Clinical Paper

Medical 3

NeuroScience Ward

I. History

Patients Profile

Patient’s Name: Patient X

Address: Agoo, La Union

Gender: Male

Age: 72 years old

Birthplace: Manaoag, Pangasinan

Nationality: Filipino

Civil Status: Married

Religion: Iglesia Ni Cristo

Occupation: Appliances Sales Agent

ADMISSION

Admitting Diagnosis: Epilepsy general tonic-clonic t/c structured

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 NURSING HEALTH HISTORY

A. History of Present Illness

According to the significant others of the client, patient x was

active and energetic. He was able to do household chores at minimal

period of time. He was aware that he has a hypertension.

The client went to attend church activities with his friends.

Suddenly they saw him unconscious and unresponsive. His friends rushed

him to the hospital. Patient X was diagnosed with Epilepsy General

Tonic-Clonic To Consider Structured.

Therefore, the patient wasn’t able to move on his own. He needed

full assistance in doing activities of Daily living which causes him

to be at risk of impaired skin integrity related to immobilization.

Patient X was prescribed with the following medication:

Ampicillin Sulbactam 1.5g - OD

Valproic Acid 500mg – BID

N-Acetylcystein 600mg – BID

Azithromycin 500mg – OD

Past Medical History:

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 Months prior to admission, the client was a known case of

hypertension ranging from 160/100 mmHg – 190/110mmHg. Patient X was

also reported to experienced embolic stroke last 2018. He was taking

losartan once a day to control blood pressure. A week prior to

admission the client loss his consciousness which results to his

admission with a diagnosis of Seizure Tonic-Clonic to consider

structured. There is a history of Hypertension.

B. Personal, Social and Environmental History:

Patient X is an appliances sales agent. He is married and has 3

children. The client was smoking tobacco when he was 20 years old

until he was late 40’s.The client was also drinking alcohol

occasionally as verbalized by the family members. The client was

reported to have rich in fat and poor in vegetable, fiber diet.

Patient X also loves eating a lot of processed meat according to

family members.

C. Family Medical History:

The client has a known family history of Hypertension and

hypercholesterolemia on mother side, Hence the client doesn’t have any

family history of DM, Asthma, Cancer or Heart disease.

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 II. PHYSICAL EXAMINATION
General Impression

The patient is weak, and hard to converse with. His mood is

appropriate with the current and recent events.
Patient X has a hard time talking and verbalizing words. He
wasn’t able to do activities of daily living alone. His
significant others do sponge bath for him and changes his
clothing while he is confined to bed. His significant others is
assisting him to sit specially when they are going to feed or
change his clothes. He has a limited range of motion and weak
muscle strength. There is also presence of lumbar pressure
ulcers because of his immobility. He is not able to stand and
walk because of the weakness he feels.
Patient X is with intact NGT – the significant others is the
one responsible on feeding him.
Vital Signs:
Blood Pressure : 160/90
SPO2: 96%
Pulse Rate: 75
Respiratory Rate: 20
Temperature: 36.8

SKIN, HAIR, NAILS

In inspection, it is noticeable that there are signs of aging

such as wrinkling lessened elasticity and turgor. The skin from head
to toe is usually dry and with no proper moisture. His hair was not
dyed and naturally color black with presence of hypopigmentation in
other parts. On his body, the skin appears to be transparent, loose,
thin and fragile already. There is no presence of lesions except on
the lumber area which has pressure ulcers. There are no signs of skin

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infection from the scalp to lower extremities except for the bedsore.
The bedsore is stage 2: there is redness in color, partial loss of
dermis and shallow opening of the ulcer. Braden Scale was used to
assess the pressure sore. It consist of six categories: Sensory
perception, Moisture, Activity, Mobility, Nutrition and
friction/shear. The total score for the patient is 12
 Sensory : Slightly limited: responds to verbal commands but
cannot always communicate discomfort or need to be turned, or has
sensory impairment limiting ability to feel pain/ discomfort in
1-2 extremities : 3
 Moisture: Rarely moist: skin usually dry, linen only requires
changing at routine intervals: 4

 Activity: Bedfast: Confined to bed: 1

 Mobility: Completely immobile: does not make even slight changes
in body or extremity position without assistance: 1
 Nutrition: Probably inadequate: rarely eats complete meal and
generally eats only about ½ of any food offered, protein intake
includes only 3 servings of meat or dairy products daily,
receives less than optimum amount of fluid or on tube feeding: 2
 Friction/Shear: Problem: requires moderate to maximum assistance
in moving, complete lifting without sliding against sheets is
impossible, frequently slides down in bed or chair, requiring
frequents repositioning with maximum assistance, spasticity,
contractures or agitation leads to almost constant friction: 1

Upon palpation, skin feels cool and dry. The capillary refill is
2-3 seconds on both upper and lower extremities. There is no presence
of edema noted. The nails appears to be yellowish and thickened .
There is presence of nail clubbing on both hands.

HEENT

a. Head
Head is symmetrically round, hard, and smooth without
lesions or bumps. Face is oval, symmetric with presence of
wrinkles. Bilateral temporal arteries are smooth and elastic, no
tenderness noted. Bilateral temporomandibular joints will full
ROM with no tenderness. There is no tenderness upon percussion of
the frontal, maxillary and mandibular area. Skin of the eyelids
becomes wrinkled. Facial movements are symmetrical.

b. Ears

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 Auricles are without deformity, lumps or lesions. Auricles
are same color as facial skin and symmetrically aligned with
outer canthus of the eye, mobile firm and not tender, there is no
presence of impacted serumen

c. Eyes
Eyebrows are symmetrically aligned, with equal movement.
Eyelids close symmetrically and eyelashes are evenly distributed.
No discharges or discoloration noted. Palpebral conjunctiva
appears to be pale and less moist. Arcus snelis was noted upon
inspection of cornea. Pupils are black in color and equal in
size. Pupils are equally rounded and react to light.

d. Nose
No external structure deformity, asymmetry or inflammation
noted upon inspection. Nares are patent. Nasogastric tube is
intact on left nares. There is no swelling, bleeding or lesions
noted. Frontal and maxillary sinuses are non tender.

e. Mouth
Lips is slightly pink, chapped and dry. No lesions or
ulcerations noted inside bucal mucosa. Bucal mucosa is pink and
moist with patchy areas of white pigment on the surface of
tongue. No ulcers or nodules noted.

f. Throat
Gums are pink and moist without inflammation, bleeding or
and lesions. Hard and soft palates are smooth with no ulcers or
nodules. Tonsils are present, there is no exudate, inflammation,
edema or ulcers. Tongue is in the midline, pinkish with patches
of white pigmentation.

g. Neck
Neck is symmetric without any bulging masses. Cervical
vertebra 7 is visible and palpable. No bruits noted upon
auscultation. Trachea is midline. No lymphadenopathy noted. The
occipital, mastoid, preauricular, submaxillary, submental,
superficial cervical, deep cervical, posterior cervical, and
supra clavicular lymph nodes are non-palpable and non-tender.

CHEST
a. Thorax and Lungs
Respiration rate is between 18-20 bpm, it is unlabored, even
and regular with out use of accessory muscles. No nasal flaring.

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 Skin is brown without tenderness. Thorax expands symmetrically
without retractions or bulging. Resonant is heard throughout
percussion. Diaphragmatic excursion : 1-2 cm and equal and
bilaterally. Normal breath sounds is heard in both lung fields
upon auscultation

b. Breast
Breast are symmetric. Skin is uniformly brown. No dimpling
noted bilaterally. No masses, thickening, tenderness,
lymphadenopathy noted.

CARDIOVASCULAR
a. Heart and Neck Vessel
Carotid pulses 2+ bilaterally. No carotid bruits or jugular
vein distention noted. No Precordial pulsation, heaves noted. PMI
is palpable at 5th intercostal space left mid clavicular. No
presence of thrill or bruit on tricuspid, mitral, pulmonic and
aortic valves.

b. Peripheral Vascular
Upper extremities: Equal in size and symmetric. Skin is
brown. No lesion and edema noted. Radial and brachial pulses are
2+ and equal bilaterally.
Lower extremities: Symmetric in size and shape. Skin is
intact and brown in color. Dorsalis pedal and posterior tibial
pulses 2+ and equal bilaterally. With a capillary refill of 2-3
seconds.

ABDOMEN

Abdomen is symmetric, without masses, lesions and pulsation.

No pain when patient is moving. Umbilicus is midline without any
herniation, swelling or discoloration. Bowel sounds is low
pitched and gurgling. No bruits noted. Abdomen is tympanic upon
percussion. No tenderness noted upon light and deep palpation.

GENITOURINARY

The patient is with intact intra foley catheter which is

being change every 5 days. It is draining yellowish urine with
an average of 500cc every shift. There are no abnormal
discharges noted.

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 MUSKULOSKELETAL

The client has difficulty in changing position, He needs

full assistance in order for him to change his position and do
his activities of daily living. There is diminished muscle
strength on both upper and lower extremities. The client has a
limited range of motion.

NEUROLOGICAL

a. Mental Status
Client Is not able to converse well, he has difficulty in
verbalizing words. The client can not identify common objects in
the hospital. Client can not express feelings of pain or
discomfort.

b. Cranial Nerve Examination

 CN I: Has difficulty in identifying scents of coffee,
vinegar, soy sauce and alcohol
 CN II: The client needs eyeglasses , and was reported to
have a grade of 20/100by the significant others
 CN III, IV and VI: EOM’s are intact, Lid covers 2mm of iris
with bilateral eye movement
 CN V: Identifies light touch to forehead, cheek, and chin
 CN VII: Patient has difficulty in smiling, frowning and
showing teet.
 CN VIII: Able to hear whispered words within close distance
 CN IX and X: Uvula in midline and elevates on phonation
 CN XI: Patient has difficulty on moving head to right and
left against resistance
 CN XII: Tongue is midline when protruded without
fasciculation

Motor and Cerebellar Examination: Muscle tone is decreased. There is

atrophy and weakness noted.
Muscle Strength Right upper extremities: 2/5 Movement at the joint
with gravity eliminated
Muscle Strength Left upper extremities: 2/5 Movement at the joint with
gravity eliminated

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Muscle Strength Right lower extremities: 2/5 Movement at the joint
with gravity eliminated
Muscle Strength Left lower extremities: 2/5 Movement at the joint with
gravity eliminated

Gait and ability to walk are not assessed because of the inability
to stand and walk. Patient can not perform finger to nose with his
eyes closed.

Sensory Status Examination:

Superficial dull and sharp sensation is decreased. There is
decreased senses on fingers on both hands. The client was not able to
recognize objects such as pen, paper, and watch.
III. INSIGHTS
Stroke is the most common cause of seizures in the elderly, and
seizures are among the most common neurologic sequelae of stroke.
About 10% of all stroke patients experience seizures, from stroke
onset until several years later. This review discusses current
understanding of the epidemiology, pathogenesis, classification,
clinical manifestations, diagnostic studies, differential diagnosis,
and management issues of seizures associated with various
cerebrovascular lesions, with a focus on anticonvulsant use in the
elderly. In population studies, stroke is the most commonly identified
cause of epilepsy in adult populations older than 35 years
Knowing that having a stroke could result to immobility of the
client which causes blockage on the blood flow on the bony prominence
area resulting to pressure ulcers we should know basic precautions on
how to manage such complications.
As a nurse, For a stage I sore, you can wash the area gently
with mild soap and water. If needed, use a moisture barrier to protect
the area from bodily fluids. Stage II pressure sores should be cleaned
with a salt water (saline) rinse to remove loose, dead tissue..DO NOT
use hydrogen peroxide or iodine cleansers. They can damage skin. Keep
the sore covered with a special dressing. This protects against
infection and helps keep the sore moist so it can heal. Powder your
sheets lightly so your skin doesn't rub on them in bed. Avoid slipping
or sliding as you move positions. Try to avoid positions that put
pressure on your sore.

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 Let us always remember prevention is better than cure. As one of
the future member of the health care team let us always share the
concept that we know to others so that we can avoid pressure ulcers
and any other complications brought by this situation; such as
teaching them on how to properly change the clients position while
avoiding frictions, emphasizing the importance of frequent log
rolling, and applying the ordered ointment for a fast healing of the
pressure ulcer.

IV. PATHOPHYSIOLOGY

Precipitating Factors :
- Alcohol Use Predisposing Factors:
- Smoking Tobacco - Hypertension
- History of Stroke ( Year 2018)
- Idiopathic

Reduce inhibitory for Neurotransmitter imbalance

control of neurons (Too active Excitatory)

Sudden spontaneous, uncontrolled

depolarization of neurons

Depolarization spreads through

focal cells stimulating the
surrounding cells via cortical
synapses

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 The neuronal firing spreads to adjacent neuron,
ultimately resulting to seizure ( Too much electrical
impulses)

Signs and Symptoms: Laboratory :

Tonic Phase:
-Fall -MRI and CT Scan = may detect lesion in
-Loss Of Consciousness the brain and cereberal
-Stiffness of muscles degenerative changes
-Increased BP, HR, Salivation -EEG = May allow diagnosis of the type
and occurring seizure
Clonic Phase:
-Muscles Relax Completely
-Muscle tone returns which causes jerking
of head and Body

Post-ictal Phase:
-Semi-Conscious
-Poor Coordination
-Mild impairment of the motor
movements

Nursing Diagnosis :
- Risk for Fall
- Risk for Aspiration
Nursing Management:
- Risk for impaired
- Protect the patients head
elimination pattern
during the episode of
- Risk for injury
seizure Medical Management:
- Do not attempt to put - Administer diazepam as
anything into patients ordered
mouth - Give valproic acid as anti
- Try to turn the client into epileptic medication 10
the recovery position - Give Amlodipine to control
- Document the seizure patients highblood
episode pressure
 VI. REFERENCES

 Bregstrom Nancy. Braden Scoring retrieved from

https://www.mdcalc.com/braden-score-pressure-ulcers
 James WD, Berger TG, Elston DM. Dermatoses resulting from
physical factors retrieved from
https://medlineplus.gov/ency/patientinstructions/000740.htm
 Pressure ulcers. Merck Manual Professional Version.
http://www.merck.com/mmpe/sec10/ch126/ch126a.html. Accessed Dec.
16, 2016.

 Berlowitz D. Clinical staging and management of pressure-induced

injury. http://www.uptodate.com/home. Accessed Dec. 16, 2016.

 National Pressure Ulcer Advisory Panel (NPUAP) announces a change

in terminology from pressure ulcer to pressure injury and updates
the stages of pressure injury. News release. www.npuap.org.
Accessed April 13, 2016.

 The epilepsies and seizures: Hope through research. National

Institute of Neurological Disorders and Stroke.
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-
Education/Hope-Through-Research/Epilepsies-and-Seizures-Hope-
Through. Accessed May 24, 2017.

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