CHAPTER I

LITERATUR REVIEW

1.1. Definition

Febrile seizured or febrile convulsion are accuring at an increase in body temperature

(rectal temperature above 38°C) caused by process ekstracraium.

Febrile convulsion are the release of a group of neurons suddenly resulting in a

breakdown of consciousness, movement, sensation or memory, which is temporary.

A febrile convulsion is an attack in children occurs from a collection of symptoms

with fever.

Febrile Convulsion are seizures occurred in the increase in body temperature (a rectal

temperature above 38°C ) that is caused by a process ekstrakranium. Febrile seizures are

often also called febrile seizures, tonic- clonic, very common in children under 5 years of

age. These seizures caused by a sudden onset hypertermia arising in a bacterial or viral

infection.

From the above understanding can be concluded febrile convulsion are seizures that

occur due to an increase in body temperature that is often found in children under 5 years

of age.

1.2. Etiology

Causes of Febrile convulsion until now not known with certainty, fever is often

caused by upper respiratory tract infections, otitis media, pneumonia, gastroenteritis and

urinary tract infections. Convulsion in baby and children caused by a rise in body

temperature is high and fast. Convulsion are not always arise at elevated temperatures.

Sometimes fever is not so high can cause seizures (Mansjoer, 2000).

Convulsions can occur in any person who suffered hypoxia (decreased oxygen in the

blood) in weight, hypoglycemia, asodemia, alkalemia, dehydration, water intoxication, or

high fever. Convulsion are caused by metabolic disorders are reversible when the

stimulus is removed originators (Corwin, 2001).

1

1.3. Patofisiology

In the state of fever, a temperature rise of 1 degree Celsius would cause a 10-15%

increase basal metabolism and oxygen demand increased by 20%. On a 3-year-old boy

brain circulation reached 65% of the entire body, whereas in adults is only 15%. So at a

certain rise in body temperature can change the balance of the membrane and in a short

time diffusion of potassium and sodium ions through the membrane before, with the

result of loose electrical charge. Remove the electric charge is so great that can be

extended to the whole cell or the cell membrane to the other with the help of a material

called neurotransmitters, causing seizures.

1.4. Classification

Febrile seizures occur in 2-4% of children with ages ranging from 6 months to 5

years, the highest incidence at the age of 18 months.

Febrile seizures are divided into:

1. Febrile seizures (simple febrile seizure)

a. Held a short (<15 minutes) and generally will stop on its own.

b. Seizures general shape (seizures and tonic or clonic seizures), without a focal

movement.

c. Seizures only once / not repeated within 24 hours.

d. Simple febrile seizures was 80% among all febrile seizures.

2. complex febrile seizures (Complex febrile seizure)

a. Lasts a long time (> 15 minutes).

b. Focal or partial seizures one side, or a generalized seizure which preceded partial

seizures.

c. Seizures Recurrent or more than 1 time in 24 hours.

Long seizures are seizures that lasts longer than 15 minutes or recurrent seizures more

than 2 times and between seizures the child is unconscious. Long Seizures occurred in 8%

of febrile seizures.

Focal seizures are one-sided partial seizures, generalized seizures that preceded partial

seizures.

2

Recurrent seizures are seizures 2 times or more in one day, between two seizures

conscious child. Recurrent seizures occurred in 16% among children who experience

febrile seizures.

1.5. Clinical Symptoms

The occurrence of convulsion in baby and children most in conjunction with the

increase in body temperature is high and fast due to infections outside the central nervous

system, such as tonsillitis, acute otitis media and others. Factors causing febrile

convulsion among others, is the degree of fever, age and genetic factors.febrile

convulsion are often experienced by baby and children aged 6 months to 5 years and the

most frequenthly encountered at the age of 9 to 20 months.

Febrile convulsion are divided into two, namely, simple febrile convulsion and

complex febrile convulsion. Understanding simple febrile convulsion are seizures that

the moment is less than 15 minutes and not recurring. Simple febrile convulsion are

seizures that are often found form and have a low risk of complications. Whereas

complex febrile convulsion are usually the more than 15 minutes and at higher risk for

repetition of the attack and can develop into epilepsy. In general, a febrile convulsion is a

disease that is not dangerous and has a low risk of complications. Only if left without

proper treatment then there will be some complications that will occur, include: recurring

seizures, epilepsy, decreased IQ and neurological disorders.

1.6. Complication

1. Epilepsy

Occurs due to damage to the temporal lobe area that lasts longer and can be mature.

2. Retardation mental

Febrile convulsion occurred in patients who had previously been found

developmental disorders or neurological disorders.

3. Hemipharesis

Hemipharesis is paralysis of half the body caused by ischemic stroke that causes

sudden neurological deficit in the brain. The damage to the central sistemsaraf cause

motor disturbances in bawah.Biasanya members occur in patients who experience a

seizure of time (lasting more than 30 minutes).

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4. Failure Respiratory

As a result of seizure activity that causes respiratory muscles into spasm.

5. Death

1.7. Supporting Investigation

A. Laboratory examination

Laboratory tests are not done routinely in febrile seizures, but can be done to

evaluate the source of the infection causes fever, or other circumstances, such as

gastroenteritis dehydration fever.

Laboratory tests that can be done for example: peripheral blood, electrolytes

and blood sugar.

Lumbar puncture:

CSF examination carried out to establish or rule out meningitis. The risk of bacterial

meningitis is 0.6% -6.7%. Meningitis can accompany a seizure, even though seizures

usually are not the only signs of meningitis. Meningitis risk factors in patients

presenting with seizures and fever include the following:

a. visit to the doctor within 48 hours

b. Seizure activity when arriving in hospital

c. Focal seizures, suspicious physical findings (such as redness on the skin,

petechiae) cyanosis, hypotension

Abnormal neurological exam

1. In small babies is often difficult to establish or rule out a diagnosis of meningitis

because of its clinical manifestations are not clear. Therefore, a lumbar puncture is

recommended to:

a. Infants less than 12 months is highly recommended to do

b. Infants between 12-18 months recommended

c. Infants> 18 months is not a routine

2. If you are sure not meningitis are not clinically necessary lumbar puncture.

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B. Imaging

1. X-ray head and imaging such as computed tomography scan (CT scan) or

magnetic resonance imaging (MRI) is rarely done, not routine and just above

indications such as:

a. Persistent focal neurologic abnormalities (hemiparesis)

b. VI nerve paresis

c. Papilloedema

2. CT scan should be considered in patients with complex febrile seizures.

C. Another test (EEG)

Examination of electroencephalography (EEG) can not predict the recurrence

of seizures, or estimate the probability of occurrence of epilepsy in patients with

febrile seizures. Therefore not recommended.

Examination of EEG can be done on febrile seizures is not typical; for

example in children aged >6 years or focal febrile seizures.

EEG is not required pascakejang simple fever because the tape will prove the

form of non-epileptic or normal and the findings would not alter management. EEG

indicated for atypical febrile seizures or in children who are at risk for developing

epilepsy. Atypical febrile seizures include seizures that persist for more than 15

minutes, repeat for a few hours or days, and local seizures. Approximately 50% of

children suffer recurrent febrile seizures, and a small percentage suffer from recurrent

seizures repeatedly. Risk factors for the development of epilepsy as a complication of

febrile seizures is a positive family history of epilepsy, febrile seizures beginning

before age 9 months, long or atypical febrile seizures, signs of delayed development,

and abnormal neurological examination. Indidens epilepsy is around 9% when

multiple risk factors exist compared with a 1% incidence in children with febrile

seizures and no risk factors

1.8. Management of Febrile Seizures

Management of febrile seizures during the treatment includes prevention of seizures

and convulsions.

1. Handling When Using Seizures

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a. Stopping a seizure:

Diazepam initial dose of 0.3-0.5 mg / kg / dose IV (slowly) or 0,4-0,6mg / Kg

Weight / Rectal suppository dosage. When the seizure is still not resolved can be

repeated with the same dose 20 minutes later

b. Lower fever:

Antipiretika: Paracetamol 10 mg / kg / dose PO or Ibuprofen 5-10 mg / kg /

dose PO, both given 3-4 times per day Compress: temperature> 39C: warm water;

temperature> 38C: plain water

c. Treatment causes:

given antibiotics as indicated by essentially disease

d. Other supportive treatment includes:

Release airway

Giving oxygen

Maintain water and electrolyte balance

Maintain blood pressure balance

2. Prevention Seizures

a. Prevention periodic (intermittent)

for simple febrile seizures with Diazepam 0.3 mg / kg / dose PO and

antipiretika when children suffering from diseases accompanied by fever

b. Prevention continuous

for febrile seizures Valproate acid is complicated by 15-40 mg / kg / day PO

divided in 2-3 doses

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1.9. Pathway

Pharyngitis

↓

Difficulty in swallowing Infection process

↓ ↓

Reduced nutrient intake stimulates the hypothalamus

↓ ↓

Central regulation of

body temperature disturbed

↓

Increased body temperature

↓

Changes in the balance of neuronal cells

↓

diffusion of ions of potassium and sodium

↓

loose electric charge

↓

extends throughout the cell and into the cell membrane mediated by neurotransmitters

↓

Convulsive disease process

↓ ↓

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Nutrition imbalance less than body requirements

The risk of reccurent convulsion

Less exposure to information↓

CHAPTER II

CASE REVIEW

Case :

Child who name AL 15 months, when she comes to the hospital mom said that

her daughter was fever since 07th September 2015 at 02:30 pm. Mother said that on 06th

September 2015 her daughter suffering from pharyngitis and on 07 th September 2015

02:30 pm her daughter was fever, cough and runny nose. Besides, AL also accompanied

by vomiting and a few moments later seizures but do not foaming from the mouth.

Before, the child never suffer or experience seizures, epilepsy, head trauma, meningitis,

acute otitis media. Disease was ever suffered by child are fever, cough, runny nose, but it

rarely happens. Mother said her daughter suffered from phayingitis since 2 month ago

and has already been checked to the doctor and was given medication but mother forget

the name of the medicine. For family information, no family suffering from epilepsy,

neurological disorders, infectious diseases of any kind.

3.1. Assessment

A. Biodata / identity

Name of child : AL

Age : 15 months

Gender : Female

Medical record number : 10082571

Born : normal (spontaneous B)

Place / date of birth : Surabaya, 23 May 2014

Medical diagnosis : febrile seizures + pharyngitis

Date of hospitalized : on 8th September 2015 at 3:30 am

Mother's name : Mrs.. "H"

Age : 29 years old

Religion : Islam

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Lack of knowledge

Tribe / nation : Java Indonesia

Education : High School

Job : -

Income : -

Address : Pucang row 24 surabaya

Father Name : Mr. "B"

Age : 31 years old

Religion : Islam

Tribe / nation : the hobo Indonesia

Education : High School

Occupation : Private

Income : Rp.1.500.000 / month

Address : Pucang row 42 surabaya

B. History of present illness

The main complaint: Mom says that her daughter was fever since 07th September

2015 at 02:30 pm

History of present illness:

Mother said her daughter suffered from phayingitis since 2 month ago and has

already been checked to the doctor and was given medication but mother forget the

name of the medicine, and then 06th September 2015 the child begins difficulty eating

and mother considers her daughter’s pharyngitis relaps but don’t be checked to the

doctor, on 07th September 2015 02:30 pm her daughter was fever and given

medication for fever (Syrup Sanmol) 1 times and compressed, cough and runny nose.

But the fever does not go down. Vomiting as much as 2 times at 11:30 pm and 1:30

am with 2-3 tablespoons of food. Then the seizures occurred at 02:30 am 1 times.

The duration of 5-10 minutes, no foaming from the mouth.

The current state of febrile seizures are the eyes glancing upward, arms flexed,

and legs stiff (extension). After the seizure occurred directly the child crying. Cough

sputum, sound grokgrok, consistention colds slightly viscous, clear, and go out some

times but not claustrophobic.

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C. Disease former history

Before, the child never suffer or experience seizures, epilepsy, head trauma,

meningitis, otitis media akute. Disease was ever suffered by child are fever, cough,

runny nose, but it rarely happens.

D. Immunization history

Mother said that the child has been fully immunized.

E. History of development

a. Social personal history:

Children easily adapt to the surrounding environment.

Children are still wet and has not been able to tell parents if he want

urination/defecate.

b. Gross motor movement: Children's walking, pushing, and dancing chairs, can

teach simple commands.

c. Fine motor movements: the child can hold a pencil and scribble.

d. Language: the child is able to speak a few words, for example: Mama, papa,

calling his sister (iza), and their family pets (dogs), drink etc.

F. Family health history

Father: no family suffering from epilepsy, neurological disorders, infectious diseases

of any kind.

Mother: women suffer from maternal hypotension parents suffering from diabetes

mellitus since 1992. From the mother's family suffered no neurological disorders,

epilepsy.

G. Social history

a) Nurturing mother herself, there is no maid or others.

b) Relationship with family members: children and lower very close to his mother.

Usually a child playing with a brother when the mother left to cook, wash and

clean the house. His brother 9 years old and 4th grade.

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c) Relationship with peers: more children to play at home with his mother.

Sometimes children play with their peers that is close to her home

d) Nature in general

Children looked nervous and fussy, sometimes ask his mom to picked him up,

children are very spoiled by her mother.

H. pattern of habits and functions

a) The pattern of perception and management of healthy living

Before the pain: take a bath 2 times for a day, washing the hair 2 times for a

week, replace any wet pants, a change of clothes each morning and afternoon.

Each hospital: take a bath 2 times a day, never washing the hair, change clothes

every morning and afternoon and replace any wet pants.

The family was very worried when her seizures as long as there is no family that

seizures. If a child is sick is usually taken to the doctor or hospital-when after

being given the drug paracetamol or bodrexin not cured. Cranky sick children,

often ask the mother to picked him up . Children looked scared when health

workers will perform maintenance / medical action

b) Patterns of nutrients

Before the pain: eat 3-4 times a day, and a small portion of the bowl-out, there are

no restrictions on food, rice team and the side dishes varies composition every

day that tempe, tofu, fish, eggs, and meat occasionally with a size 1 portion of

lighters. Vegetable such as spinach, soup, soto, etc.

Drinking: water 3-5 cups (size 100 cc), the child is still sucking.

During illness: a day to eat 3 times / day, provided the hospital portion of a half-

eaten. Team composition is rice, side dishes, vegetables, and fruit. Children are

more often sucking. Drinking water 4-6 times per 100 cc, ation companion (SGM

2) has given 2 spoons and spit.

c) The pattern of elimination

Before the pain: urination 4-5 times a day, yellow, pain does not exist. defecate

smoothly every morning, soft consistency, yellow color.

d) The pattern of activity and exercise

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Before the pain: playing with her sister 4-5 hours a day, the most time with the

mother. Together with father sometimes, between 3-4 hours. Usually children are

also playing himself while looking at the TV and learn the music while dancing.

During sick the child's activity is reduced due to a drip attached on the left hand,

children often ask the mother to picked him up

e) The pattern of sleep and rest

Before ill: night sleep between the hours of 08:00 pm to 05:00 am

Siesta between the hours of 12:00 am to 15:00 pm woke up when wet.

During illness: on the day of her difficult half- 1 hour sleep often wake up and

fuss being held. At night sleep hours of 1:00 am to 04:00 am, children are often

cranky and sleep awake.

I. General examination

1. The general situation: weak

2. Awareness: composmentis

3. Vital Sign

Pulse: 132 beats / min

Respiration: 30 times / min

Temperature: 38.2º C

4. W / H: 9kg / 77cm

5. Nutritional status : 2n + 8

2 (1.5) + 8 = 11

9/11 x 100% = 81.8% (malnutrition)

J. A general physical examination

1) Head

No sign microchepali or sign macrochepali, head circumference 46 cm, large

fontanel closes, normal head shape.

2) Hair

Blond, hair is not easily removed, the hair thickness enough, do not have fleas.

3) Face

No rhisus sardonicus, symmetrical, there is no edema, the face does not look pale.

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4) Eye

Good visual acuity, palphera symmetrical, no mydriasis or miosis, sclera no

jaundice, no conjunctival pallor, normal movement, no strasbismus.

5) Nose

Normal shape, there are no epiktasis, appears out colored viscous secretions and

few in number, no polyps, no breathing nostrils.

6) Ear

Symmetrical right and left, normal hearing, invisible fluid.

7) Mouth

Symmetrical invisible cyanosis, tooth numbering 8buah, no caries, tongue

cleaner, there are stomatitis, no strismus, lips look dry and cracked.

8) Throat

Tonsils not appear reddish and invisible enlargement, pharynx looks reddish, no

exudate.

9) Neck

There was no neck stiffness, no enlargement of the thyroid gland, there was no

jugular vein enlargement, there is no lymph gland enlargement.

10) Chest / thorax

Chest circumference 46 cm, normal breast shape, no refraction intercostae, there

aren’t ronchi, no wheezing, rapid breathing and a regular rhythm.

11) Heart

Heart rate normal and regular frequency.

12) Abdomen

Turgor skin enough, no meteorismus, spleen and liver normal circumstances, no

palpable lump / tumor, normal peristalsis.

13) Skin

Enough skin hygiene, no hemagioma, no edema, hot clammy skin.

14) Extremities

a. Upper extremity: no edema, abnormal movements, the left hand is attached

infusion since 8th September 2015, there was no signs of phlebitis, akral

warm, upper arm circumference 14cm.

b. Lower extremity: no edema, abnormal movements, akral warm.

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15) Genitalia

Vulva: cleanliness enough, does not seem out secretions, no edema and irritation.

Anus: cleanliness enough, haemorroid not appear.

K. Supporting investigation

Laboratory Data

08th September 2015 3:30 am

Blood examination:

a. Hb: 12,00 gr/dl (N 11 to 15.1)

b. Leukocytes: 19x10 /µl (N 4.3 to 11.3)

c. Trombosyt: 173X10 103/ µl (150-350)

d. PCV: 0.35 (F 0.38 to 0.42)

e. Random blood glucose: 288 mq / dl (<200)

f. Electrolytes: Potassium = 3.6 mEq / L (3.8 to 5)

Sodium = 133 mEq / L (135-144)

g. Lumbar puncture: The family refused even after the explanation purpose and

procedures

Other Data

Therapy given:

08th September2015

Ampicillin 3x300 mg IV

Paracetamol 3x100 mg orally

Diazepam 2.7 mg IV (seizures)

Infusion D5 ¼ S 500 cc / 24 hours

Data Analysis and Synthesis

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No

.

Data Etiology problem

1. SD: Mom says that her daughter is

still fever and cranky want to

sucking continues, before the child

was never sick seizures but on 07th

September 2015 at 02:30 am the

seizures occurred 1 times. The

duration of 5-10 minutes, no foaming

from the mouth. The child begins

difficulty eating and mother

considers her daughter’s pharyngitis

relapse

OD: the awarness composmentis

Vital Signs:

Temperature: 38.2º C (N 36.5-37.5 º

C)

Pulse: 132x / min (N 100-110/min)

Respiratory Range: 30x / min (24-

28/min)

Skin feels warm, warm akral, the

child seemed fussy and was sucking,

Pharyngitis

↓

Infection process

↓

stimulates the

hypothalamus

↓

Central regulation of

body temperature

disturbed

↓

Hyperthermia

↓

metabolic disorders

brain

↓

changes in the balance

of neuronal cells

↓

The risk of

reccurent seizures

15

mouth looks dry and chapped, skin

turgot enough, appear out secretions

colored, thick and slightly, pharynx

looks reddish

Laboratory examination:

Hb: 12 gr/dl

(N: 11.4 to 15.1)

Leucocyt: 19x10 /µl

(N: 4.3 to 11.3)

Trombocyt: 173x10 103/ µl

(N: 150-350)

PCV: 0.35

(N: 0.38 to 0.42)

Random blood glucose:

288 mq / dl

(N: <200)

Electrolytes:

• Potassium: 3.6 mEq / L

(N: 3.8 to 5)

diffusion of ions of

potassium and sodium

↓

loose electric charge

↓

extends throughout the

cell and into the cell

membrane mediated by

neurotransmitters

↓

convulsive

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• Sodium 133 mEq / L

(N: 135-144)

3.2. Nursing diagnoses

1. The risk of reccurent seizures associated with hyperthermia

3.3. Intervention

No. Intervention Rational

1. Diagnose: The risk of reccurent seizures associated with hyperthermia

Objective: repeated seizures do not occur within 2x24 hours

criteria:

a. There’s not recurrent seizuresb. Normal body temperature (36,5-

37,5º C)Pulse (100-110x / min)Respiratory Range (24-28x / min)

c. Awareness composmentis

Plans:1. Loosen clothing, provide thin

clothing that absorbs sweat

2. Apply a warm compress to the head and armpit

3. Give extra fluid (ation companion, breast milk, juice, etc.)Liquids: 1150-1300 cc / 24 hours

4. Observations of seizures and vital signs every 4 hours

5. Limit your child's activity during the heat

6. Provide antipiretika and appropriate treatment doctors advise

1. The process of convection will be hindered by tight clothing and do not absorb perspiration

2. Heat conduction

3. When the fever will need increasing body fluids

4. Regular monitoring determines what to do next

5. Activities can increase thereby increasing the temperature of the body metabolism

6. Lower the heat at the center of the hypothalamus and as prophylactic

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Valium 2.7 mg IV (seizures)

Ampicillin 3x300 mg IV

Paracetamol 3x100 mg (orally)

7. Provide health education to families about personal hygiene: clean the mouth with warm water 2 times a day and smeared with honey

7. Maintain the cleanliness and moisture lip

3.4. Implementation

Date / Time Execution Implementation

on 8th September 2015

At 11:30 am

At 11:31 am

At 11:32 am

At 11:35 am

At 11:40 am

Diagnose: The risk of reccurent convulsion associated with hyperthermia

1. Loosen clothing, provide thin clothing that is easy to absorb sweat

2. Provide a warm compress on the head and armpit

3. Give extra fluids:

Infuse: D5 ¼S, 500cc / 24 hours, ASI

Drink: children refuse (spit)

4. Observe seizures and vital sign every 4 hours

P: 132x / m RR: 30x / m Temperature: 38,2ºC

5. Restrict activity during hot boy. Therapy: bedrest

6. Provides antipyretic and advise appropriate treatment

18

At 07.00 am

At 15:00 am

At 11:00 pm

At 11:50 am

Treatment:

a. Valium 2.7 mg IV (seizures)

b. 3x300 mg IV ampicillin

c. Paracetamol 3x100 mg (orally)

7. Provide health education to families about personal hygiene: clean the lip area with warm water 2 times a day, and smearing her lips with honey

3.5. Evaluation and Development Notes

Diagnose : The risk of reccurent convulsion associated with hyperthermia

Notes developments:

Date 09th September 2015 at 09.00 am

S: Mom says that her daughter did not have seizures again and his body is still hot, still

fussy child, the mother has been cleaning her lips and smearing with honey

O: repeated seizures do not occur, the body felt hot akral warm, good skin turgor, children

seem cranky, enough moisture lips, lips look clean

Temperature: 38º C P: 128X / min RR: 28x / min

A: The purpose have not been successful

P: Intervention maintained

1) Loosen clothing, provide thin clothing that is easy to absorb sweat

2) Give a warm compress on the head and armpit

3) Give extra fluids

Infusion: D5 ¼ S 500cc / 24 hours, ASI, companion ation: 6x100cc

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4) Observation vital signs every 4 hours

5) Limit your child's activity during the heat

6) Provide appropriate treatment doctors advise

7) Therapy: Valium 2.7 mg IV (seizures)

3x300 mg IV ampicillin

Paracetamol 3x100 mg orally

Evaluation

Date 10th September2015 at 11:00 am

S: Mom says that her daughter did not have seizures again and the child’s fever no

longer, not fussy and can sleep soundly, child cheerful again

O: repeated seizures do not occur, the skin is not palpable heat, good skin turgor children

appear cheerful, removable infusion since at 09.00 am

Awareness: composmentis

Vital Sign Temperature: 37,2ºC P: 100x / min RR: 25x / min

A: The purpose successfully

P: Intervention is stopped

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