CHAPTER ONE

INTRODUCTION OF PATIENT’S DISEASE

This is a case study of Miss A.A, a 22 months old girl who was admitted into the emergency
pediatric unit of Federal Teaching Hospital Ido , Ido-Ekiti, Ekiti-State about 3:50pm on the 12 th of
February, 2018, presenting with history of convulsion of several episode for 5days described as
generalized tonic clonic in nature with upward rolling of eye and grinding of teeth, she was said to
always have about 8-9 episode per day lasting about 2-3min and usually self-abortive also gain
consciousness in between episode. No history of fever prior onset the child was said to have fall a
week prior to onset of convulsion.

The child was said to have fever 2 weeks ago and was treated with antimalarial and antibiotics, she
was received and vital signs monitored and charted.

On examination, she was semiconscious, not pale, nill pedal edema, afebrile, acyanosis and no
obvious wound seen.

The vital signs observed on admission were as follows;

 Temperature-37.10c
 Pulse-128 b/m
 Respiration-34c/m

Other observations include;

 Weight-10 kilogram
 SPO2-91%

Following an assessment by the managing physician a diagnosis of Seizure disorder secondary to

severe malaria was made and the following investigations was done.

 Malaria parasite test

 Cerebrospinal fluid macroscopy and microscopy view
 Lumbar puncture
 Film appearance
 PCV
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  Genotype

The results of the investigations revealed;

Malaria parasite test

 Ringform of plasmodium falciparum(288,000)parasite seen(Hyperparasitemia)

Cerebrospinal fluid macroscopy and microscopy view

 Macroscopy – clear and colorless

 Microscopy – WBC(5x106/L)
 RBC(5x106/L)
 Direct gram; no organism seen after organism incubation at 370c

Lumbar puncture

 Rule out meningitis

Film appearance

 Hypocomia; Normal
 Polychromasia; Normal
 Microcytosis; Normal
 Target cell; Normal
 Sickle cell; Normal
 Nucleated RBC; Normal
 Platelet;++

Genotype; AA

PCV;41%

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After been reviewed with the results of the investigation, Her Seizures have been largely afebrile
though now having fever, Temperature was (37.90c), she was placed on the following medications;

 Iv phenytoin 150mg/kg start 8hourly for 24hours

 Iv fluid 4.3% dextrose saline 500mls 12hourly
 Iv Artesunate 30mg 12hourly for 24hours
 Cefixime syrup 40ml
 Phenobabitone 25mg 12hourly

Other plans include

 Keep seizure chart

 Vital signs monitor every 4hours
 Invite Pediatrics Neurologist

Miss A.A. was taken care of in emergency pediatrics unit to be transfer to pediatrics unit after
gaining full consciousness for further management.

During hospitalization, necessary nursing and medical care were duly rendered to Miss A.A to
enhance his quick recovery, She was discharge home on 23 rd of February, 2018, after spending 11
days on admission.

Seizure disorder Is an abnormal electrical discharge that occurs in the brain. Usually brain cells or
neuron, flow in an organized fashion along the surface of the brain .A seizure occurs when there is
an excess of electrical activity. Seizure can cause symptoms such as muscle spasms, limb twitches,
and loss of consciousness. They can also lead to changes in feeling and behavior.
(healthline.com,2016).

The aim of managing seizure is to reduce seizures frequency and severity, it also aims at
enhancing quality of life, to promote coping and improve external circumstances. also to prevent
premature death and in children to promote growth and development. However this is subject to
certain qualifications. For examples seizures frequency and severity is not to be reduced under all

3
conditions, but only when such reduction can be expected to have beneficial effects on quality of life
or on life expectancy. The proposed goal should not be considered in isolation, but incorporated in a
multidimensional model. (B. Brulde 2012).

Seizure happens because of abnormal electrical activity in the brain. It may go nearly
unnoticed. or, in some severe cases, it may cause unconsciousness and convulsions ,when the
body shakes. The signs and symptoms of seizure include; (healthline.com.2016).

 Losing consciousness followed by confusion

 Having uncontrolled muscle spasm
 Drooling or frothing at the mouth
 Strange taste in the mouth, biting of tongue and stalling

The goal of treatment in patient with seizure disorder is to achieve a seizure-free status
without adverse effects. This goal is accomplished in more than 60% of patients who require
treatment with anticonvulsants. (emedicine.medscape.com).

4
IDENTIFICATION DATA OF PATIENT

Name Miss A.A

Sex Female

Age 22months

Address 5,Obateru street, Anaye Ikere

Date of Admission 12th of February,2018

Religion Christianity

Nationality Nigerian

Tribe Yoruba

State of origin Ikere Ekiti

Hospital Federal Teaching Hospital Ido, Ido-Ekiti, Ekiti-State

Case Note Number 079607

Bed Number Bed 5

Next Of Kin Mr.A.A

Relationship Father

Diagnosis Seizure Disorder Secondary to Severe Malaria

Date Of Discharge 23th February, 2018.

5
OBJECTIVES OF THE STUDY

 To improve my knowledge on the cause, course of treatment and the management of seizure
disorder
 To participate in the care and management of Miss A.A.
 To provide quality nursing care to Miss A.A. In other to ensure her quick recovery.
 To prevent complication of seizure disorder in Miss A.A.
 To implement acquired knowledge in successful management of patient presenting with the
same case

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 CHAPTER TWO

LITERATURE REVIEW OF SEIZURE DISORDER

DEFINITION

Seizure disorder this is one of the great medical condition that are characterized by
episodes of uncontrolled electrical activity in the brain. Some seizure disorders are hereditary, but
others are caused by birth defects or environmental hazards, such as lead poisoning. Seizure
disorders are more likely to develop in patient who have other neurological disorders, psychiatric
conditions or immune-system problems. In some cases, uncontrolled seizures can cause brain
damage, lowered intelligence and permanent mental and physical impairment (medicinet.com
2016).

Seizure is a sudden surge of electrical activity in the brain. A seizure usually affects how a
person appears or act for a short time, many different things can occur during a seizure, Whatever
the brain and the body can do normally can also occur during a seizure.(Epilepsy foundation of
America. 2017).

The electrical activity is caused by complex chemical changes that occurs in nerve cells.
Brain cells either or inhibit other brain cells from sending messages. Usually there is a balance of
cells that excite and those that can stop these messages. However, when a seizure occurs, there may
be too much or too little activity, causing an imbalance between exciting and stopping activity. The
chemical changes can lead to surges of electrical activity that cause seizure. Seizure are not a disease
in themselves. Instead, they are a symptom of many different disorders that can affect the brain.
Some seizures can hardly be noticed, while others are totally disabling, The nature of seizure varies
because the lobes of the brain control different behaviors, movements and experience. (Epilepsy
foundation of America. 2017).

Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a
combination of these) that result from sudden excessive discharge from cerebral neurons (Hickey,
2009). A part or all of the brain may be involved.

Relationship between seizure disorder and severe malaria: It is estimated that

plasmodium falciparum caused over 500 million episodes of clinical malaria in 2002, and 70% of
this in west Africa. Falciparum malaria is said to be the most common cause of acute seizures and

7
convulsive status epileptic in children admitted to hospitals in malaria endemic regions of sub-
saharan Africa. Most of these seizures are likely to be acute symptomatic seizures rather than febrile
seizures since the infected erythrocyte adheres to the post-capillaries vessels in the brain and over
half of these seizures occur when the child is afebrile. Phenotype of acute symptomatic seizures and
various age groups, since parasitaemia is uncommon in children younger than six months of age we
did not model malaria attributable fractions for seizures for this group.(Berkley, 2011).

EPIDEMIOLOGY

PREVALENCE

Seizures are one of the most common neurological symptoms that occur in Infancy
and childhood. They represent many different disorders with many different causes Neonatal
seizures occur in ~1.5% of neonates, febrile seizures in 2-4% of young children and epilepsy in up to
1% of children and adolescents. Seizures provoked by other acute insults such as head trauma also
occur although their precise frequency in children is hard to estimate. Ultimately, Seizures are
symptoms of various neurological insults and conditions. Although neonatal seizures, febrile
seizures, and epilepsy overlap to a degree in that children with neonatal or febrile seizures are at
increased risk of epilepsy, these different disorders have somewhat different risk factors and their
own epidemiology. (Berg, 2013).

Furthermore, to the extent that environmental(e.g., infections, malnutrition) and

medical system factors ( including vaccination, prenatal care) and population genetics play roles,
very different risks and patterns are seen in different areas of the world . Within each of these sets of
disorders designated as neonatal or febrile seizures and epilepsy, there are many highly specific
conditions that, especially in the case of epilepsy, may have considerable implications for treatment
and prognosis and consequently may require care from a specialist (Berg, 2013).

INCIDENCE

Each year, about 150,000 children and adolescents in the united states will come to medical
attention for evaluation of a newly occurring seizure disorder of some type. Between 2% and 4% of
all children in Europe and the United State experience at least one convulsion associated with a
febrile illness before the age of 5 years. The cumulative incidence of febrile convulsions among

8
children ranges from about 1% in china to more than 8% in japan and 14% in Guam. The peak
incidence of a first febrile convulsion occurs in the second year of life. Between 0.5% and 1% of
children and adolescents experience a seizure associated with other acute metabolic or neurologic
insults; most of these occur in the neonatal period .The incidence of epilepsy (recurrent unprovoked
seizures) in children and adolescents seems relatively consistent across all populations studied,
ranging from 50 to 100/100,000. The highest incidence of epilepsy is in the first year of life. West

syndrome accounts for about 2% of all childhood epilepsy. Lennox-Gastaut syndrome for 1-2%,
childhood absence epilepsy (pyknolepsy) for 10-15%,juvenile myoclonic epilepsy for 5% and
idiopathic localization-related epilepsy for 10%. Between 0.5 and 1% of children experience a
nonrecurring, single, unprovoked convulsive episode. Following are the estimated numbers of
children and adolescents with newly diagnosed convulsive disorders in the united states for the year
1990: Febrile seizure, 100,000; Neonatal seizure, 4000; Other provoked seizures, 6000; Single
unprovoked seizures, 10,000; and epilepsy, 30,000 ( Camfield, 2015).

TYPES OF SEIZURE DISORDER

There are four different types of seizure disorder, which are;

 Generalized tonic-clonic seizure

 Focal seizure
 Absence seizure
 Atonic seizure

GENERALIZED TONIC-CLONIC SEIZURE

This is one of the seizure that involves the entire body. It is also called grand mal seizure.
The terms seizure, convulsion, or epilepsy are most often associated with generalized tonic-clonic
seizure. This may occur in people of any age. Or, They can occur as part of a repeated, chronic
illness(epilepsy).some are due to psychological problems(psychogenic) (Health and Human Service,
2015).

Many people with generalized tonic-clonic seizures have vision, taste, smell, or dizziness
before the seizure. This is called an aura. The seizure is often result in rigid muscles. This is

9
followed by violent muscle contractions and loss of alertness (consciousness). (Health and Human
Service, 2015).

Other symptoms that occur during the seizure include;

 Biting the cheek or tongue

 Clenched teeth or jaw
 Loss of urine or stool control ( incontinence)
 Stopped breathing or difficulty breathing

 Blue skin color

After the seizure, the person may have:

 Confusion
 Drowsiness or sleepiness that last for 1 hour or longer
 Loss of memory(amnesia) about the seizure episode
 Headache
 Weakness of one side of the body for a few minutes to a few hours following seizure (called
Todd paralysis). ( Health and Human Services, 2015).

FOCAL SEIZURE

This is also known as partial seizure; All seizures are caused by abnormal electrical
Disturbances in the brain. Partial (Focal) Seizures occurs when this electrical activity remains in a
limited area of the brain. The seizure can sometimes turn into generalized seizures, which affect the
whole brain. This is called secondary generalization. (Johns Hopkins, 2016).

Partial seizures can be divided into:

 Simple, not affecting awareness or memory

 Complex, affecting awareness or memory of events before, during, and immediately after the
seizure, and affecting behavior

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Partial seizures are the most common type of seizure in people one year and older. In people older
than sixty-five who have blood vessel disease of the brain or brain tumors, partial seizures are
very common .People with complex partial seizures may or may not remember any or all of the
symptoms or events during the seizure, depending on where in the brain the seizures starts,

Symptoms can include:

 Abnormal muscle contraction, such as abnormal head

Movements
 Staring spells, sometimes with repetitive movements such as picking at clothes

 Eyes moving from side to side

 Abnormal sensation such as numbness, tingling.
 Hallucination seeing, smelling, hearing things that are not there
 Abdominal pain or discomfort (Johns Hopkins, 2016).

ABSENCE SEIZURE

This is one of the several kinds of seizures. These seizures are sometimes referred to as petit mal
seizure( from the French for “little illness”. Absence seizures are characterized by brief loss and
return of consciousness, generally not followed by a period of lethargy

.Signs and Symptoms of absence seizure;

 Absence with Impairment of consciousness is the essential symptoms

 Absence with mild clonic component
 Absence with atonic component
 Absence with tonic component
 Absence with automatisms
 Absence with autonomic (Daly, 2011).

ATONIC SEIZURE

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 This are type of generalized seizure. They involve a sudden loss of muscle tone, So that
the child goes limp and falls to the ground. They are often present in children who also have other
seizure types ,such as tonic or myoclonic seizures. They occur in all groups, but more common in
children.
Atonic seizure can occur while standing, walking or sitting, and are often noticeable by
a head drop (The neck muscle relaxing) and injury may result from hitting the face or the head. As
with common epileptic occurrences, no first aid is need post-seizure, except in the instances where
falling injuries have occurred, In some cases, a person may become temporarily paralyzed in part of
his or her body. This usually does not last longer than 3 minute.

The seizure itself causes no injury, but the loss of muscle control can result in direct
injury from falling. Electroencephalography can be use to confirm diagnosis.

Possible signs and symptoms include;

 Sudden loss of muscle tone

 The child goes limp and falls straight to the ground
 The child remains conscious or has a brief loss of Consciousness
 Eyelids drop, head nods Jerking (Johns Hopkins 2016).

CAUSES OF SEIZURE DISORDER

Causes of seizure disorder include;

Abnormal level of sodium or glucose in the body: Sodium is an important element in maintaining
the body’s balance of fluids. Water usually goes to the areas of higher sodium concentration. The
sodium concentration of sodium is regulated by many factors, Including various hormones from the
brain and the kidneys. Hypernatremia is the medical term for the condition in which the sodium level
fall below the normal range. When this happens, Seizures can occur. (Ruben J.Nazario, 2017).

Brain infection including meningitis: The brain, the spinal cord, and its surrounding structures can
become infected by a large spectrum of germs. Bacteria and viruses are the most common
offenders .Parasites, fungi and other organisms can infect the central nervous system, although more
rarely.

12
The infection germ causes an inflammation of the affected area. Depending on the location of the
infection, different names are given to the diseases. (Merck & Dohme, 2018).

Brain injury that occur to the baby during labor or childbirth: Birth injuries causes seizure
brain injuries are among the most common forms of birth injuries and can result in neurological
problems like seizures. some of the most common birth injuries and related factors that contribute to
development of seizures include;

 Asphyxia( oxygen deprivation)

 Hypoxic ischemic encephalopathy
 Trauma to the head such as forced labor or improper use of delivery tools

 Placental complications
 Prolonged labor. (Birth injury guide, 2018).

Brain problem that occur before birth(congenital brain defects): In the united states alone, over
1 million people currently have some form of brain damage, and an overwhelming amount of these
people are infants. The medical costs associated with baby brain damage are astronomical, reaching
in the millions each year. Infant brain damage typically occurs during pregnancy, during the delivery
process, or shortly after birth. A variety of factors can cause infant brain damage, and it’s important
to look out for any telltale signs if you suspect baby is injured. One of the leading causes of infant
brain damage is lack of oxygen shortly after birth. (Birth injury guide,2018)

Brain damage caused by lack of oxygen falls into two categories: Anoxia and Hypoxia. Hypoxia
occurs when the infant is deprive of the adequate amount of oxygen, leading to mild to moderate
brain damage. Both hypoxia and anoxia can lead to cerebral palsy and a host of other medical
disorders. (Birth injury guide,2018)

The most common reasons while infants are deprived of oxygen at birth include:

 Umbilical cord problems

 Birth canal problems
 Blocked airway
 Placental eruption (Birth injury guide, 2018)
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Drug Abuse: Drug addiction is associated with many health issues and additional social and
economic problems. As far as health is concerned, in some individuals drug abuse may be a trigger
of seizures. It is also possible that sudden drug discontinuation in case the addiction has already
developed initiates seizures. All in All, there is a connection between abuse of certain substance and
seizures. (steadyhealth.com, 2018).

Electric Shock: Researchers have shown that an electric shock ranging from 120 to 52,000 volts can
cause neurologic and neuropsychological symptoms in human. Following an electrical injury, some
patients may show various emotional and behavioral effects such as memory loss and symptoms of
depression.

ER Pediatrician and toxicologist Dr. Benoit Bailey, in collaboration with pediatricians

pierre Gaudreault and Robert thivierge, assessed the prevalence of short-term neurologic and
neuropsychological symptoms as well as one year after an electric shock severe enough to require
24-hour cardiac monitoring. Their goal was to explore whether any symptoms were associated with
risk factors such as transthoracic current, neuromuscular spasms (tetany), loss of consciousness or
shock of 1000 volts or more.

The cause of neurologic and neuropsychological symptoms after an electrical shock is

unclear, says Dr. Bailey. several mechanism are probably involved, and observe that symptoms from
electrical shocks are similar to symptoms following a cranial trauma.(Sciencedaily.com 2018)

Epilepsy: A trigger is something that occurs fairly consistently before seizures and more often than
by chance. People living with reflex epilepsy have seizures that occur in response to a specific
stimuli, like flashing lights or by noises. Knowing what triggers seizure can help one to recognize
when a seizure may be coming and help one to be prepared to lesson the chance that one may occur
the next time one face a similar trigger.

What is reflex epilepsy: Some people may notice that their seizure occurs in response to
very specific stimuli or situations, as if the seizure is a reflex, There is a type of Epilepsy called”
reflex epilepsy” In this type seizure occur consistently in relation to a Specific trigger. For example,
one type of reflex epilepsy is photosensitive epilepsy where seizures are triggered specifically by
flashing lights. Other types of reflex epilepsies may be seizure triggered by the act of reading or by

14
noises. Those reflex epilepsy are not common, but knowing if you have this form of epilepsy will
help you learn how to manage them. (epilepsy foundation of America 2017).

PROGNOSIS OF SEIZURE DISORDER

One hundred and four unselected adolescent and adult seizure (between the range of 15 to 23 years)
treated in Lagos university teaching hospital were followed up for 3 years to determine their seizure
prognosis. They found out that 37% was completely free of seizures; marked improvement in 30%,
moderate improvement in 11%, slight improvement in 10% and no improvement in seizure control
in 13% of the patients. The study also indicated that prognosis of seizure control is more favorable
in, (Okazaki M, 2017).

 Patient with generalized tonic clonic than in partial seizure

 Patient with onset of seizures after the age of 10 years and in particular after the age of 30
years
 Patient with less frequent seizure
 Patient who started treatment within 2 years of onset of seizures
 Patient who had initially a normal electro encephalogram.

The prognosis of seizure control was less favorable in patient who were treated with native herbs by
traditional healers prior to hospital treatment probably because the majority of them started medical
treatment later than 2 years after the onset of seizure. (Okazaki M, 2017).

15
ANATOMY AND PHYSIOLOGY OF THE CENTRAL NERVOUS SYSTEM

DIAGRAM SHOWING THE CENTRAL NERVOUS SYSTEM

16
ANATOMY AND PHYSIOLOGY OF THE CENTRAL NERVOUS SYSTEM

DIAGRAM SHOWING THE NERVOUS SYSTEM

17
The nervous system consists of the brain and spinal cord. The central nervous system is thepart of
the nervous system that deals with consciousness at all level and it is also concerned with movement
and sensation of all time. This system supplies nerve to structure forming the head, trunk, limbs,
muscles and skin.( Mustapha 2010).

The brain is the largest part of the central nervous system and it lies within the cranium. The
brain plays a central role in the control of most of the bodily functions including awareness,
movements, sensations, thoughts, speech, memory as well as regulation of homeostasis

NEUROGLIA

The neurons of the central nervous system are supported by four typed of non-excitable glial
cells. Unlike nerve cells which cannot divide, glial cells continue to replicate throughout life. They
are astrocytes, oligodendrocytes, ependymal cells and microglia.

Neuroglia is also called glial cells or simply glia, they are non- neuronal cells that maintain
homeostasis, from myelin, and provide support and protect for neurons in the central and peripheral
nervous systems.( Ross and Wilson 2010).

ASTROCYTE

These cells form the main supporting tissue of the central nervous system. They are star
shaped with fine branching processes and they lie in a mucopolysaccharide ground substance. At the
ends of some of the processes are small swellings called foot processes.

Astrocytes are found in large numbers adjacent to blood vessels with their foot processes
forming a sleeve round them. This means that the blood is separated from the neurons by the
capillary wall and a layer of astrocyte foot processes which together constitute the blood brain
barrier.

Astrocyte get their name because they are star-shaped. They are the most abundant glial
cells in the brain that are closely associated with neuronal synapses. They regulate the transmission
of electrical impulses within the brain. (Verkhratsky, A. 2013)

18
OLIGODENDROCYTE
These cells are smaller than astrocytes and are found in clusters round nerve cell bodies in
grey matter, where they are thought to have a supportive function, an adjacent to and along thelength
of myelinated nerve fibres. The oligodendrocytes form and maintain myelin, having the same
function as schwann cells in peripheral nerve.

Oligodendrocytes are a type of large glial cell found in the central nervous system in the
central nervous system. Oligodendrocytes produce the myelin sheath insulating neuronal axons,
although some oligodendrocyte are not involved in myelination. (Ethan G. 2018)

EPIDENDYMAL CELLS
These are cells from the epithelial lining of the ventricles of the brain and the central canal
of the spinal cord. Those cells that form the choroid plexuses of the ventricles secrete cerebrospinal
fluid.

The ependymal is made up of ependymal cells called ependymocytes, a type of glial cell.
These cells line the cerebrospinal fluid – filled ventricles in the brain and the central canal of the
spinal cord. These are nervous tissue cells with a ciliated simple columnar shape much like that of
some mucosa epithelial cells. (Ethan G. 2018).

MICROGLIA

These cells may be derived from monocytes that migrate from the blood into the central
nervous system before birth. They are found mainly in the areas of the blood vessels. They enlarge
and becomes phagocytic, removing microbes and damages tissue, in areas of inflammation and cell
destruction.

Microglia are type of neuroglia(glial cell) located throughout the brain and spinal cord.
Microglia account for 10-15% of all cells found within the brain. As the resident macrophage cells,
they act as the first and main form of active immune defense in the central nervous system (CNS).
(Robert H.Miller, 2017).

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ANATOMY AND PHYSIOLOGY OF THE BRAIN

The central nervous system consists of the brain and the spinal cord. The peripheral nervous system
consists of the extensions of neural structures beyond the central nervous system and includes
somatic and autonomic divisions.

The brain is composed of 3 main structural divisions: the cerebrum, the brainstem, and the
cerebellum. At the base of the brain is the brainstem, which extends from the upper cervical spinal
cord to the diencephalon of the cerebrum. The brainstem is divided into the medulla, pons, and
midbrain. Posterior to the brainstem lies the cerebellum.(Ross and Wilson 2010)

THE CEREBRUM

The cerebrum is the largest component of the brain. It is divided into right and left hemispheres. The
corpus callosum is the collection of white matter fibers that joins these hemispheres.

Each of the cerebral hemispheres is further divided into 4 lobes: the frontal lobe, the parietal lobe,
the temporal lobe, and the occipital lobe. The medial temporal lobe structures are considered by
some to be part of the so-called limbic lobe.

The frontal lobe is distinguished from the parietal lobe posteriorly by the central sulcus . The frontal
lobe and parietal lobes are divided inferiorly from the temporal lobe by the lateral sulcus. The
parietal lobe is distinguished from the occipital lobe by the parieto-occipital sulcus on the medial
surface.

The cerebrum is further divided into the telencephalon and diencephalon. The telencephalon consists
of the cortex, the subcortical fibers, and the basal nuclei. The diencephalon mainly consists of the
thalamus and hypothalamus. The telencephalon of the cerebrum is disproportionately well-
developed in humans as compared with other mammals. (Ross and Wilson 2011).

Cortex and subcortical fibers

The outermost layer of the cerebrum is the cortex, which has a slightly gray appearance--hence the
term "gray matter." The cortex has a folded structure; each fold is termed a gyrus, while each groove
between the folds is termed a sulcus. Cortical anatomy is discussed in greater detail below.

20
Below the cortex are axons, which are long fibers that emanate from and connect neurons. Axons are
insulated by myelin, which increases the speed of conduction. Myelin is what gives the white
appearance to these fibers of the brain--hence the term "white matter."(Ross and Wilson 2010).

Basal nuclei (ganglia)

The basal nuclei (formerly referred to as the basal ganglia) comprise the caudate nucleus, putamen,
globus pallidus, subthalamic nucleus, and substantial nigra. Pairs of these structures bear different
names. The putamen and globus pallidus combined form the lentiform nuclei. The putamen and
caudate nucleus combined form the striatum. The striatum derives its name from the striped
appearance given by the gray matter connections bridging across the internal capsule. The basal
nucleus are closely integrated with the motor cortex, premotor cortex, and motor nuclei of the
thalamus and plays a crucial role in modulation of movements. (Ross and Wilson 2010).

The primary input to the basal nuclei is from the primary motor cortex and premotor cortex
(Brodmann areas 4 and 6) and consists primarily of the pyramidal cells in cortical layer V. These
excitatory projections lead primarily to the striatum. The striatum also receives input from the
dopaminergic cells of the substantial Ingra. In turn, the striatum sends inhibitory projections to the
Globus pallidus external and internal. The Globus pallidus external sends inhibitory projections to
the subthalamic nucleus, which sends excitatory projections to the Globus pallidus internal. The
Globus pallidus internal in turn projects to the ventral anterior and ventral lateral nuclei of the
thalamus.

Certain movement disorders can be traced to pathologies in the basal nuclei, the most notable being
Parkinson disease, which is related to deficiencies of dopaminergic cells of the substantial Ingra.
Huntington disease is a heritable disorder that involves degeneration of the striatum and leads to
progressive jerky, or chloroform, movement. (Ross and Wilson 2010).

Thalamus

Positioned between the brainstem and the telencephalon, the diencephalon is composed of the
thalamus, the epithalamus, the subthalamus, and the hypothalamus. The thalamus serves as a relay
station for ascending input to the cortex and receives information from each of the cardinal senses
(except smell). It is hypothesized that the thalamus serves a gating function in filtering information.

21
The anterior thalamic nuclei are functionally associated with the limbic system and share reciprocal
connections with the cingulate gyrus and the mammillary bodies. The medial nuclei project to the
frontal association cortex and premotor cortex, with reciprocal connectivity. (Ross and Wilson,
2010).

Hypothalamus

Thy hypothalamic nuclei lie in the walls of the third ventricle anteriorly. The hypothalamus is
involved in mediating endocrine, autonomic, visceral, and homeostatic functions. It can roughly be
divided into anterior, posterior, and middle groups of nuclei.

The anterior nuclei include the preoptic, the supraoptic, and paraventricular nuclei. The posterior
nuclei include the supramammillary nucleus, the mammillary nucleus, the intercalate nucleus, and
the posterior nucleus. The middle nuclei include the infundibular, tuberal, dorsomedial,
ventromedial, and lateral nuclei.

Parasympathetic control can be attributed to the anterior and medial nuclear groups, whereas
sympathetic control can be attributed to the posterior and lateral nuclear groups. Satiety can be
localized to stimulation of medial nuclei, and hunger can be localized to stimulation of lateral nuclei.
Other functions of the hypothalamus include regulation of body temperature, heart rate, blood
pressure, and water balance.

The hypothalamus has close connections with the cingulate gyrus, frontal lobe, hippocampus,
thalamus, brainstem, spinal cord, basal nuclei, and pituitary gland. (Ross and Wilson, 2011).

BRAINSTERM AND CRANIAL NERVE

The brainstem is the most ancient part of the brain. Structurally, it can be divided into the medulla
oblongata, pons, and midbrain. These three structures are briefly described below. Cross-sectional
anatomy of the brainstem is rather complex, given the multiple traversing pathways and cranial
nerve nuclei. (Ross and Wilson, 2010).

Medulla oblongata

The medulla oblongata, or simply medulla, is continuous with and superior to the cervical spinal
cord. There are several external anatomic features of the medulla that can be visible grossly.
Ventrally, the pyramids and pyramidal degustation is visualized just below the pons. These are the

22
descending corticospinal tracts. Just lateral to the pyramids, the rootlets of the hypoglossal nerve can
be seen as they exit the brainstem. Lateral to the rootlets of the hypoglossal nerve is the inferior
olive. Dorsolateral to the inferior olive, the rootlets of the 9th and 10th cranial nerves
(glossopharyngeal and vagus) exit.

Pons

Superior to the medulla lies the pons, the ventral surface of which has a characteristic band of
horizontal fibers. These fibers are the Ponto cerebellar fibers that are in turn projections from the
corticopontine fibers. They cross to enter the contralateral middle cerebellar peduncle and thus enter
the cerebellum.

On either side of the midline, there are bulges that are produced by the descending corticospinal
tracts. At the Ponto medullary junction, the 6th cranial nerve (abducens) can be seen exiting the
brainstem. Laterally, but anterior to the middle cerebellar peduncle, the fifth cranial nerve
(trigeminal) is seen exiting the brainstem. Below the middle cerebellar peduncle, the seventh and
eighth cranial nerves (facial and vestibulocochlear) can be seen exiting. Dorsally, the pons forms the
floor of the fourth ventricle. (Ross and Wilson,2011).

Midbrain

The midbrain, also termed the mesencephalon, is the superior most aspect of the brainstem.
Ventrally, the midbrain appears as 2 bundles that diverge rostrally as the cerebral peduncles.
Between the cerebral peduncles, the third cranial nerve (oculomotor) can be seen exiting. The fourth
cranial nerve (trochlear) exits dorsally and is unique in this regard. It then courses anteriorly against
the cerebral peduncles.

The posterior aspect of the midbrain has 2 pairs of characteristic protrusions, the superior and
inferior colliculi. The superior colliculi are involved in mediating the vestibulo-ocular reflex,
whereas the inferior colliculi are involved in sound localization. (Mustapha, 2010).

CRANIAL NERVE

There are 12 pairs of cranial nerves that function mainly to convey motor signals to and sensory
information from the head and neck. The lower cranial nerves have somewhat more complex
visceral functions that are not strictly limited to the head and neck. The cranial nerves are as follows:

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I: The olfactory nerve: relays information from the nerves of the olfactory epithelium to mesial
temporal lobe and frontal lobe structures

II: The optic nerve: relays visual information from the retina; the right and left optic nerves then
join at the optic chiasm, where they give rise to the optic tracts, which convey visual information to
the thalamus and brainstem and, ultimately, the visual cortex; optic gliomas can arise from the optic
nerve

III: The occulomotor nerve: is principally involved in the control of eye movements through its
innervation of the superior rectus, the medial rectus, the inferior rectus, and the inferior oblique
muscles

IV: The trochlear nerve: innervates the superior oblique muscle and is purely a motor nerve

V: The trigeminal nerve: is both a motor and sensory nerve and has 3 divisions, V

1, the ophthalmic Nerve; It is divided into two the maxillary and mandibular division it is involved
in conveying sensory information from the face and also in controlling the muscles of mastication;
vascular compression of the branches of the trigeminal nerve near its entry into the brainstem has
been associated with some types of facial pain, including trigeminal neuralgia

VI: The abducens nerve: innervates the lateral rectus nerve, allowing lateral eye movements

VII: The facial nerve: is principally involved in innervation of the muscles of facial expression and
also plays a role in tearing, salivation, and taste; Bell's palsy is a relatively common facial nerve
palsy

VIII: The vestibulocochlear nerve: is a purely sensory nerve that conveys auditory information
from the cochlea to the brainstem via the cochlear branch; the vestibular branch conveys
proprioceptive information about head position and movement from the inner ear to the brainstem;
acoustic neuromas are typically benign tumors that can arise from the vestibular portion of this nerve

IX: The glossopharyngeal nerve: is involved in taste and salivation, as well as sensation in the
oropharynx; the afferent limb of the gag reflex is mediated by the glossopharyngeal nerve

X: The vagus nerve: conveys visceral sensation to the brainstem and also controls some visceral
functions, such as heart rate and gastrointestinal motility

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XI: The accessory nerve: has contributions from a spinal component and innervates neck muscles
involved in head turning

XII: The hypoglossal nerve: is a motor nerve that innervates muscles of the tongue (Mustapha,
2010).

CEREBELLUM

The cerebellum occupies the posterior fossa, dorsal to the pons and medulla. It is involved primarily
in modulating motor control to enable precisely coordinated body movements. Similar to the
cerebrum, which has gyri and sulci, the cerebellum has finer folia and fissures that increase the
surface area.

The cerebellum consists of 2 hemispheres, connected by a midline structure called the vermis. In
contrast to the neocortex of the cerebrum, the cerebellar cortex has 3 layers: molecular, Purkinje, and
granular. There are 4 deep cerebellar nuclei: the fastigial, globose, emboliform, and dentate nuclei,
in sequence from medial to lateral. The afferent and efferent pathways to and from the cerebellum
exist within the 3 cerebellar peduncles.

In children, the cerebellum is a common location for tumors such as juvenile pilocytic astrocytomas
and;

medulloblastomas : In adults, the posterior fossa is a very common location for metastatic tumors
but also a common location for tumors such as

hemangioblastomas: Another pathology of the posterior fossa can occur when the cerebellar tonsils
descend below the foramen magnum; this is termed a Chiari. (Ross and Wilson, 2010).

PART OF THE BRAIN AFFECTED

A tonic clonic seizure usually begins on both sides of the brain, but can start in one side and spread
to the whole brain. A person loses consciousness, muscles stiffen, and jerking movements are seen.
These types of seizures usually last 1 to 3 minutes and take longer for a person to recover, A tonic-
clonic seizure lasting more than 5 minutes is a medical emergency (Robert fisher 2017).

25
Left and Right side of the brain: The brain is divided into two hemispheres, which are able to
perform functions independently of one another. It is a complex and hardworking organ. It is made
up of as many as 100 billion neurons or brain cells but only weighs 3 pounds. The left and right sides
of the brain are connected by a great number of nerve fibers. In a healthy brain, the two sides
communicate with one another. The two sides do not necessarily have to communicate, though if a
person has an injury that separate the two brain hemispheres, they are still able to function relatively
normally.(Daniel murrell, 2018)

Everyone has one side of their brain that is dominant and determines their personality,
thoughts and behavior. Left brained people are said to be more analytical, logical, numerical and
likely to think in words. While does with right brain are said to be creative, free-thinking and able to
see the big picture. Recent research suggests that the left brain and right brain theory is not correct.
A 2013 study looked at 3-D pictures of over 1,000 people’s brains. They measured the activity of
left and right hemispheres, using an MRI scanner. The result show that a person uses both
hemispheres of the brain and that there does not seem to be a dominant side, however, a person’s
brain activity does differ, depending on what task they are doing. (Daniel murrell, 2018).

FUNCTIONS AND CHARACTERISTICS OF EACH HEMISPHERE

Emotions: This is the domain of the right brain, In both human and non-human. Emotions are
expressed and recognized in others by the right brain.

Language: The left brain is more active in speech production than the right. In most people the two
main language areas, known as broca’s area and wernicke’s area are found in the left hemisphere.

Handedness: Left and right-handed people use the left and right brain differently. For example, a
left-handed person uses their right brain for manual tasks and vice versa. (Daniel murrell, 2018).

26
THE SPINAL CORD

The spinal cord is a long cylinder of nerves that runs from the base of the brain through the vertebral
canal to the backbone. It is part of the central nervous system (CNS) along with the brain.

It is divided into different segments. Each segment contains a pair roots made out of nerve fibres.
The two roots in the pair are called the dorsal (towards the back) and ventral (away from the back)
roots. The spinal cord is about 45 cm in length and 2 cm in diameter in adults, and is involved in
many important functions of the body

FUNCTION OF THE SPINAL CORD

The spinal cord carries out the following major functions:

1. Electrical communication: Electrical signals are conducted up and down the cord, allowing
communication between different sections of the body and with the brain, since the cord runs
through different levels of the trunk section.

2. Walking (also known as locomotion: During walking, several muscle groups in the legs are
coordinated to contract over and over again. Although the act of putting one foot in front of the other
while walking may seem simple to us, it has to be carefully coordinated by several groups of neurons
known as central pattern generators in the spinal cord! These neurons send signals to the muscles in
the legs, causing to the extend or contract, producing the alternating movements that are involved in
walking.

3. Reflexes: These are predictable involuntary responses to stimuli that involve the brain, spinal cord
and nerves of the peripheral nervous system (PNS).

NERVE SUPPLY TO PARTS OF THE BODY

The nerve supplies to various parts of the body by the branches of the spinal nerves are as follows;

CERVICAL PLEXUS OF THE NERVES

 Muscles and skin at the back and sides of the head

 Muscles and skin forming anterior and posterior parts of the neck
 Skin over the sternum

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 Diaphragm through the phrenic nerve, which is a branch of the cervical nerves

THORACIC SPINAL NERVES

 Intercostal muscles and skin

 Muscles and skin forming the anterior abdominal wall

LUMBER PLEXUS OF NERVES

 Anterior- lateral muscles of the thigh muscles and skin

 They control signal to the lower parts of the abdomen and the back, buttocks, some parts of the
external genital organs and parts of the leg.

SACRAL PLEXUS OF NERVES

 Hamstring muscles on posterior part of the thigh

 They control signals to the lower parts of the legs, the feet, most of the external genital organs
and the area around the anus.

COCCYGEAL PLEXUS

 Skin and muscles forming the pelvic floor

PATHOPHYSIOLOGY OF SEIZURE DISORDER

Think of a lightning storm on a warm, summer evening. Sometimes you can look in the clouds and
see random, rapid bursts of lightning shooting throughout the sky. Neurons in the brain look this way
during a seizure episode.

Neurons are nerve cells, which communicate through membrane potential, Positive and negative
ions in an appropriate balance inside and outside of a neuron determine if the neuron is at rest or at
work (i.e. sending messages). Ions are chemical messengers with positive or negative charges that
cause an electrical signal to be sent by the brain. A neuron is at a resting membrane potential when
the charge inside the cell is more negative than the outside. When a neuron is at work, its action
potential is engaged through the change in balance of positive and negative ions and an

28
electrochemical message is sent, which causes the body to voluntarily or involuntarily move, feel, or
behave. Thus, neurons are electrochemical messengers in the body.

During a seizure episode, the membrane potential of neurons is altered in a way that causes neurons
to be hypersensitive or overactive due to certain stimuli or triggering events. As we discussed, the
causes of seizures can be known or unknown. Environmental triggers can include loud noises, strobe
lights, and rhythmic music. Medical triggers include high fevers, infections, tumors, hypoglycemia,
poor nutrition (causing electrolyte imbalances), trauma, physical exhaustion, menses, and toxic
substances, such as medications, alcohol, and illicit drugs. Seizures can even have psychosocial
triggers, including emotional stress and shock. (Candice Jones 2018)

CLINICAL MANIFESTATION OF SEIZURE DISORDER

Depending on the location of the discharging neurons;

 Seizure may range from a simple staring episode (absence seizure) to prolonged convulsive
movements with loss of consciousness.
 The initial pattern of the seizures indicates the region of the brain in which the seizure
originates, only a finger and hand may shake, or the mouth may jerk uncontrollably.
 The person may talk unintelligibly; may be dizzy and may experience unusual or unpleasant
sights.
 Unpleasant sounds, odors, or taste, but without loss of consciousness (Hickey,2009).
 Generalized seizure often involve both hemisphere of the brain, causing both sides of the body
to react.
 Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and
contraction( generalized tonic-clonic contraction).
 The simultaneous contractions of the diaphragm and chest muscles may produce a
characteristic epileptic cry.
 The tongue is often chewed, and the patient is incontinence of urine and feces
 After 1 or 2 minutes, the convulsive movements begin to subside, the patient relaxes and lies in
deep coma, breathing noisily.
 The respiration at this point are chiefly abdominal. In the postictal state (after the seizure), the
patient is often confused and hard to arouse and may sleep for hours. Many patient may report
headache, sore muscle, fatigue, and depression

29
 Generalized seizures may also be asymptomatic, as with absence types of seizures.
 Focal seizures have no natural classification. There may be an impairment of consciousness or
awareness or other dyscognitive features. Berg et al. 2010).

DIAGNOSTIC PROCEDURES

The diagnosis assessment is aimed at determining the type of seizure, their frequency and severity,
and the factors that precipitate them;

History taking and physical examination: These include events of pregnancy and childbirth, to
seek evidence of preexisting injury. The patient is also question about illnesses or head injuries that
may have affected the brain. The patient is observed closely from head to toe and presences of
generalized muscle spasm are documented, this helps to gather that from signs and symptoms
presented by the patient.

Laboratory investigations: This include biochemical, hematologic, and serologic studies. Magnetic
resonance imaging is done to detect structural lesions such as focal abnormalities, cerebrovascular
abnormalities, and cerebral degenerative changes. Electro encephalogram furnishes diagnostic
evidence for a substantial proportion of patient epilepsy and assist in classifying the type of seizure.

GENERAL MANAGEMENT OF SEIZURE DISORDER

NURSING MANAGEMENT

Admission: patient is admitted in a noise-free ward, with the bed not at a higher level, to prevent
patient from falling.

Maintenance of airway: airway should be cleared by adjusting the position of the head extension,
suctioning of the nose and mouth secretions.

Physical examination: Auscultation of breath sounds every 2-4 hours to detect upper respiratory
problems due to fluid or secretions.

Observations: The vital signs are important to determine further deviation from normal. This is
done every 2 hours. Temperature should be checked and charted regularly.

Protection from injury: Patient is admitted on a bed with side rails to prevent falling which may
cause injury. Violent convulsive spasm may include physical injury; bed should be padded and put

30
in place to prevent injury and patient from falling off the bed. Stimuli such as noise including
handling of patient and bright light are likely to increase spasm and pains; hence, they should be kept
minimal.

Nutrition and fluid: The patient is unable to tolerate anything orally due to spasm of the muscles
that help in chewing and swallowing. Feeding is done parentally to prevent aspiration pneumonia
during oral fluid intake. Intravenous fluids are given to correct electrolyte imbalance and replace
fluid loss. A high calorie feed to provide for energy expanded during muscular contraction should be
commenced through nasogastric tube feeding as soon as control muscular spasm is achieved. As
patient condition improves, oral fluids and food may be commenced.

Physical care: patient should be assisted in normal daily activities like bed bath, oral care. It helps to
aid patient personal hygiene.

Elimination: Fluid intake and urinary output should be monitored. A urinary catheter may be used
to drain urine directly from the bladder because urinary retention is likely common when perinea
muscles are affected. A stool softener or rectal suppository may be administered to overcome
constipation resulting from muscle spasticity.

Medication: Ensure all prescribed medications are given to the patient at the appropriate time.
Ensure proper documentation after serving the medication to the patient.

Control of spasm: The spasm is controlled with the administration of diazepam to relax the
muscles. Prevention of pneumonia with the use of antibiotics.

Rehabilitation/physiotherapy: the patient should be encourage to perform active and passive range
of motion exercise which involves slow movements of the extremities after contraction has stopped.
Contraction and spasms in range of motion are consequences of prolong immobility. Intake should
be improved overtime as the patient tolerates it.

DAY TO DAY MANAGEMENT OF MISS A.A

The following are the nursing managements rendered to Miss A.A from the day she was admitted till
the day she was discharged.

12th February, 2018 .

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 Miss A.A was admitted into emergency pediatrics unit inside a baby cot to prevent injury of
falling from height.
 Convulsed shortly after presentation in to the hospital which was aborted on it own
 Vital signs were checked and recorded and it reads thus;

Temperature-37.1ocelsius, Pulse-128 beats per minutes, Respiration-34 cycles per

minute.

 She had iv phenytoin 150mg given

 Iv fluid 4.3% dextrose saline 500mls at 14drop per minutes was put up
 Patient convulsed, and was aborted with iv diazepam 5mg start.
 Intake and output was monitored and charted
 Patent airway was ensured
 Adequate nursing care rendered
 Seizure was closely monitored
 Mother was psychologically supported

13th February, 2018

 Personal hygiene attended to, bed bath and oral care done.
 Bed linen changed and made comfortable in bed
 Intravenous fluid 4.3% dextrose saline dripping into the vein
 Vital signs done and charted
 Temperature read 37.6oc and patient was tepid sponge
 Malaria parasite result came out and positive
 Iv artesunate 30mg commenced
 Iv ceftriaxone 1g and Iv gentamicin 20mg

14th February, 2018

 Patient was made calm on bed

 Bed bath and oral care attended to
 Vital signs checked and properly charted
 Medication was served and properly tolerated

32
 Patient made comfortable
 Mother was psychologically supported

15th February, 2018.

 She was transferred to children pediatrics ward inside a baby cot

 Vital signs was checked on arrival and read; temperature-36.9oc, Pulse-116 beat per minute,
Respiration-32 cycle per minutes.
 Patient convulsed for about 35 seconds and aborted on it own
 Intake and output chart monitored
 Reviewed on Tab carbamazepine 50mg
 Tab artesunate 50mg, Tab camoquine 100mg
 She had tab carbamazepine 50mg given and well tolerated
 Iv phenytoin was changed to Iv phenobarbitone 25mg 12hrly and commenced

16th February, 2018

 Personal hygiene attended to, bed bath and oral care done.
 Had an episode of seizure and was self-aborted
 Iv drugs were administered as per chart
 Vital signs done and properly charted
 Temperature read about 37.8oc and tepid sponging was done
 Total care rendered
 Mother was psychologically supported

17th February, 2018.

 Personal hygiene was attended to

 Vital signs done and properly charted
 Medication served and well tolerated
 Patient had a generalized seizure that lasted for 30-45 seconds, aborted with 2mls of
paraldehyde, 5mg of diazepam Im was given
 Patient was suction to keep air way patent
 Patient was closely monitored

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  Seizure chart closely monitored

18th February ,2018

 Patient was still convulsing

 Several episode and self-aborted
 Personal hygiene rendered
 Iv line re-established due to infiltration
 Parent was reassured

19th February, 2018.

 Bed linen straighten and patient was made comfortable

 Iv cannula was on the left leg
 Medication served and well tolerated
 Patient had a calm shift no episode of seizure
 Vital signs were taken and recorded

20th February, 2018.

 Personal hygiene including bed bath, oral care done

 Vital signs was done and recorded
 Medication was served; Iv phenobabitone 25mg, cefixime syrup 40mg
 Adequate bed rest was ensured
 Total nursing care was rendered

21th February, 2018.

 Vital signs was done and properly charted

 Medication was served and properly tolerated
 Patient was closely monitored
 Parent was psychologically supported and reassured

22th February, 2018.

34
 Vital signs were checked and recorded; Temperature-37.0oc, Pulse-108 beat per minutes,
respiration-30 cycle per minute.
 She was discharge home in good condition by the managing team
 Personal hygiene was ensured
 Patient parent was psychologically prepared for home discharge
 Parent was encourage on the need for the baby to take adequate nutrition
 Parent was encouraged on the need for follow up care.

35
DATE NATURE SPONTANEOUS METHOD OF ABORTION

12/2/2018
4:25pm Generalized 10seconds Self aborted
4:40pm Generalized 3seconds Self aborted
13/2/2018
9:20am Generalized 5seconds Self aborted
1:14pm Generalized 10seconds Self aborted
2:50pm Generalized 10seconds Self aborted
4:30pm Generalized 1min 45seconds Iv diazepam 5mg
14/2/2018
1pm-6pm No seizure

15/2/2018
3pm Generalized 30seconds Self aborted
6pm Generalized 1minutes Aborted with iv diazepam
16/2/2018
1:10pm Generalized 25seconds Self aborted
4:20pm Generalized 5-10minutes Aborted with 5mg diazepam
17/2/2018
2:12am Generalized 30seconds Aborted with 2.5mg of diazepam
4:00am Generalized 30seconds Aborted with 5mg of diazepam
1:20pm Generalized 1minutes Self aborted
18/2/2018
5:00am Generalized 2minutes Iv diazepam 5mg
10:00am Generalized 15seconds Self aborted
3:10pm Generalized 20seconds Self aborted
6:40pm Generalized 10seconds Self aborted
5am Generalized 10seconds Self aborted
SEIZURE CHART

ADVICE ON DISCHARGE

36
The aim of giving advice on discharge is to ensure continuity of care and maintenance of health.
Patient parent was advice on the following.

Diet: The parent was advised to give at least three balanced meals a day to the child. Which are rich
in proteins, minerals and vitamins to facilitate proper body functioning.

Stress reduction and rest: The parent was encouraged to closely monitor the child for dangerous
plays and to take adequate rest. This is done to minimize stress and aid optimum level functioning.

Health education: parent was health educated on how to prevent injury, monitor the child
movement, The use of medication as properly described by the physician.

Frequent follow-up care: The importance of follow-up treatment was emphasized so as to monitor
the health progress of the patient, and the need to comply with follow-up treatment appointments
should also be stressed out.

FOLLOW-UP CARE

Contact was kept with the patient after discharge on phone to ask about and monitor the
patient’s health. Patient was encouraged on how to identify, prevent and avoid subsequent re-
occurrence. Parent was reminded about compliance with drug regimen and good personal hygiene.

REHABILITATION

Rehabilitation of the patient began on the first day from the first day of admission throughout
the period of hospitalization and discharge. This was done in order to promote healing and to help
reduce the period of hospitalization.

The following are the rehabilitative measures that were ensure from the period of
hospitalization to discharge.

 Adequate information on the disease condition, the cause, importance of early intervention
and its prognosis
 As condition improved, intravenous line was discontinued and oral fluid diet was commenced
 Passive and active exercises of the joints were ensured.
 Patient was able to feed normally before discharge.

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 CHAPTER THREE

PHARMACOLOGY OF DRUGS

PHENYTOIN

Therapeutic category: Anticonvulsant

Mode of Action: It inhibits paroxysmal discharges from epileptogenic foci or areas within the brain
by modifying ionic activities of sodium, potassium and calcium, thereby preventing or blocking
seizure activity within the motor cortex.

Indication: Grand mal Epilepsy, Status Epilepticus, Digitalis induced Arrhythmias, head trauma,
post-surgery on brain.

Route of Administration: Orally, Intravenously, And Intramuscularly.

Dosage: 50-100mg twice or thrice daily with or after meals. Maintenance dose is 5mg-8mg per kg
body weight once daily orally.

Side effect: Gingival hyperplasia (swelling), Ataxia, Dermatitis, vomiting, constipation, headache.

Contraindication: Hepatic disorder, hypersensitivity to hydantoin products, hypoglycemic seizures,

First Trimester of pregnancy.

Nursing Actions:

 If given intravenously, it should run at a rate of 50mg per minute in normal saline.
 Monitor the patient’s blood pressure and pulse rates.

CEFIXIME:

Therapeutic category: Antibiotics

Mode of Actions: It inhibits the synthesis of bacterial cell wall, mitosis and growth of bacterial.

Indication: Gonorrhea, Urinary Tract Infections, Respiratory Tract Infections, Sinusitis, Skin and soft
tissue infections.

Route of Administration: Orally

Dosage: Adult and Children over 10years 200-400mg daily in one to two divided doses. Children
over 6months old 8mg/kg daily in 1-2 divided doses. 6months to 1year 75mg daily. 1-4years 100mg
daily. 5-10years 200mg daily. For Gonorrhea 400mg as a single dose.

38
Side effect: Nausea, vomiting, Abdominal discomfort, Headache, Allergic reaction (like rashes,
pruritus, Urticaria, Serum sickness).

Contraindication: Hypersensitivity to cephalosporin.

Nursing Action:

 Don’t administer to patients with history of Stevens-Johnson syndrome and a case of

hypersensitivity to cephalosporin.

PHENOBARBITONE

Therapeutic category: Anticonvulsant, long-acting barbiturate.

Mode of Action: It raises the threshold for electrical stimulation of the motor cortex and reduces
the transmission of impulses in nerve cells. It also promotes bilirubin conjugation and excretion,
hence it is used for rhesus hemolytic disease of the new born, It inhibits post-tetanic potentiation
and raises the seizure threshold.

Indication: All forms of epilepsy, Febrile convulsion, Rhesus hemolytic disease of the newborn.

Route of Administration: Orally, Intravenously, Intramuscularly, Rectally.

Dosage: 30-120mg twice or thrice daily.

Side effect: Respiratory failure, hypotension ( if given intravenously), skin rashes, nystagmus,
hepatitis, folate deficiency in long-term use.

Contraindication: Acute intermittent porphyria, pregnancy, lactation, hepatic and renal disease.

Nursing Action:

 It should not be withdrawn suddenly to avoid the precipitation of seizures.

 Should not be given intravenously since it may cause respiratory arrest or hypotension.

GENTAMICIN

Therapeutic category: Aminoglycosides.

Mode of Action: It binds irreversible to 30s (ribosomal unit) to inhibit bacterial ability to synthesis
protein necessary for it normal function and replication.

39
Indication: treatment of systemic infection such as gastro intestinal tract- peritonitis, pneumonia,
respiratory tract, central nervous system disorder, pyelonephritis, prostatis.

Route of administration: intramuscularly, intravenously.

Dosage: 3-5mg per kg per day in divided doses.

Side effect: Nausea, vomiting, diarrhea, ototoxicity, nephrotoxicity, confusion, tremor.

Contraindication: Patient with known allergic to any aminoglycoside, pregnancy, lactation.

Nursing Actions:

 Obtain specimen for culture and sensitivity before given first dose.
 Monitor the patient for signs of ototoxicity, before administering each dose. Assess the
patient balance and gross hearing.
 Monitor laboratory test, such as renal, hepatic function test.
 Monitor intake and output of the patients.

CARBAMAZEPINE

Therapeutic category: Anticonvulsant, anti-epileptic and psychotropic drug.

Mode of Action: It inhibits the spread of seizure activity by reducing post-tetanic potential at the
synapses and invariably reducing the maximal activity of the brain stem centers responsible for the
tonic phase of grand mal seizures. It stabilizes hyper-excited nerve membranes, inhibits repetitive
neuronal discharges and reduces the synaptic propagation of excitatory impulses.

Indications: Psychomotor grand mal epilepsy, pain of trigeminal neuralgia, usually used when other
drugs are ineffective. Diabetic neuropathy Alcoholic withdrawal syndrome.

Route of Administration: orally, suppository.

Dosage: Adults, initially 100-200mg once or twice daily in tablet or oral suspension. Maximum
general dose is 400mg 2-3 times daily.

Side effects: Dizziness, fatigue, Diplopia, Bone marrow depression, Drowsiness, Nausea, vomiting,
Dry mouth.

Contraindication: Hypersensitivity to tricyclic compounds, history of bone marrow depression,

history hepatic porphyrias.

Nursing Actions:

40
  Advice the patient to report any easy bruising, bleeding, sore throat or malaise resulting
from blood dyscrasias.
 To avoid driving or operating hazardous equipment because of drowsiness.
 It should not be use as a routine analgesic, since it is for the pain of trigeminal neuralgia
specifically.
 The tablet and the oral suspension must be shaken before use and may be taken during or
after or before meals.

CEFTRIAXONE

Therapeutic category: Antibiotics.

Mode of Action: It inhibits the synthesis of bacterial cell wall, mitosis and growth of bacterial.

Indication: Infectious fever, Gonococci infection, meningitis, urinary tract infection.

Route of administration: Intramuscularly, Intravenously.

Dosage: 1-2g daily or 500mg-1g twice daily.

Side effect: Abdominal pains, pruritus, Diarrhea, mouth soreness.

Contraindication: history of hypersensitivity to penicillin.

Nursing Actions:

 Use with caution if patient is hypersensitive to penicillin.

 Instruct client to take full course of drug to maintain therapeutic blood level.

4.3% DEXTROSE SALINE

Therapeutic category: parenteral electrolyte solution.

Mode of Action: 4.3% Dextrose in saline improves the patient’s condition by increasing the level of the
blood sugar, and increasing the blood volume, possessing the sodium chloride content.

Indication: It is used for the treatment, control, prevention and improvement of the following diseases;
fluid and nutrient replacement, low sodium levels, low potassium levels, low magnesium level, low calcium
level, blood and fluid loss.

Route of administration: Intravenously.

Dosage: 100-1000ml per day for infants, 200-2000ml per day for children, 1-3 L in adults depending on the
age, weight and condition of the patients.

41
Side effect: Increased blood glucose, blood clot, inflammation of injection site, nausea, vomiting, muscular
twitching, congestion, diarrhea.

Contraindication: Hypersensitivity to 4.3% dextrose saline, congestive heart failure, liver cirrhosis, severe
renal impairment, sodium retention and oedema.

Nursing Action:

 Monitor vital signs closely especially blood pressure, apical beat, pulse, respiration and temperature.
 Monitor site of infusion for edema, phlebitis and venous thrombosis.

ARTESUNATE

Therapeutic category: Anti-malaria drug.

Mode of action: it has effect on chloroquine resistant falciparum malaria having a remarkable
inhibitory and gametocidal effect on falciparum gametocyte, it is a schzonticide.

Indication: falciparum malaria, vivax malaria.

Route of administration: orally, intravenously, intramuscularly.

Dosage: Adult 1-2 tablets of 100mg, for children 1-2mg tablet per kg.

Side effect: No side effect when recormemded dose are taken strictly.

Contraindication: Pregnancy, lactation.

Nursing Actions:

 Avoid over dose

 Consult the doctor before using during pregnancy and lactation especially during the 3
month of pregnancy.

DIAZEPAM

Therapeutic category: Anxiolytic drug

Mode of action: It sedates the central nervous system and also relaxes the muscles thereby
producing anticonvulsant, anti-anxiety and muscle relaxant effects.

Indication: Insomia, anxiety states, multiple sclerosis, status epilepticus,Agitation.

Route of administration: orally, intravenously, intramuscularly, rectally.

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Dosage: usually 2-5mg thrice daily. For status of epilepticus 10-20mg intravenously at a rate of
0.5ml.

Side effects: Sleepiness, memory disorder, skin rash, dizziness,headache, slurred speech,
drowsiness.

Contraindication: known allergy to benzodiazepine, respiratory failure, Acute narrow angle

glaucoma.

Nursing Actions:

 It should not be taken with alcohol since it will potentiate the action of valium.
 There should be restrictions of its use in liver, as well as in pregnancy and lactation.
 Should be advice not to drive or operate machinery while on valium because of dizziness.
 Valium should not be mixed with other drugs in the same syringe.

COMPLICATIONS OF SEIZURE DISORDER

Cognitive and behavioral complication

Complications affecting your cognitive and behavioral functioning generally stem from
complex partial seizures, this seizure affect the limbic structure in the brain. this structure is
responsible for emotions and motivation. When areas of the brain, such as the hippocampus and
hypothalamus become damaged over time due to seizure activity, cognitive and behavioral
complications result.

INJURIES

Injuries are common complications of tonic-clonic seizures, during these episodes epileptic
lose consciousness and may fall to the floor if not in a safe position when the seizure begins

ACCIDENTS

Epileptics are at an increased risk for accidents versus those who are not diagnosed with this
condition, perhaps the most dangerous are car accidents if a person loss consciousness while
driving the results could be fatal for both the person and the other drivers on the road.(Hannah rice
myers, 2017).

43
PATIENT’S HISTORY (USING THE ELEVEN HEALTH PATTERN BY GORDON)

1. STATE OF HEALTH

Past medical History: Miss A.A had no history of hospitalization

Present Medical History: She was admitted into the Emergency Pediatric unit of the

hospital presenting with history of convulsion of several episode associated with upward rolling
of eye, grinding of teeth. Patient confirmed an history of falling a week prior to onset of the
presentation.

On examination, she was semiconscious, not pale, nill pedal edema, afebrile, acyanosis and no obvious
wound seen.

Vital signs on admission

Temperature : 37.10c

Pulse :128 beat per minute,

Respiration:34 cycle per minute.

Nutrition: Miss A.A. eats three times a day before the onset of illness and prefers Rice and stew.

Elimination: patient opens her bowel daily and she voids normally whenever she has the urge to
do so but occasionally open her bowel during hospitalization.

2. ACTIVITY AND EXERCISE: She performed some of her activities of daily living unaided like Sitting,
working, and playing but this has been altered due to the illness.
3. SLEEP AND REST: He sleeps regularly, for at least 8hours before the onset of the illness, but he had
insomnia since the illness started.
4. COMMUNICATION AND SPECIAL SENCES: She communicate with gestures or saying words Little by
little to his parent especially in Yoruba language, All her special senses are intact.

5. FEELING ABOUT SELF IMAGE: She feels good about herself but a little bit disturb because of Her illness.

6. FAMILY/SOCIAL RELATIONSHIP: She is from a monogamous family and the third of 3 children. She relate
well with other members of the family.

7. SEXUALITY/REPRODUCTION: She is not married, not of reproductive age.

8. COPING WITH STRESS: She copes well with stress.

9. VALUES AND BELIEFS: She believes in God.

10. OTHER INFORMATIONS i.e (HABITS): She does not drink alcohol or smoke.

11. GENERAL INSPECTION ( HEAD-TOE)

44
 Head: She as a well groomed hair, No lice in the hair.
 Eye: The two eyes are symmetrically positioned with no discharges, not pale, anicteric.
 Nose: The nose is well placed above the mouth with no abnormality.
 Ear: no discharge from ears, and any abnormal growth or infection.
 Mouth: There is difficulty and pain associated with opening the mouth.
 Neck: No abnormal growth, no goiter, but there is difficulty in neck rotation.
 Chest: No scars on the chest region, nipples are well placed.
 Upper limbs: They are symmetrically placed, No abnormality detected.
 Abdomen: The abdomen is not distended. No presence of scar.
 Lower limbs: They are symmetrically placed, no abnormalities detected.

45
 CHAPTER FOUR

NURSING CARE PLAN FOR MR A.A, A PATIENT WITH SIEZURE DISORDER

S/N NURSING NURSING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTIO RATIONALE
N
1 Ineffective Miss A.A will 1. Assess 1. To serve as Miss A.A
breathing breathe with airway and baseline data breathe with
pattern ease at the vital signs and progress ease at the
related to rate of 25-30 especially the of client rate of 30
several cycles per respiratory condition. cycles per
episode of minute within rate. minute after
convulsion 30-45 30 minutes of
evidence by minutes of 2. Put her in 2. To drain nursing
increased nursing lateral position out any intervention.
respiratory intervention. i.e recovery secretion
rate of 37 position. from the
cycles per mouth and to
minute. prevent
aspiration.
3. Check the 3. To remove
airway for any
clearance, obstruction
suction from the
mucous with mouth.
suctioning
machine.

4. Give oxygen 4. To ensure

when adequate
necessary. intake of
oxygen.

2 Hyperthermia Miss A.A’S 1. Check body 1.This serve Miss A.A

related to the body temperature as baseline temperature
effects of temperature using a data reduces to 36
parasite in will reduce by thermometer. degree
the blood 0.5 to 1 Celsius after
stream degree 2. Expose Miss 2. This allows 30 minute of
evidence by Celsius within A.A to fresh heat loss nursing
thermometer 30minutes of air. through intervention.
reading of nursing convection.
38.0 degree intervention.

46
 Celsius. 3. Tepid 3. This
sponge ensures heat
patient. loss by
evaporation.
4. Administer 4. It act on
prescribed the resistance
antipyretic and falciparum
antimalarial malaria to
drug e.g iv cause a
artesunate reduction in
30mg. body
temperature.
3. Anxiety Parent level 1. Assess the 1. This serves Miss A.A’s
(parent) of anxiety will level of as baseline parent
related to reduce within anxiety. for planning. verbalized
unknown 30 minute – 1 and express
prognosis of hour of 2. Allow 2. It helps to less anxiety
the disease nursing expression of identify fears after 45
evidence by intervention. fear. and clarifies minutes of
parent facial his concern. nursing
expression. intervention.
3. Answer all 3. Honesty
Questions establishes
honestly and trust and thus
thoroughly. helps relieve
Anxiety.

4. Reassure 4. This
and give promotes
psychological boldness and
support. calmness.

47
 CONCLUSION

This is a case study of Miss A.A, a 22months old girl who was admitted into Federal
Teaching Hospital, Ido-Ekiti, on 12th of February, 2018 on account of several episode of convulsion,
upward rolling of eye, grinding of teeth, She was said to have 8-9 episode per day lasting for 5-6
minutes. The child was said to have fall a week prior to onset of the presentation. After several
investigations and assessment, a diagnosis of generalized seizure disorder was made and she was
nursed in a quiet place under close monitoring, observations closely monitored, due drugs duly
administered, fluid therapy was ensured in order to maintain hydration, Appropriate nursing and
medical interventions were ensured to enhance her quick recovery and health status and no
complication was noticed. She was discharged home in good condition on 22nd of February, 2018.
She came back for follow-up on 5th of March, 2018 and she was observed to be recovering rapidly.

During the course of study, diverse knowledge was acquired about the definition,
causes, nursing and medical management of seizures. Seizure is a life threatening disease which
could be fatal with serious complications if left untreated, but with prompt medical intervention,
patients with seizure disorder attain full restoration and back to normal condition.

48
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David, ko. (2018): Seizure treatment and management. Accessed April 2, 2018 from

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Hannah rice myers. (2017): Complication of seizure disorders. New edition, Lagos

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