Lipa City Colleges College of Nursing

Febrile Seizure

Bautista, Gladys Cabrera, Donna Andrea Gonzales,Joen Gonzalvo,Marvie Manalo,Wendice Monsanto, Jill Frances Munar,Cristina Reye ,Gene Edward Valencia,Evangeline

Crispina Linang,RN,MAN Clinical Instruuctor

March 11-15,2013 Dra.Aracelli Medical Center

I.

Demographic profile Name: Patient X Address: Age: Gender: Civil status: Admitting Diagnosis: Chief complaint: convulsion Present Diagnosis:

II.History History of present Illness 1 day history of fever with rhino rhea vomit and colic and few weeks PTA general tonic clonic seizure (-) allergies (-) drugs

Past Medical history Family History (+) asthma (+)HPN father side mother

Socioeconomic history Developmental history Maternal History Nutritional History

IV.Physical Asssessment

Body part Skin

Method Use

Findings warm (-) rash Dry oral mucosa Supple

Significance Analysis

Heent Neck

Chest/Lungs Heart Abdomen Extremities Impression SFS

Clear breath sounds (-) murmur soft, tympanic

IV.Normal Anatomy and Physiology V.Pathophysiology VI.Diagnostic Procedures CLINICAL MICROSCOPY URINE ANALYSIS 10-30-12

EXAMINATION Color Transparency CHEM. EXAM

RESULTS Yellow Clear

Reaction Sp. Gravity Sugar Albumin MICROSCOPIC EXAM Pus Cells/ WBC RBC Epithelial Cells Amorphous Urates Bacteria Crystals Cast Others

6.0 1.010 Negative Negative

1-2/hpf 1-3/hpf Few Few Few

COMPLETE BLOOD COUNT 10/30/12 9:26 AM

RESULT FLAGS WBC 8.9 LYM 1.1 MID 1.1 GRA 6.8 LYM % 11.8 MID % 12.2 GRA % 76.0 RBC 4.42 HGB 11.4 HCT 34.0 MCV 77.0 MCH 25.8 MCHC 33.5 RDW 14.6 PLT 426 MPV 6.4 H H H L L L L SL SH SH SH SH SH

EXPECTED VALUES 5.0-11.0 1.5-3.0 0.1-0.5 3.0-5.8 25.0-35.0 1.0-7.6 50.0-65.0 4.40-5.00 12.0-16.0 37.0-47.0 80.0-96.0 27.0-32.0 32.0-36.0 9.0-14.5 180-400 0.0-0.0

CLINICAL MICROSCOPY URINE ANALYSIS 10-03-12

EXAMINATION Color Transparency CHEM. EXAM Reaction Sp. Gravity Sugar Albumin MICROSCOPIC EXAM Pus Cells/ WBC RBC Epithelial Cells Amorphous Urates Bacteria Crystals Cast Others

RESULTS Light Yellow Clear

6.0 1.010 Negative Negative

1-2/hpf 0-2/hpf Few Few Few

COMPLETE BLOOD COUNT 10/03/12

RESULT FLAGS WBC 4.4 L LYM 1.2 L MID 0.5 GRA 2.7 L

EXPECTED VALUES 5.0-11.0 1.5-3.0 0.1-0.5 3.0-5.8 25.0-35.0 H 1.0-7.6 50.0-65.0 4.40-5.00 12.0-16.0 37.0-47.0 L L 80.0-96.0 27.0-32.0 32.0-36.0 9.0-14.5 H H 180-400 0.0-0.0

LYM % 27.0 MID % 11.9 GRA % 61.1 RBC 4.76 HGB 12.0 HCT 37.4 MCV 78.6 MCH 25.2 MCHC 32.1 RDW 13.7 PLT 413 MPV 6.2

VII.Medical management VIII.Surgical management

IX.Drug Study Name of the drug Classification Action Indication Contraindication Nursing Responsibilities

X.Course in the ward XI.NCP XII.Discharge Planning M E T H O D