. Assess for airway breathing and circulation

3. Provide the recovery position

4. Administer the mergency medication if necessary

4. Provide blanket if is so cold

5. Once he has recovered

6. Orientation

7. Administration of medication

2. The patient has tonic clinic seizures. The phases of seizures are :

* prodormal phase signs or activity that precede seizure

* aural phase sensory warning of seizure can be a partial seizures that proceeds into tonic clonic seizures

* ictal phase were it is stage full of seizures

* post ictal phase period of recovery after seizure

Tonic phase : sudden jerky movement with loss of consciousness

Clonic phase twitching movements present in one or several muscles

Tonic Clonic combination of both and is severe form wereby patient go for coma.

3.the medication given in order are:

* benzodiazipines

* hydantois

* phenytoin like drugs

* succininamides