Nursing Care Plan for Children
with Febrile Seizures - Hyperthermia
1. Assessment
The study aims to obtain basic data about the client's health, both physical, psychosocial, and emotional. This basic data is used to determine the client's health status, find actual or potential problems and as a reference in providing education to clients (Ode Debora, 2013).
Assessment is a systematic and continuous collection, arrangement, validation, and documentation of data (information) carried out in all phases of the nursing process, for example in the evaluation phase, assessment, carried out to determine strategic nursing outcomes and evaluate the achievement of goals (Kozier, 2011).
The data that need to be collected during the assessment of children with febrile seizures are:
a. Biodata/ Patient ID
Patient biodata includes name, age, gender. Meanwhile, parents' biodata needs to be asked to find out the child's social status including name, age, religion, ethnicity/nation, education, occupation, address.
b. Main complaint
Covering the main complaints experienced by patients, usually the complaints experienced by patients with febrile seizures are children experiencing seizures when the heat is above > 37.5.- 39.5 oC.
c. Current medical history
- Ask the history of the disease suffered now without seizures. It is hoped that the mother or family knows the seizures experienced by the child.
- By knowing the presence or absence of fever that accompanies the seizure, it is known whether there is an infection. Infection plays an important role in the occurrence of seizures in children.
- The duration of the attack. A mother whose child has a seizure feels that time is going on for a long time. From the duration of seizures we can know the response to prognosis and treatment.
- Attack pattern. Efforts should be made to obtain a complete picture of the attack pattern whether it is general, focal, tonic or clonic. In simple febrile seizures, these seizures are generalized.
- Frequency of attacks. Ask if the patient has had previous seizures, at what age the seizure occurred for the first time and how often the seizures occur per year. The prognosis is worse if the first seizure occurs at a young age and seizures occur frequently.
- Circumstances before, during and after the attack. Before a seizure, it is necessary to ask whether there are certain auras or stimuli that can cause seizures, such as hunger, fatigue, vomiting, headaches and others. Where do seizures start and how do they occur. After the seizure, it is necessary to ask whether the patient immediately regained consciousness, fell asleep, decreased consciousness, had paralysis, cry and so on.
- History of accompanying current illness, whether vomiting, diarrhea, head trauma, stuttering speech (especially in people with epilepsy), kidney failure, heart disorders, DHF, ARI, AOM, Morbili and others.
d. Past medical history
Before the patient has a current seizure, ask if he has had a seizure before, how old he was when the seizure occurred for the first time. Is there a history of head trauma, inflammation of the lining of the brain, AOM and others.
e. Family history of illness
Is there a family who has a febrile seizure like the patient (25% of patients with febrile seizures have hereditary factors). Is there a family member who suffers from neurological or other diseases. Are there any family members who suffer from diseases such as ARI, diarrhea or infectious diseases that can trigger febrile seizures.
f. History of pregnancy and childbirth
Abnormalities of the mother during pregnancy per trimester, whether the mother had an infection or fever during pregnancy. History of bleeding trauma during pregnancy, use of drugs or herbs during pregnancy. The history of labor was asked whether it was difficult, spontaneous or with action (forceps/vacuum), ante partum bleeding, asphyxia and others. The situation during the neonatal period was the baby having fever, diarrhea, vomiting, refusal to breastfeed and convulsing.
g. Immunization history
Types of immunizations that have been obtained and which have not been asked as well as the age of receiving immunizations and reactions to immunizations. In general, after receiving DPT immunization, the side effect is heat which can cause seizures.
h. Development history
Children's developmental abilities include:
- Personal social (personality / social behavior): related to the ability to be independent, socialize, and interact with the environment.
- Fine motor: relates to the child's ability to observe something, perform movements that involve only certain body parts and are carried out by small muscles and require careful coordination, for example drawing, holding an object and others.
- Gross motor: related to movement and posture.
- Language: the ability to respond to sounds, follow commands and speak spontaneously.
i. Social history
To find out the behavior of children and their emotional state, it is necessary to study who is taking care of children. How to relate to family members and peers.
- Patterns of perception and management of healthy living. Lifestyle related to health, knowledge of health, prevention and adherence to every treatment and medical action. View of the illness suffered, the health services provided, the action when a family member is sick, the use of first aid drugs.
- Nutritional pattern. To find out the intake of children's nutritional needs, they were asked how the quality and quantity of food consumed by children, what foods they liked and didn't like, how the children's appetites were, how many times they drank, the type and amount per day.
- Elimination pattern. Urination: asked for frequency, amount, macroscopically asked what color, characteristic smell, and presence of blood is, and asked whether it is accompanied by pain when the child urinates. Defecation: ask when the bowel movements, regular or not, how the consistency is soft, hard, runny or slimy.
- Activity and exercise patterns. Ask whether the child likes to play alone or with his peers, how many hours a day he gathers with his family, what activities he likes.
- Sleep/rest patterns. Ask how many hours a day sleep, what time go to bed. When to wake up, habits before bed, and what about naps.
Objective Data
1) General Inspection
First note the general state of vitals: level of consciousness, blood pressure, respiration, pulse and temperature. In a simple febrile seizure, a high temperature will be obtained, while consciousness after the seizure will return to normal as before the seizure without neurological abnormalities.
2) Physical examination
Physical examination is a thorough examination from head to toe to obtain objective data about the patient's condition (Perry, 2005).
a) Head
Micro or macro signs of sepals, Look for dispersion of the shape of the head, look for signs of increased intracranial pressure, namely the large convex crown, how is the condition of the large crown closing or not.
b) Hair
Starting with the color, thickness, distribution and other characteristics of the hair. Patients with protein energy malnutrition have hair that is sparse, reddish like corn silk and is easily removed without causing pain to the patient.
c) Face/Face
Facial paralysis causes facial asymmetry; the paretic side is left behind when the child cries or laughs, so that the face is drawn to the healthy side. Look for signs of rhisus sardonicus, opisthotonus, trimus, for cranial nerve disorders.
d) Eyes
During a seizure, the pupil dilates, so check the pupil and visual acuity. Look at the state of the sclera, conjunctiva.
e) Ears
Check ear function, ear hygiene and signs of infection such as: swelling and pain in the area behind the ear, discharge from the ear, decreased
f) Nose
Look for nostrils breathing, polyps that block the airway, whether the secretions come out, how the consistency and amount.
g) Mouth
Look for signs of sardonicus, how is the condition of the tongue, is there stomatitis, how many teeth have grown, are there any tooth carriers.
h) Throat
Look for signs of inflammation of the tonsils, are there signs of pharyngeal infection.
i) Neck
Look for signs of stiff neck, enlarged thyroid gland, look for enlarged jugular veins.
j) Thorax
In infection, observe the client's chest shape, how the breathing movement, frequency, rhythm, depth, is there any chest retraction. On auscultation there are additional breath sounds.
k) Heart
Look at the condition and heart rate and rhythm, listen for additional sounds, whether bradycardia or tachycardia.
l) Abdomen
Look for abdominal distension and muscle rigidity in the abdomen, how is skin turgor and intestinal peristalsis, is there any sign of meteorismus, is there an enlarged liver.
m) Skin
Look at the condition of the skin, both cleanliness and color, look for edema, hemangiomas, skin turgor conditions.
n) Extremities
Look at the condition of the skin, both cleanliness and color, look for edema, hemangiomas, how the skin turgor is.
o) Genetalia
Look for deformity oedema, discharge from the vagina, signs of infection.
2. Nursing Diagnosis
The nursing diagnosis that can be taken in cases of febrile seizures is hyperthermia, which is related to the disease process.
Symptoms and Signs :
Major Symptoms and Signs
1. Subjective : not available
2. Objective: body temperature is not normal.
Minor Symptoms and Signs
1. Subjective : not available
2. Objective: red skin, seizures, tachycardia, tachypnea, warm skin
Causes :
1. Dehydration
2. Exposed to hot environment
3. Disease process (eg infection, cancer)
4. Incompatibility of clothes with ambient temperature
5. Increased metabolic rate
6. Trauma response
7. Excessive activity
8. Use of incubator
Problem
Hyperthermia
Category : environment
Subcategory : security and protection
Definition: body temperature rises above the normal range.
3. Nursing Intervention
Nursing Diagnosis :
Hyperthermia is related to the disease process (salmonella typhi bacterial infection)
Goals and Outcome Criteria :
After being given nursing care for 3x24 hours, it is expected that:
1. No chills
2. Red skin: none
3. Seizures: none
4. Tachycardia: none
5. Tachypnea: none
6. Body temperature improves
7. Skin temperature improves
Nursing Intervention:
Hyperthermia management
1. Observation
a. Identify causes of hyperthermia (eg dehydration, exposure to hot environments, use of incubators).
b. Monitor body temperature
c. Monitor urine output.
2. Therapeutic
a. Provide a cool environment.
b. Loosen or remove clothing.
c. Give oral fluids.
d. Wet and fan the body surface.
e. Perform external cooling (eg, hypothermic blanket or cold compress on forehead, neck, chest, abdomen, axilla).
3. Education
a. Recommend bed rest
4. Collaboration
a. Collaborate on intravenous fluids and electrolytes, if necessary.
4. Implementation
Implementation is the fourth stage of the nursing process. This stage appears when the plans made are applied to the client. The actions taken may be the same or may be different from the sequence that has been made in the plan. Nursing implementation requires flexibility and creativity of nurses. Before taking an action, the nurse must know the nursing action that was carried out in accordance with the planned action, carried out with the right plan, safe, and in accordance with the patient's condition (Ode Debora, 2013).
As for the implementation that can be done in accordance with the intervention, namely:
a. Identify causes of hyperthermia (eg dehydration, exposure to hot environment).
b. Monitor body temperature.
c. Monitor urine output.
d. Provides a cool environment.
e. Loosen or remove clothing.
f. Give oral medication.
g. Wet and fan the body surface.
h. Perform external cooling (eg cold compresses on forehead, and axilla).
i. Advise bed rest.
j. Collaborate for administration of electrolytes and intravenous fluids.
5. Evaluation
Evaluation is the fifth stage of the nursing process. At this stage the nurse compares the results of the actions that have been taken with the predetermined outcome criteria and assesses whether the problems that have occurred have been completely resolved, only partially, or not completely resolved. Evaluation is an ongoing process, which is a process used to measure and monitor the client's condition to determine the suitability of nursing actions, improvement of nursing actions, current client needs, the need to be referred to other health facilities and the need to reorder diagnostic priorities, so that client needs can be met or resolved (Ode Deborah, 2013).
Evaluation is assessed based on the patient's response to the implementation that has been carried out, so that the expected outcome criteria are:
a. Chills decreased.
b. Body temperature improves to 36.5⁰ c – 37.5⁰ c
c. Seizures decreased.
d. Improved skin temperature.
e. Tachycardia decreased.
f. Tachypnea decreased.
g. Redness decreased.
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