[PEDIATRIC NURSING] PICU CASE STUDY - Epilepsy

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[PEDIATRIC NURSING] PICU CASE STUDY - Epilepsy에 대한 보고서 자료입니다.

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A. ASSESSMENT:
I. REASON FOR HOSPITALIZATION:
a. Describe reason for hospitalization: Rigidity aggravation for 7 days
b. Medical Diagnosis : Epilepsy, unspecified, With intractable epilepsy
Congenital malformation of brain, unspecified
c. All signs and symptoms : vomiting, coughing, seizure & rigidity, stridor, cyanosis

II. HISTORY OF PRESENT ILLNESS
Known #Pontocerebellar hypoplasia # Hearing defect # Convulsive disorder # High arch palate로 Phenobarbital ~2.5mg/kg/d, keppra ~0.2ml/kg/d med하는 환아로 평소에도 feeding(FF,160-200cc*4/day) 시마다 chocking(#4/day, 대개 먹는 동안 #2-3) regurgitation(#4/day, not bloody, not bilous) rigidity on whole body(intermittent, <1min, #5/day, 깨어있을 때는 opisthotonus 양상) 있었으나 tolerable하게 지내며 gross stridor occa. 있으나 tolerable하게 지내던 환아.
내원 6일 전부터 rigidity on whole body (<10mins, #10-15/day, same nature), feeding 중 chocking (#4/day, 대개 먹는 내내, cyanosis on face올 정도로) gross stridor aggravation 되었고,
내원 당일 gross stridor, feeding시 choking(same nature) 지속되어 외래를 통해 입원함.

Irritability(+) for 7days, not colicky, not cyclic, not nocturnal fever/coughing/rhinorrhea(-/-/-), vomiting (+) for 7days, #1/day chocking 끝에 not bloody, not bilous diarrhea(-), poor feeding(+) for 7days, 평소 양의 2/3, urine volume 감소(+) for 7days, 평소 양의 2/3 body weight loss(-)
-평소 only feeding FF 160-200cc *4/day 중

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