Video Case Study - Caring for Patients With Seizure Disorder

Nurse Cody works in a long-term care facility and is caring for Estelle, a 78-year-old with a history of epilepsy. In collaboration with the registered nurse, RN William, Nurse Cody goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Estelle’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Cody recognizes important cues, including Estelle’s vital signs, which are temperature 98.2 F or 36.8 C, heart rate 78 beats per minute, respirations 16 breaths per minute, and blood pressure 118/72 mmHg.

They review the electronic health record, or EHR, and note that Estelle takes lamotrigine twice daily for epilepsy and hasn’t had any seizures or associated auras recently.

Nurse Cody also sees Estelle had a routine blood draw yesterday to monitor her lamotrigine serum level, and that Estelle’s lamotrigine level is below therapeutic level, meaning it’s too low to achieve the medication’s desired effect.

Next, Nurse Cody analyzes these cues. They know that epilepsy is a chronic seizure disorder caused by abnormal, excessive, and synchronous firing from neurons in the brain.

They also recognize that Estelle’s risk of having a seizure is greater when her antiepileptic medication is at a subtherapeutic level.

Nurse Cody realizes that, until Estelle’s lamotrigine levels stabilize, she will need additional safety precautions to prevent injury related to a seizure.

Now, using the information they’ve gathered, along with Estelle’s medical history, Nurse Cody reports their findings to RN William, and together they choose a priority hypothesis of risk for injury.

Then, Nurse Cody collaborates with RN William to generate solutions to address Estelle’s increased risk for injury that include pharmacologic and nonpharmacologic interventions.

Together, they establish the expected outcome that after intervening, Estelle will not sustain an injury related to seizures while her seizure risk is elevated.

Nurse Cody then takes action to implement these solutions. First, they report their findings to Estelle’s health care provider, who orders an increased dose of lamotrigine.

RN William educates Estelle about her dosage increase and reviews the plan of care with her. Nurse Cody then gathers supplies and re-enters Estelle’s room.

Nurse Cody: Hi, Estelle. I have a new dose of lamotrigine for you.

Estelle: Nurse William told me the doctor ordered a higher dose, but why? I’ve been taking this dose for years.

Nurse Cody: The blood test you had yesterday shows there isn’t enough medication in your system to keep you from having seizures.

This increased dose will raise the amount of medication in your blood so you can remain seizure-free. Until the medication reaches normal levels in your system, we’ll take extra measures to keep you safe.

Nurse Cody then administers the lamotrigine according to the principles of safe medication administration. Nurse Cody: Now, I want to ask you about your previous experiences with seizures.

Do you know if you have any specific triggers? Estelle: Well, in the past, seizures usually happened when I got over-stressed or didn’t get enough sleep.

I always know I’m going to have one because I get this lightheaded feeling and I smell something burning. Nurse Cody: I see.

If you have those feelings, I want you to push your call button right away. In the meantime, we can address your triggers.

I’ll make sure a nurse’s aide comes to help with your bedtime care earlier in the evening, and we’ll place a do-not-disturb sign on your door at night.

Are there any relaxing activities you’d like to do during the day? Estelle: I really enjoy reading and I like to listen to music in the mornings.

Nurse Cody: Great, that sounds very relaxing! Nurse Cody and RN William implement seizure precautions by securing seizure pads to Estelle’s bedrails and placing oxygen and suction equipment at the bedside.

Then, Nurse Cody brings Estelle some magazines and books to read as well as a portable radio to listen to music. One week later, Nurse Cody evaluates the outcome of their actions.

They take Estelle’s vital signs which are temperature 98.6 F, or 37 C, heart rate 82 beats per minute, respirations 16 breaths per minute, and blood pressure 122/68 mmHg.

Nurse Cody then reviews the EHR and sees Estelle hasn’t experienced a seizure during the past week. Additionally, Estelle’s lamotrigine serum level is now within the therapeutic range, meaning her seizure risk has decreased.

Alright, as a quick recap… Nurse Cody recognized and analyzed cues related to Estelle’s risk for injury due to seizures and, in collaboration with RN William, prioritized hypotheses, and generated solutions to address this problem.

Nurse Cody and RN William then implemented pharmacologic and nonpharmacologic measures, evaluated Estelle's outcomes, and compared them to the expected outcome.

Since Estelle didn’t experience any injuries from seizures, they determined the plan of care was successful.