CHAPTER I

LITERATUR REVIEW

1.1.

Definition
Febrile seizured or febrile convulsion are accuring at an increase in body temperature
(rectal temperature above 38C) 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 38C ) 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).

1.3.

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.
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
2

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).
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:
3

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.

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,
4

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
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

1.9.

Pathway

Pharyngitis

Difficulty in swallowing

Infection process

Reduced nutrient intake

stimulates the hypothalamus

Nutrition imbalance
less than body
requirements

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

Less exposure to information

The risk of reccurent

convulsion

Lack of knowledge

CHAPTER II
6

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
Age
Gender
Medical record number
Born
Place / date of birth
Medical diagnosis
Date of hospitalized
Mother's name
Age
Religion
Tribe / nation
Education
Job
Income
Address
Father Name
Age
Religion
Tribe / nation
Education
Occupation
Income
Address

: AL
: 15 months
: Female
: 10082571
: normal (spontaneous B)
: Surabaya, 23 May 2014
: febrile seizures + pharyngitis
: on 8th September 2015 at 3:30 am
: Mrs.. "H"
: 29 years old
: Islam
: Java Indonesia
: High School
::: Pucang row 24 surabaya
: Mr. "B"
: 31 years old
: Islam
: the hobo Indonesia
: High School
: Private
: Rp.1.500.000 / month
: Pucang row 42 surabaya

B. History of present illness

7

The main complaint: Mom says that her daughter was fever since 07 th 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 daughters pharyngitis relaps but dont 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.
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.
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 halfeaten. 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
9

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: 38.2 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.
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

10

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
arent 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.
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 /l (N 4.3 to 11.3)
c. Trombosyt: 173X10 103/ l (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

11

Ampicillin 3x300 mg IV
Paracetamol 3x100 mg orally
Diazepam 2.7 mg IV (seizures)
Infusion D5 S 500 cc / 24 hours
Data Analysis and Synthesis

No

Data

Etiology

problem

1.

SD: Mom says that her daughter is

Pharyngitis

still fever and cranky want to

sucking continues, before the child
was never sick seizures but on 07th

The risk of
reccurent seizures

Infection process

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 daughters pharyngitis

relapse

stimulates the
hypothalamus

Central regulation of
body temperature

OD: the awarness composmentis

disturbed

Vital Signs:
Temperature: 38.2 C (N 36.5-37.5

Hyperthermia

C)
12

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

Respiratory Range: 30x / min (24-

metabolic disorders
brain

28/min)

changes in the balance

Skin feels warm, warm akral, the

of neuronal cells

child seemed fussy and was sucking,

mouth looks dry and chapped, skin
turgot enough, appear out secretions
colored, thick and slightly, pharynx

diffusion of ions of
potassium and sodium

looks reddish

Laboratory examination:
loose electric charge
Hb: 12 gr/dl

(N: 11.4 to 15.1)

extends throughout the
Leucocyt: 19x10 /l
(N: 4.3 to 11.3)

cell and into the cell

membrane mediated
by neurotransmitters

Trombocyt: 173x10 103/ l

(N: 150-350)
convulsive
PCV: 0.35
(N: 0.38 to 0.42)
Random blood glucose:
288 mq / dl
(N: <200)

13

Electrolytes:
Potassium: 3.6 mEq / L
(N: 3.8 to 5)
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. Theres not recurrent seizures
b. Normal body temperature (36,537,5 C)
Pulse (100-110x / min)
Respiratory Range (24-28x / min)
1. The process of convection will be
c. Awareness composmentis
hindered by tight clothing and do
not absorb perspiration
Plans:
2.
Heat conduction
1. Loosen clothing, provide thin
clothing that absorbs sweat
3. When the fever will need increasing
body fluids
2. Apply a warm compress to
the head and armpit
3. Give extra fluid (ation
14

companion, breast milk, juice,

etc.)
Liquids: 1150-1300 cc / 24
hours
4. Observations of seizures and 4. Regular monitoring determines
vital signs every 4 hours
what to do next
5. Limit your child's activity 5. Activities can increase thereby
during the heat
increasing the temperature of the
6. Provide
antipiretika
and
body metabolism
appropriate treatment doctors 6. Lower the heat at the center of the
advise
hypothalamus and as prophylactic
Valium 2.7 mg IV (seizures)
Ampicillin 3x300 mg IV
Paracetamol
(orally)

3x100

mg

7. Provide health education to

families
about
personal 7. Maintain the
hygiene: clean the mouth with
moisture lip
warm water 2 times a day and
smeared with honey

cleanliness

and

3.4. Implementation
Date / Time Execution

Implementation

on 8th September 2015

Diagnose: The risk of reccurent convulsion

associated with hyperthermia

At 11:30 am

1. Loosen clothing, provide thin clothing that is

easy to absorb sweat
2. Provide a warm compress on the head and
armpit

At 11:31 am
3. Give extra fluids:
Infuse: D5 S, 500cc / 24 hours, ASI
15

At 11:32 am

Drink: children refuse (spit)

4. Observe seizures and vital sign every 4 hours
P: 132x / m RR: 30x / m Temperature: 38,2C

At 11:35 am

At 11:40 am

5. Restrict activity during hot boy. Therapy:

bedrest
6. Provides antipyretic and advise appropriate
treatment
Treatment:

At 07.00 am

a. Valium 2.7 mg IV (seizures)

At 15:00 am

b. 3x300 mg IV ampicillin

At 11:00 pm

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

At 11:50 am

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: 38 C P: 128X / min RR: 28x / min
A: The purpose have not been successful
P: Intervention maintained
16

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 S 500cc / 24 hours, ASI, companion ation: 6x100cc
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 childs 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: 37,2C P: 100x / min RR: 25x / min
A: The purpose successfully
P: Intervention is stopped

17