MORELOS CHARMANE L.

BSN 2Y2-3

COURSE TASK 13

Jack, age 6 years, was admitted to the pediatric unit for diagnosis and treatment of a possible
seizure
1. What are the two major foci of the process of diagnosis in a child with a seizure disorder?
(5pts)
It must first be determined whether Jack is having Focal (partial) or Generalized seizures. This
will assist in determining which part of the brain is the most impacted. A nervous system
diagnosis, such as a CT scan, MRI, EEG, and Lumbar tap, should always be performed.
Focal onset seizures start in one area and can spread across the brain and cause mild or severe
symptoms, depending on how the electrical discharges spread.
Generalized seizures can start as focal seizures that spread to both sides of the brain. They also
can occur as “generalized onset” seizures in which seizure activity starts simultaneously over
both sides of the brain. Generalized onset seizures usually start during childhood and are similar
to a thermostat surge or a light flash — abnormal regulation between parts of the brain causes the
seizures.
It is important for the doctor to get an accurate seizure diagnosis in order to implement the most
appropriate kind of treatment. Focal and generalized onset seizures usually have different causes and
accurately diagnosing seizure types often helps identify the cause for the seizures.

2. While the nurse is assisting with breakfast, Jack has a brief loss of consciousness. The nurse
noted that his eyelids twitched and his hands moved slightly. He then needed to reorient himself to
previous activity. How would the nurse keep Jack safe?
Based on the symptoms of what happened, Jack had an Absence Seizure. To help keep him safe we must
do the following interventions:
Maintain safe environment if client is experiencing prodromal signs or aura. Remove sharp
objects or steer client clear of dangerous situations if client tries to walk around. Explain
necessity for actions.
Keep padded side rails up with bed in lowest position, or place bed up against the wall, and add
floor pad if rails are not available or appropriate.
Document pre-seizure activity, presence of aura or unusual behavior, type of seizure activity,
such as location and duration of motor activity, loss of consciousness, incontinence, eye activity,
respiratory impairment, and cyanosis, and frequency or recurrence. Note whether client fell,
expressed vocalizations, drooled, or had automatisms, such as lip smacking, chewing, and
picking at clothes.
Stay with client during and after seizure.
The nurse must stay with the patient and call for help. It is important to time the seizure and note its
characteristics. Protection must be given to the patient’s head, especially with any convulsive movements
occurring that may injure the patient. You can protect the patient from harming themselves by placing
something soft under their head and shoulders. The surrounding area must be made clear to decrease the
risk of injury, however, do not try to physically restrict the movement of the patient’s limbs as this can
cause musculoskeletal damage. Do not put anything in the patient’s mouth or attempt to move them.