K.G. is a 5 year old kindergarten student that is brought to the ER by his mothe
ID: 124260 • Letter: K
Question
K.G. is a 5 year old kindergarten student that is brought to the ER by his mother after she witnessed apparent seizure activity. His mother describes it as jerking of both arms and legs, and that he wouldn’t answer when she called his name. She doesn’t remember much else, thinks it might have lasted a few minutes, but she is not sure “it seemed like forever”. She doesn’t know any family history, K.G. is adopted and health records were not provided. He has never had an episode like this before. Upon examination K.G. appears lethargic, makes eye contact when his name is called, but quickly drifts back to sleep. Vital Signs are unremarkable, shorts are damp and there is a urine smell. K.G.’s right arm is in a cast and there is ecchymosis on his right chest and abdomen. Upon questioning his mother reports he fell off the jungle gym at school last week.
What is the first assessment the nurse should perform? Provide rationale.
Explanation / Answer
Check the child vital signs. Most convulsions occur as a result of fever. The child has ecchymosis that may be a cause for fever. Assess the duration of seizures. If it is atypical and lasts more than 20 minutes, there is a chance of reoccurs. Undress the child. Because its shorts are wet and covered with the blanket. Assess the site of ecchymosis. To know the size and color of ecchymosis. The nurse should observe changes in facial expression, sound utterances or movements. Assess the eye for pupillary equality, size, reaction to light. Assess the mouth movements, teeth clenching, tongue biting. Assess the degree of consciousness, drowsy, confused alert. Assess the length of postictal sleep Assess for other physical changes such as bladder incontinence because the child shorts are wet.
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