Case study - Seizure: Nursing

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 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.