This case study describes a 16-year-old female patient, Amy Latino, who was admitted to the hospital for status epilepticus and suicidal tendencies. Her medical history is unknown. On physical exam, she was conscious with normal vital signs. Neurological exam was normal. She has been prescribed carbamazepine 200mg twice daily to treat her seizures, with monitoring for side effects. Phenytoin may be given intravenously if needed. The case provides details on her admission, exams, medications, and nursing responsibilities.

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WESLEYAN UNIVERSITY PHILIPPINES
Mabini Ext. Cabanatuan City, Nueva Ecija
College Of Nursing
SY: 2012-2013
AFFILIATION IN

2. National Center for mental Health
CASE STUDY
Presented By:
BJ Adette J. Hilario
BSN III-Blk. 3; Group 3
Presented To:
Mrs. Marjorie Trinidad RN, MAN
Clinical Instructor
A. PATIENT’SPROFILE
Name Amy Belga Latino
Age 16 years old
Gender Female
Status Single
Permanent Address
No., St.
Town/City
Brgy.
Province
c/oBahayKalinga R. Jacinto St.
City of Valenzuela
Canumay
NCR 3rd district

3. Birthdate July 21, 1996
Birthplace Valenzuela City
Nationality Filipino
Citizenship Filipino
Religion Roman Catholic
Educational Attainment None
Occupation None
Father’sName Victor DK Latino
Mother’s Name Emily DK Belga
Spouse N/A
Informant Arnel V. De Leon
Valenzuela City
445-6136/09327796932
Date and Time of
Admission
4/28/2013
09:06pm
Hospital No. 000000000039897
Pavilion/Ward Pavilion 7; Infirmary-Female
Re-Admission 4/30/2013
Pavilion 12; Zonta
Physician Dr. Mapa
Dr. Tuazon
AdmittingDiagnosis F06.8
Other specified mental d/o due to brain damage and
dysfunction and to physical disease (seizure d/o) t/c:
status epilepticus
Introduction
Few experiences match the drama of a convulsive seizure. A person having a severe seizure
may cry out, fall to the floor unconscious, twitch or move uncontrollably, drool, or even lose
bladder control. Within minutes, the attack is over, and the person regains consciousness
but is exhausted and dazed. This is the image most people have when they hear the word
epilepsy. However, this type of seizure – ageneralized tonic-clonic seizure -- is only one
kind of epilepsy. There are many other kinds, each with a different set of symptoms.
Epilepsy was one of the first brain disorders to be described. It was mentioned in ancient
Babylon more than 3,000 years ago. The strange behavior caused by some seizures has
contributed through the ages to many superstitions and prejudices. The word epilepsy is
derived from the Greek word for "attack." People once thought that those with epilepsy
were being visited by demons or gods. However, in 400 B.C., the early
physician Hippocratessuggested that epilepsy was a disorder of the brain -- and we now
know that he was right.
What Is Epilepsy?

4. Epilepsy is a brain disorder in which clusters of nerve cells, or neurons, in the brain
sometimes signal abnormally. Neurons normally generate electrochemical impulses that
act on other neurons, glands, and muscles to produce human thoughts, feelings, and
actions. In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing
strange sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and
loss of consciousness. During a seizure, neurons may fire as many as 500 times a second,
much faster than normal. In some people, this happens only occasionally; for others, it may
happen up to hundreds of times a day.
More than 2 million people in the United States -- about 1 in 100 -- have experienced an
unprovoked seizure or been diagnosed with epilepsy. For about 80 percent of those
diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical
techniques. However, about 25 to 30 percent of people with epilepsy will continue to
experience seizures even with the best available treatment. Doctors call this situation
intractable epilepsy. Having a seizure does not necessarily mean that a person has epilepsy.
Only when a person has had two or more seizures is he or she considered to have epilepsy.
Epilepsy is not contagious and is not caused by mental illness or mental retardation. Some
people with mental retardation may experience seizures, but seizures do not necessarily
mean the person has or will develop mental impairment. Many people with epilepsy have
normal or above-average intelligence. Famous people who are known or rumored to have
had epilepsy include the Russian writer Dostoyevsky, the philosopher Socrates, the military
general Napoleon, and the inventor of dynamite, Alfred Nobel, who established the Nobel
Prize. Several Olympic medalists and other athletes also have had epilepsy. Seizures
sometimes do cause brain damage, particularly if they are severe. However, most seizures
do not seem to have a detrimental effect on the brain. Any changes that do occur are
usually subtle, and it is often unclear whether these changes are caused by the seizures
themselves or by the underlying problem that caused the seizures.
While epilepsy cannot currently be cured, for some people it does eventually go away. One
study found that children with idiopathic epilepsy, or epilepsy with an unknown cause, had
a 68 to 92 percent chance of becoming seizure-free by 20 years after their diagnosis. The
odds of becoming seizure-free are not as good for adults or for children with severe
epilepsy syndromes, but it is nonetheless possible that seizures may decrease or even stop
over time. This is more likely if the epilepsy has been well-controlled by medication or if
the person has had epilepsy surgery.
What Causes Epilepsy?
Epilepsy is a disorder with many possible causes. Anything that disturbs the normal
pattern of neuron activity -- from illness to brain damage to abnormal brain development --
can lead to seizures.

5. Epilepsy may develop because of an abnormality in brain wiring, an imbalance of nerve
signaling chemicals called neurotransmitters, or some combination of these factors.
Researchers believe that some people with epilepsy have an abnormally high level of
excitatory neurotransmitters that increase neuronal activity, while others have an
abnormally low level of inhibitory neurotransmitters that decrease neuronal activity in the
brain. Either situation can result in too much neuronal activity and cause epilepsy. One of
the most-studied neurotransmitters that play a role in epilepsy is GABA, or gamma-
aminobutyric acid, which is an inhibitoryneurotransmitter. Research on GABA has led to
drugs that alter the amount of this neurotransmitter in the brain or change how the brain
responds to it. Researchers also are studying excitatory neurotransmitters such
as glutamate.
In some cases, the brain's attempts to repair itself after a head injury, stroke, or other
problem may inadvertently generate abnormal nerve connections that lead to epilepsy.
Abnormalities in brain wiring that occur during brain development also may disturb
neuronal activity and lead to epilepsy.
Research has shown that the cell membrane that surrounds each neuron plays an
important role in epilepsy. Cell membranes are crucial for a neuron to generate electrical
impulses. For this reason, researchers arestudying details of the membrane structure, how
molecules move in and out of membranes, and how the cell nourishes and repairs the
membrane. A disruption in any of these processes may lead to epilepsy. Studies in animals
have shown that, because the brain continually adapts to changes in stimuli, a small change
in neuronal activity, if repeated, may eventually lead to full-blown epilepsy. Researchers
are investigating whether this phenomenon, called kindling, may also occur in humans.
In some cases, epilepsy may result from changes in non-neuronal brain cells called glia.
These cells regulate concentrations of chemicals in the brain that can affect neuronal
signaling.
About half of all seizures have no known cause. However, in other cases, the seizures are
clearly linked to infection, trauma, or other identifiable problems.
Genetic Factors
Research suggests that genetic abnormalities may be some of the most important factors
contributing to epilepsy. Some types of epilepsy have been traced to an abnormality in a
specific gene. Many other types of epilepsy tend to run in families, which suggests that
genes influence epilepsy. Some researchers estimate that more than 500 genes could play a
role in this disorder. However, it is increasingly clear that, for many forms of epilepsy,

6. genetic abnormalities play only a partial role, perhaps by increasing a person's
susceptibility to seizures that are triggered by an environmental factor.
Several types of epilepsy have now been linked to defective genes for ion channels, the
"gates" that control the flow of ions in and out of cells and regulate neuron signaling.
Another gene, which is missing in people with progressive myoclonus epilepsy, codes for a
protein called cystatin B. This protein regulates enzymes that break down other proteins.
Another gene, which is altered in a severe form of epilepsy called LaFora's disease, has
been linked to a gene that helps to break down carbohydrates.
While abnormal genes sometimes cause epilepsy, they also may influence the disorder in
subtler ways. For example, one study showed that many people with epilepsy have an
abnormally active version of a gene that increases resistance to drugs. This may help
explain why anticonvulsant drugs do not work for some people. Genes also may control
other aspects of the body's response to medications and each person's susceptibility to
seizures, or seizure threshold. Abnormalities in the genes that control neuronal migration -
- a critical step in brain development -- can lead to areas of misplaced or abnormally
formed neurons, or dysplasia, in the brain that can cause epilepsy. In some cases, genes
may contribute to development of epilepsy even in people with no family history of the
disorder. These people may have a newly developed abnormality, ormutation, in an
epilepsy-related gene.
Status Epilepticus (SE)
Status Epilepticusis a life-threatening condition in which the brain is in a state of
persistent seizure. Definitions vary, but traditionally it is defined as one continuous,
unremitting seizure lasting longer than 5 minutes,or recurrent seizures without regaining
consciousness between seizures for greater than 5 minutes. Treatment is, however,
generally started after the seizure has lasted five minutes. It is always considered a medical
emergency. There is some evidence that five minutes is sufficient to damage neurons and
that seizures are unlikely to self-terminate by that time.
First aid guidelines for seizures state that, as a rule, an ambulance should be called for
seizures lasting longer than five minutes (or sooner if this is the patient's first seizure
episode and no precipitating factors are known, or if SE happens to a person with epilepsy
whose seizures were previously absent or well controlled for a considerable time period).
The mortality rate of status epilepticus has the potential to be quite high (at least 20%),
especially if treatment is not initiated quickly. However, with optimal neurological care,
adherence to the medication regimen, and a good prognosis (no other underlying
uncontrolled brain or other organic disease), the patient- even people who have been
diagnosed with epilepsy- in otherwise good health can survive with minimal or no brain
damage, and can decrease their risk of death and even avoid future seizures.

7. B. PATIENT’SIDENTIFICATION
Hair: Black
Eyes: Black
Complexion: Fair
Built: Medium
Mustache: none
Identifying Marks: (scars, tattoos, moles, etc.)
With moles on the nose, right lower eye, inner back.
With dark pigmentations on both upper extremities
Physical Peculiarities:
With healed wounds on both knees
C. ADMISSIONNOTES
This is the case of Amy Latino, 16 years old, female, born on July 21, 1996, Roman
Catholic, Filipino render by shift from BahayKalinga.
NPI:
The patient was turned over by the Brgy. after a care of physical abuse of her was
filed.
Last week, she was brought to the center for 4 days due to her suicidal tendencies,
as she slashed her wrist. She was behaved but referred intake of medication.
A month PTA, she had episode of epileptic attacks. Then she was brought to this
center for further observation and management.
D. PATIENT’SHISTORY
Past Medical History ------------- Unknown
PMx ------------- Unknown
Obstetric History ------------- Unknown
E. LABORATORY EXAMS
Physical Exam
Vital Signs
BP: 110/80 mmHgPR: 83bpm
RR: 22cpm BT: 37 ˚C
General:
 Conscious, coherent, with Oxygen cannula inserted.

8. HEENT:
 Pink palpebral conjunctivae, anicteric sclerae, no naso-oral discharge,
notonsillopharyngeal congestion.
Neck:
 Supple, no neck vein engorgement, no cervicolymphadenopathy.
Chest:
 Symmetrical chest expansion, no retraction, no wheezes, no nodules.
Neurologic Exam
Cerebrum:
 Conscious, coherent, with a GCS score of 15/15.
Cerebellum:
 No nystagmus
Cranial Nerves:
I N/A
II Pupils reactive to light
III, IV, VI EOM is intact
V Equal sensation of the face
VII No facial asymmetry
VIII Normal gross hearing
IX, X Uvula is midline, can swallow
XI Can shrug shoulder against
resistance, no sign of
meningeal irritation
XII Tongue is in midline
Motor Systems:
 Limbs
 Trunks 5/5 | 5/5
 Stance 5/5 | 5/5
 Gait
 Rombergo
Reflexes:
 J.J

9.  B.J H| H
 S.J H |H
 T.J
 Plaster
Sensational:
 Pain and Touch
 Temperature
 Vibration N/A
 J.P.S.
 Two Point Discrimination
F. DRUG STUDY
1. CARBAMAZEPINE 200mg/tablet 2x a day P.O
Generic Name CARBAMAZEPINE
BrandName Tegretol, Tegretol XR , Equetro, Carbatrol
Preparation Tablets: 200 mg. Chewable tablets; 100 mg. Extended release
tablets; 100, 200, and 400 mg. Suspension; 100 mg/5 ml. Equetro
is available in 100, 200, and 300 mg extended release tablets
Classification Anticonvulstant
Action • Decreases synaptic transmission in the CNS by affecting sodium
channels in neurons
• Prevention of seizures
Indication/Uses • Reduces anxiety, irritability, elation
• Impulse control behavior
Side Effects •CNS: headache, tremors, confusion, restlessness, memory loss,
seizures, slurred speech, muscle weakness, lack of coordination,
lethargy, stupor
•CV: bradycardia, ECG changes, arrhythmias, hypotension,
peripheral circulatory collapse
•EENT: blurred vision, tinnitus
• GI: anorexia, nausea, vomiting, abdominal cramps or pain,
diarrhea, dry mouth, extreme thirst, metallic taste, weight gain
• GU: polyuria, glycosuria, proteinuria, incontinence, edema,
hyponatremia
• Hematologic: leukocytosis
• Skin: rash, pruritus, alopecia, sweating, dryness or thinning of
hair
Contraindication • Hypersensitivity
• Kidney disease

10. • Cardiovascular disease
• Seizure disorder, myasthenia gravis
• Dehydration
• Hypothyroidism
Nursing
Responsibilities
• Administer medication with food to minimize gastric irritation.
Tablets may be crushed if patient has difficulty swallowing. Do
not crush or chew extended-release tablets.
• Instruct patient to take carbamazepine around the clock,
exactly as directed. If a dose is missed, take as soon as possible
but not just before next dose; do not double doses. Medication
should be gradually discontinued to prevent seizures.
• May cause dizziness or drowsiness.
• Instruct patients that fever, sore throat, mouth ulcers, easy
bruising, petechiae, unusual bleeding, abdominal pain, chills,
rash, pale stools, dark urine or jaundice should be reported.
• Advise patient not to take alcohol or other CNS depressant
concurrently with this medication.
• Caution patients to use sunscreen and protecting clothing to
prevent photosensitivity reactions.
•Inform patient that frequent mouth rinses, good oral hygiene,
and sugarless gum or candy may help reduce dry mouth. Saliva
substitute may be used.
2. May give PHENYTOIN 1amp IV
Generic Name PHENYTOIN (diphenylhydantoin, phenytoin sodium)
BrandName Dilantin-125, Dilantin Infatab, Dilantin Injection, Dilantin
Kapseals, Phenytek
Classification Antiepileptic, Antiarrhythmic, group 1b, HydantoinPregnancy
Category D
Dosage and Route Available forms :Chewable tablets—50 mg; oral suspension—
125 mg/5 mL; capsules—100 mg; ER capsules—30, 100, 200,
300 mg; injection—50 mg/mL
ADULTS
Phenytoin sodium, parenteral
 Status epilepticus: 10–15 mg/kg by slow IV. For
maintenance, 100 mg PO or IV q 6–8 hr. Higher doses
may be required. Do not exceed an infusion rate of 50
mg/min. Follow each IV injection with an injection of
sterile saline through the same needle or IV catheter to
avoid local venous irritation by the alkaline solution.
Continuous IV infusion is not recommended.

11.  Neurosurgery (prophylaxis): 100–200 mg IM q 4 hr
during surgery and the postoperative period (IM route is
not recommended because of erratic absorption, pain
and muscle damage at the injection site).
 IM therapy in a patient previously stabilized on oral
dosage: Increase dosage by 50% over oral dosage. When
returning to oral dosage, decrease dose by 50% of the
original oral dose for 1 wk to prevent excessive plasma
levels due to continued absorption from IM tissue sites.
Avoid IM route of administration if possible due to
erratic absorption and pain and muscle damage at
injection site.
Phenytoin and phenytoin sodium, oral
Individualize dosage. Determine serum levels for optimal
dosage adjustments. The clinically effective serum level is
usually between 10 and 20 mcg/mL.
 Loading dose (hospitalized patients without renal or
liver disease): Initially, 1 g of phenytoin capsules
(phenytoin sodium, prompt) is divided into three doses
(400 mg, 300 mg, 300 mg) and given q 2 hr. Normal
maintenance dosage is then instituted 24 hr after the
loading dose with frequent serum determinations.
 No previous treatment: Start with 100 mg tid PO.
Satisfactory maintenance dosage is usually 300–400
mg/day. An increase to 600 mg/day may be needed.
 Single daily dosage (phenytoin sodium, extended): If
seizure control is established with divided doses of three
100-mg extended phenytoin sodium capsules per day,
once-a-day dosage with 300 mg PO may be considered.
PEDIATRIC PATIENTS
Phenytoin sodium, parenteral
 Status epilepticus: Administer phenytoin IV. Determine
dosage according to weight in proportion to dose for a
150-lb (70-kg) adult (see adult dosage above; see
Appendix Calculating Pediatric Doses). Pediatric dosage
may be calculated on the basis of 250 mg/m2. Dosage for
infants and children also may be calculated on the basis
of 10–15 mg/kg, given in divided doses of 5–10 mg/kg.
For neonates, 15–20 mg/kg in divided doses of 5–10

12. mg/kg is recommended.
Phenytoin and phenytoin sodium, oral
 Children not previously treated: Initially, 5 mg/kg/day
in two to three equally divided doses. Subsequent
dosage should be individualized to a maximum of 300
mg/day. Daily maintenance dosage is 4–8 mg/kg.
Children > 6 yr may require the minimum adult dose of
300 mg/day.
GERIATRIC PATIENTS AND PATIENTS WITH HEPATIC
IMPAIRMENT
 Use caution and monitor for early signs of toxicity;
phenytoin is metabolized in the liver.
Action  Phenytoin acts as an anticonvulsant by increasing efflux
or decreasing influx of sodium ions across cell
membranes in the motor cortex during generation of
nerve impulses; thus stabilizing neuronal membranes
and decreasing seizure activity. It acts as an
antiarrhythmic by extending the effective refractory
period and suppressing ventricular pacemaker
automaticity, shortening action potential in the heart.
Indication  Control of grand mal (tonic-clonic) and psychomotor
seizures
 Prevention and treatment of seizures occurring during
or following neurosurgery
 Parenteral administration: Control of status epilepticus
of the grand mal type
 Unlabeled uses: Antiarrhythmic, particularly in digitalis-
induced arrhythmias (IV preparations); treatment of
trigeminal neuralgia (tic douloureux)
Side Effects  Hypersensitivity, lack of appetite, headache, dizziness,
tremor, transient nervousness, insomnia, GI
disturbances (e.g. nausea, vomiting, constipation),
tenderness and hyperplasia of the gums, acne, hirsutism,
coarsening of the facial features, rashes, osteomalacia.
Phenytoin toxicity as manifested as a syndrome of
cerebellar, vestibular, ocular effects, notably nystagmus,
diplopia, slurred speech, and ataxia; also with mental
confusion, dyskinesias, exacerbations of seizure

13. frequency, hyperglycaemia. Solutions for inj may cause
local irritation or phlebitis. Prolonged use may produce
subtle effects on mental function and cognition,
especially in children.
 Potentially Fatal: Toxic epidermal necrolysis, Stevens-
Johnson syndrome.
Contraindication  Pregnancy. IV admin in sinus bradycardia, heart block,
or Stokes-Adams syndrome.
Nursing
Responsibilities
Assessment
 History: Hypersensitivity to hydantoins; sinus
bradycardia, AV heart block, Stokes-Adams syndrome,
acute intermittent porphyria, hypotension, severe
myocardial insufficiency, diabetes mellitus,
hyperglycemia, pregnancy, lactation
 Physical: T; skin color, lesions; lymph node palpation;
orientation, affect, reflexes, vision examination; P, BP; R,
adventitious sounds; bowel sounds, normal output, liver
evaluation; periodontal examination; LFTs, urinalysis,
CBC and differential, blood proteins, blood and urine
glucose, EEG and ECG
Interventions
 Use only clear parenteral solutions; a faint yellow color
may develop, but this has no effect on potency. If the
solution is refrigerated or frozen, a precipitate might
form, but this will dissolve if the solution is allowed to
stand at room temperature. Do not use solutions that
have haziness or a precipitate.
 WARNING: Administer IV slowly to prevent severe
hypotension; the margin of safety between full
therapeutic and toxic doses is small. Continually monitor
patient's cardiac rhythm and check BP frequently and
regularly during IV infusion. Suggest use of fosphenytoin
sodium if IV route is needed.
 Monitor injection sites carefully; drug solutions are very
alkaline and irritating.
 WARNING: Monitor for therapeutic serum levels of 10–
20 mcg/mL.
 Give oral drug with or without food in a consistent

14. manner. Give with food if patient complains of GI upset.
 Recommend that the oral phenytoin prescription be
filled with the same brand each time; differences in
bioavailability have been documented.
 Suggest that adult patients who are controlled with 300-
mg extended phenytoin capsules try once-a-day dosage
to increase compliance and convenience.
 WARNING: Reduce dosage, discontinue phenytoin, or
substitute other antiepileptic medication gradually;
abrupt discontinuation may precipitate status
epilepticus.
 Phenytoin is ineffective in controlling absence (petit
mal) seizures. Patients with combined seizures will need
other medication for their absence seizures.
 WARNING: Discontinue drug if rash, depression of blood
count, enlarged lymph nodes, hypersensitivity reaction,
signs of liver damage, or Peyronie's disease (induration
of the corpora cavernosa of the penis) occurs. Institute
another antiepileptic drug promptly.
 Monitor hepatic function periodically during long-term
therapy; monitor blood counts and urinalysis monthly.
 Monitor blood or urine sugar of patients with diabetes
mellitus regularly. Adjustment of dosage of
hypoglycemic drug may be needed because antiepileptic
may inhibit insulin release and induce hyperglycemia.
 WARNING: Have lymph node enlargement occurring
during therapy evaluated carefully. Lymphadenopathy
that simulates Hodgkin's lymphoma has occurred.
Lymph node hyperplasia may progress to lymphoma.
 Monitor blood proteins to detect early malfunction of
the immune system (eg, multiple myeloma).
 Arrange instruction in proper oral hygiene technique for
long-term patients to prevent development of gum
hyperplasia.
Teaching points
 Take this drug exactly as prescribed, with food to reduce
GI upset, or without food—but maintain consistency in
the manner in which you take it. Be especially careful not
to miss a dose if you are on once-a-day therapy.
 Do not discontinue this drug abruptly or change dosage,
except on the advice of your health care provider.

15.  Maintain good oral hygiene (regular brushing and
flossing) to prevent gum disease; arrange frequent
dental checkups to prevent serious gum disease.
 Arrange for frequent checkups to monitor your response
to this drug.
 Monitor your blood or urine sugar regularly, and report
any abnormality to your health care provider if you have
diabetes.
 This drug is not recommended for use during pregnancy.
It is advisable to use some form of contraception other
than hormonal contraceptives.
 Wear a medical alert tag so that any emergency medical
personnel will know that you have epilepsy and are
taking antiepileptic medication.
 You may experience these side effects: Drowsiness,
dizziness, confusion, blurred vision (avoid driving or
performing other tasks requiring alertness or visual
acuity; alcohol may intensify these effects); GI upset
(take drug with food, eat frequent small meals).
 Report rash, severe nausea or vomiting, drowsiness,
slurred speech, impaired coordination (ataxia), swollen
glands, bleeding, swollen or tender gums, yellowish
discoloration of the skin or eyes, joint pain, unexplained
fever, sore throat, unusual bleeding or bruising,
persistent headache, malaise, any indication of an
infection or bleeding tendency, abnormal erection,
pregnancy.
3. FERROUS SULFATE 1 tablet 2x a day P.O
Generic Name FERROUS SULFATE
Classification Hematinics
Action Provides elemental iron component in the formation of
hemoglobin.
Indication Iron deficiency
Side Effects Common: nausea, constipation, black stools
Uncommon: epigastric pain, vomiting, diarrhea, anorexia; liquid
forms may temporarily stain teeth
Nursing
Responsibilities
 Use cautiously on long-term basis
 Keep in mind that GI upset may be related to dose.
Between-meal doses are preferable, but can be given

16. with some foods, although absorption may be decreased.
Enteric-coated products reduce GI upset but also reduce
amount of iron absorbed
 Be aware that oral iron may turn stools black. Although
this unabsorbed iron is harmless, it could mask melenas.
 Monitor hemoglobin and hematocrit levels and
reticulocyte count during therapy, as ordered