A Case Study on Meningioma

A Case Study on Meningioma

In Partial Fulfilment of the Requirements In NCM 103 – Medical Surgical Nursing (Related Learning Experience)

A Requirement Presented to the Faculty of the Nursing Department of Polytechnic College of Davao del Sur, Inc.

Submitted by: BSN- III Jhensczy Hazel Maye Alba Pryll John Colita Aileen Claire Dagpin

JANUARY 2017

ACKNOWLEDGEMENT

The researchers of this case study would like to extend their warmest gratitude to all the people who made the success of this undertaking a reality. First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in making this work. To Him be all the Glory and Praise! To the institution of Polytechnic College of Davao del Sur, Inc. and the Dean of Nursing, Madam Jennifer P. Ybañez, RN , MAN; Clinical Coordinator Madam Marina Liu Ledesma, RN , MAN and Clinical Instructor, Madam Lourders P. Abecia,RN for invaluable time, knowledge and effort rendered. To the staff and personel of Southern Philippines Medical Center, especially in the Neuro Ward foe giving us the oppurtunity to complete this endeavour. To our classmates, friends and mentors, for giving the inspiration to finish this seemingly impossible task. And lastly, to the client and her family who willingly cooperated and gave their time in answering the questions and sharing some secluded information.

ACKNOWLEDGEMENT

The researchers of this case study would like to extend their warmest gratitude to all the people who made the success of this undertaking a reality. First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in making this work. To Him be all the Glory and Praise! To the institution of Polytechnic College of Davao del Sur, Inc. and the Dean of Nursing, Madam Jennifer P. Ybañez, RN , MAN; Clinical Coordinator Madam Marina Liu Ledesma, RN , MAN and Clinical Instructor, Madam Lourders P. Abecia,RN for invaluable time, knowledge

and effort rendered. To the staff and personel of Southern Philippines Medical Center, especially in the Neuro Ward foe giving us the oppurtunity to complete this endeavour. To our classmates, friends and mentors, for giving the inspiration to finish this seemingly impossible task. And lastly, to the client and her family who willingly cooperated and gave their time in answering the questions and sharing some secluded information.

TABLE OF CONTENTS

Chapter I – Introduction Chapter II – Identification of the Case Personal Information Family Health History/Genogram Background/History Medical History History of present illness Socio-economic background Chapter III – Anatomy and Physiology Chapter IV – Symptomatology Chapter V – Physiology Chapter VI – Medical Management Ideal Actual/ Doctor’s order Chapter VII – Laboratory Findings Chapter VIII – Nursing Theory Chapter IX – Nursing Assessment Chapter X – Nursing Management NCP Drug Study Chapter XI – Health Teachings Chapter XII – Discharge Plan Chapter XIII – Prognosis Chapter XIV – Evaluation Chapter XV – Implication of the Study References

Chapter I INTRODUCTION The main switch in man’s anatomical and physiological function is his brain. The brain consists of a huge network of neurons that control the body’s vital functions. So far, this system is vulnerable, and its optimal function depends on several key factors. Therefore, any alteration to this system and function greatly affects the body as a whole. A meningioma is a tumor that arises from the meninges — the membranes that surround your brain and spinal cord. Most meningiomas are noncancerous (benign), though rarely a meningioma may be cancerous (malignant). Some meningiomas are classified as atypical, meaning they're neither benign nor malignant but, rather, something in between. (Ellison D., et al). Meningiomas occur most commonly in older women around 30-60 years old. But a meningioma can occur in males and at any age, including childhood.A meningioma doesn't always require immediate treatment. A meningioma that causes no significant signs and symptoms may be monitored over time. The incidence of meningioma appears to have increased in the past few decades. An estimated 18,000 new cases of malignant meningiomas occur per year: 14.2 per 100,000 men and 13.9 per 100,000 women (ABTA, 2014). Meningiomas ultimately cause death by impairing vital function, such as respiration or through increased ICP. Despite effort in researching data in Philippines concerning cases of meningioma, however futile. It could either be that data has been held confidential and have not been published or it is likely that meningioma case is not considered relevant for studies yet. This case study which primarily talks about meningiomas is directed towards presenting the disease, the management and intervention and the other vital facts that remain in oblivion to the great number of population of this country. Considering that the brain tumor truly and evidently has a devastating impact of our nation’s health our group has regarded this study significant to the fields of nursing education practice

and research because the completion of this study does not only meet the terms for dissemination information purposes, but for sensible learning as well. Chapter II IDENTIFICATION OF THE CASE A. Personal Information Patient’s Name: “Leila” Age: 39 yrs. old Birthday: December 6, 1977 Gender: Female Nationality: Filipino Religion: Roman Catholic Civil Status: Married Address: Prk. 2 Salakot, Talomo Dist., Davao City Occupation: Housewife Educational Background: Undergraduate (3rd year high school) Mother’s Name: Leni Occupation: (Deceased) Spouse’s Name: Dayan Occupation: Carpenter/Driver Case No.: 2016063184 Date Admitted: November 12, 2016 Time Admitted: 2:10 PM Chief complaint: Severe Headache Admitting diagnosis: Meningioma Left Fronto Parietal Area Final diagnosis: Meningioma Fronto Occipital Area Procedure: Craniectomy excision of brain tumor Attending physician: Dr. Chua

B. Family Health History (GENOGRAM) Paternal Side

Maternal Side 103

79

59 79

90

88

80

55

52

49

47

45

43

41

36

Legend:

Male Female Patient

Deceas ed

Alive & Well

Unknow n

Alcohol ic

Smoke r

Cance

Strok e

Diabeti Brain c Tumor

HP N

Murdere d

39

Patient Leila’s paternal side are unknown since she claimed that she doesn’t know much of them because her parents broke up when she was 3 years old. Her family’s maternal side has hereditary diseases such as hypertension, diabetes mellitus, CVA and cancer, although the patient is the only one who have a brain tumor. Her grandmother died because of breast cancer and her mother died due to tongue cancer. The eldest brother of their mother died because he was killed by their neighbor for no reason and one of her uncles died because of CVA. The patient’s eldest sister died due to DM. C. Background/History Patient Leila was born in Gingoog City in Misamis Oriental, she is the 8th child among her siblings, but when her parents separate when she was 3 years old, her mother decided to go back to her hometown in Davao City. The patient was not able to finish her secondary level due to financial issues. She is only up to third year highschool at Davao City National High School. When she was 16, she started working in “palengke” or market as a saleslady, selling vegetables. And soon got married at the age of 27. Now, they were blessed with 5 children. According to patient Leila she is having occasional mild to moderate headaches and blurry visions since 2014 which she only disregard as she thought that it was due to stressed. On April 2016, patient observed that she started having severe headaches a couple of days after she got birth with her youngest child and sometimes with occasional grand mal convulsion which she didn’t pay attention as she thought that it was due to not taking medications due to fever. D. Medical History According to the patient, she never had any serious illnesses in the past that requires admission to the hospital but at the age of eight, she had chickenpox. Whenever she became ill, she only uses alternative ways in treating herself such as herbal medicines. She also stated that she had complete vaccinations since childhood from their local barangay health center. The patient gave birth to her first three children only at their home. However, on her 4th child, she gave birth at SPMC via caesarian section.

D. History of present illness A day prior to admission the patient experienced seizure that last from a few seconds to more than five minutes, and that was the time her husband decided to take her to the hospital on November 12, 2016. E.Socio-Economic Background Currently, the patient is a housewife. Her husband works as a carpenter in daytime and earns 300 pesos a day. After working as a carpenter, in the evening, her husband drives their tricycle to earn extra income of 250 per night. According to her husband, he earns about 15,000-16,000 a month excluding their daily needs. Their hospital bill was covered by the Lingap Para sa Mahirap.

Chapter III ANATOMY AND PHYSIOLOGY OF THE BRAIN & MENINGES

The brain, when fully developed, is a large organ which fills the cranial cavity. Early in its development the brain becomes divided into three parts known as the forebrain, the midbrain and the hindbrain. The forebrain is the largest part and is called the cerebrum; it is divided into the right and left hemispheres by a deep longitudinal fissure. The separation is complete t the front and back but in the center, the hemispheres are joined by a broad band of nerve fibers called the corpus callosum. The outer layer of the cerebrum is called the cerebral cortex and is composed of grey matter (cell bodies) thrown into numerous folds or convolutions called gyri, separated by fissures called sulci. This enables the surface area of the brain, and therefore the number of cell bodies, to be

increased greatly. The general pattern of the gyri and sulci is the same in all humans; three main sulci divide each hemisphere into four lobes, each named after the skull bone under which it lies. The central sulcus runs downwards and forwards from the top of the hemisphere to a point just above the lateral sulcus; the lateral sulcus runs backwards from the lower part of the front of the brain and the parieto-occipital sulcus runs downwards and forwards for a short way from the upper posterior part of the hemisphere. The lobes of the hemispheres are the frontal lobe, lying in front of the central sulcus and above the lateral sulcus; the parietal lobe lying between the central sulcus and the parieto-occipital sulcus and above the line of the lateral sulcus; the occipital lobe, which forms the back of the hemisphere and the temporal lobe lying below the lateral sulcus and extending back to the occipital lobe. The area lying immediately in front of the central sulcus between is known as the pre-central gyrus and is the motor area from which arise many of the motor fibres of the central nervous system. Immediately behind the central sulcus lies the sensory area, called the post-central gyrus, in the cells of which several kinds of sensation are interpreted. Longitudinal section of a hemisphere shows grey matter (cell bodies) on the outside and white matter (nerve fibres) forming the interior. The nerve fibres connect one part of the brain with the other parts and with the spinal cord, but within the white matter groups of nerve cells can be seen forming areas of grey matter. These areas of grey matter are called cerebral nuclei. The main function of these areas is coordination of movement and posture of the body: disorders affecting these areas cause jerky movements and unsteadiness. The cavities within the brain are called ventricles. There are two lateral ventricles, a central third ventricle and a fourth ventricle between the cerebellum and the pons. All are filled with cerebrospinal fluid. The midbrain lies between the forebrain and the hindbrain. It is about 2 cm in length and consists of two stalk-like bands of white matter called the cerebral peduncles, which convey impulses passing to and from the brain and spinal cord, and four small prominences called the quadrigeminal bodies, which are concerned with sight and hearing reflexes. The pineal body lies between the two upper quadrigeminal bodies. The hindbrain has three parts:

1. The pons, which lies between the midbrain above and the medulla oblongata below. It contains fibres which carry impulses upwards and downwards and some which communicate with the cerebellum. 2. The medulla oblongata lies between the pons above and the spinal cord below. It contains the cardiac and respiratory centres which are also known as the vital centres and which control the heart and respiration. 3. The cerebellum projects backwards beneath the occipital lobes of the cerebrum. It is connected to the midbrain, the pons and the medulla oblongata by three bands of fibres called the superior, middle and inferior cerebellar peduncles respectively. The cerebellum is responsible for the coordination of muscular activity, control of muscle tone and maintenance of posture. It is continuously receiving sensory impulses concerning the degree of stretch in muscles, the position of joints and information from the cerebral cortex. It sends information to the thalamus and the cerebral cortex. The midbrain, the pons and the medulla have many functions in common and together re often known as the brain stem. This area also contains the nuclei from which originate the cranial nerves. Meninges The meninges (they are serous membranes) are three layers of protective tissue called the dura mater, arachnoid mater, and pia mater — meninges of the brain and spinal cord are continuous,

being

linked

through

the

magnum

foramen.

Dura Mater Most superior of the layers — it is tough and inflexible and forms several structures that separate the cranial cavity into compartments and protect the brain from displacement. Arachnoid Mater Middle layer of the meninges — makes arachnoid villi, small protrusions through the dura mater into the venous sinuses of the brain, which allow CSF to exit the sub-arachnoid space and enter the blood stream. Cerebrospinal fluid (CSF) flows under the arachnoid in the subarachnoid space. Pia Mater, or Pia The delicate innermost layer of the meninges — a thin fibrous tissue that is impermeable to fluid which allows it to enclose CSF (cerebrospinal fluid). By containing CSF, pia works with the other meningeal layers to protect and cushion the brain. Allows blood vessels to pass through and nourish the brain. The perivascular space created between blood vessels and pia mater functions as a lymphatic system for the brain. Lines the brain down into its sulci (folds).

The Spaces Between the Layers: Epidural Space Between the dura mater and the skull. Common location for hemorrhaging in the brain. Subdural Space Between the dura mater and the middle layer of the meninges, the arachnoid mater. When bleeding occurs, blood may collect here and push down on the lower layers of the meninges, possible causing brain damage. Subarachanoid Space From the fourth ventricle, the cerebrospinal fluid passes into the subarachnoid space where it circulates around the outside of the brain and spinal cord and eventually makes its way to the superior sagittal sinus via the arachnoid granulations also called arachnoid villi. In the superior sagittal sinus, the cerebrospinal fluid is reabsorbed into the blood stream. Cerebrospinal fluid (CSF) — clear, saline bodily fluid that occupies the subarachnoid space and the ventricular system around and inside the brain. It is produced continuously at a steady rate and is essential for the normal functioning of the CNS. It acts as a cushion for the neuraxis, also bringing nutrients to the brain and spinal cord and removing waste from the system.

Chapter IV ETIOLOGY AND SYMPTOMATOLOGY ETIOLOGY PREDISPOSING FACTORS 1. Gender

PRESENT ✓

ABSENT

JUSTIFICATION Females are more likely to have meningioma. A progesterone-induced

mechanism has also been reported to be responsible for enlargement of meningiomas in pregnancy, it is believed that female hormones may play a role. Source: http://www.mayoclinic.org/diseasesconditions/meningioma/basics/risk2. Age

✓

factors/con-20026098 Meningiom are more common in female ages 30-60 years old , although people of any age can develop a tumor. Which is present to our patient since she is now 39 years old. Source: M. Ponz De Leon, Familial and Hereditary Tumors. Recent Results in Cancer 1136,

3. Heredity

✓

DOI 10.1007/978-3-642-85076-9_8 Patient Leila’s mother has tongue cancer. Grandmother also has a breast cancer. A mutant gene in the long arm of chromosome could be involved in the development of meningioma Source: M. Ponz De Leon, Familial and Hereditary Tumors. Recent Results in Cancer 1136,

4. Environment

✓

DOI 10.1007/978-3-642-85076-9_8 Exposure to a lot of toxins and radiation can increase the risk in developing a tumor. study that tested the possibility of links between cancer and chronic exposure to the

type of radiation emitted from cell phones and wireless devices Source: https://www.scientificamerican.com/article/ major-cell-phone-radiation-study-reignitescancer-questions/

PRECIPITATING FACTORS PRESENT

ABSENT

JUSTIFICATION

1. Exposure

✓

Studies have shown that there are certain types

to viral

of viruses that can cause brain tumors and there

infections

are some infections with certain viruses, bacteria, and parasites have been recognized as risk factors for several types of cancer in humans, such as Herpes simplex virus type 1 encephalitis Sources: https://www.cancer.org/cancer/cancercauses/infectious-agents/infections-that-canlead-to-cancer/intro.html http://www.elsevier.es/en-revista-neurologiaenglish-edition--495-articulo-herpes-simplex-

2. Pregnancy

✓

virus-type-1-S217358081500098X Meningiomas are linked to female hormones. Since during pregnancy there is a surge of these hormones, it is linked to having a meningioma. Source: http://www.eatingwell.com/nutrition_health/nutr ition_news_information/does_grilling_cause_ca

3. Diet

✓

ncer The client admitted that she frequently eats grilled meat. Any grilled meat when eaten frequently can cause possible tumors. It is not the meat that cause possible tumors, rather cooking meat at the high temperatures you use to grill—as well as broil and fry—creates heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs), compounds linked with some cancers.

Source: http://www.eatingwell.com/nutrition_health/nutr ition_news_information/does_grilling_cause_ca ncer

SYMPTOMATOLOGY SYMPTOMS 1. Changes in

PRESENT ✓

ABSENT

JUSTIFICATION Patient claimed that she is having blurry visions for 2 years but now the patient is

blind on both eyes but can see only vision, such

shadows.

as seeing

These symptoms occur when the

double or

meningioma directly affects a part of the

blurriness

brain that controls vision. Moreover, for the patient’s case the affected part was the occipital area, which is responsible for our visions. Source: https://www.uptodate.com/contents/ meningioma-beyond-the-basics#H1 The patient started to suffer moderate to

✓ 2. Headaches

severe headaches last 2014 until now, this

that worsen

is because of the increasing size of the

with time

tumor. As meningioma grows, it increases the pressure inside the skull, which causes the pain. Source: https://www.uptodate.com/contents/ ✓

3. Hearing loss

meningioma-beyond-the-basics#H1 Meningiomas can cause hearing loss if the tumor affects the inner ear or the nerve that controls the hearing but in our patient’s case it is absent because she has good hearing acuity. Source: https://www.uptodate.com/contents/ meningioma-beyond-the-basics#H1

✓

Patient claimed that she’s having a hard

4. Memory loss

time remembering events that happened in her life since after she delivered her youngest child. These symptoms occur when the meningioma directly affects a part of the brain that controls the memory. Moreover, for the patient’s case, the affected part was the occipital area but it also affects the medial temporal lobe because of its increasing size, which is responsible for our memory. Source: https://www.uptodate.com/contents/ ✓

5. Loss of smell

meningioma-beyond-the-basics#H1 Meningiomas can cause loss of smell if the tumor affects the nerve that controls the sense of smell but in our patient’s case it is absent because she can smell properly. Source: https://www.uptodate.com/contents/

✓ 6. Seizures

meningioma-beyond-the-basics#H1 In 2014, patient Leila suffered her first seizure attack. This symptom is caused by the meningioma that overlie the cerebrum which is in our patient’s case is present. Source: https://en.m.wikipedia.org

✓ 7. Weakness in the arms or legs

/wiki/meningioma The patient can’t tolerate well on her activities of daily living. She is dependent and needs assistance from the nurse or her husband. She claims that she started feeling this weakness a week prior to admission. Weakness in legs and arms may be caused by tumors that overlie the parasagittal frontoparietal region, which is present to our patient because of the increasing size of the tumor. Source: https://en.m.wikipedia.org/wiki/ meningioma

Chapter V PATHOPHYSIOLOGY PREDISPOSING FACTORS √ Gender √ Age √ Heredity √ Environment

PRECIPITATING FACTORS √Exposure to viral infections √Pregnancy √Diet

Glial cells in the brain

Cellular Damage

Persistence of Multibit factors

STAGES: Point mutation

Chromosomal translocation

Chromosomal amplification

Chromosomal change

Gene silencing

Cellular Aberration

Invasion to nearby cells

Tumor growth (obstruction)

Increased tumor size

Consumption of nutrients by tumor

Tumor growth to different areas of the brain

Increased ICP

Compression of parts

Signs and Symptoms:  Headaches, which can be most severe in the morning  Seizures or convulsions Anorexia  Weight loss  Dizziness  Changes in emotional state and behavior Tinnitus and vertigo

If treated:

If not treated:

Medical-Surgical   

Surgerycraniectomy/craniotomy Radiotherapy Chemotherapy (patient is in this level only)

If without complications

If with complications

Good prognosis

Poor prognosis

Cerebral ischemia

Cerebral hypoxia

Inflammation

Cerebral edema

Primary malignant neoplasm

Angiogenesis

Invasion to lymphatic and blood vessels

No room for expansion

Arrest in capillary bed organs

Transport interaction Cardiac/respiratory arrest with other blood elements

DEATH Adherence of tumor cells

Metastasis

DEATH

Chapter VI Medical Management A. Ideal Meningiomas are seldom detected before they commence to cause indications. A doctor performs a neurological assessment and may request for a brain scan: an MRI and/or a CT scan that will allow to locate the meningioma and determine the sign should clinical signs suggest the possibility of a tumor. Sometimes a biopsy may be performed, where a surgeon will remove part of all of the tumor to determine whether it is benign or malignant. Observation will then be recommended if the tumor is not causing any symptoms. To determine if the tumor is growing, regular brain scans will be performed. A surgery may be required if the tumor's growth threatens to create complications or if symptoms begin to grow. Should it be, a craniotomy will usually be performed, in which a piece of bone from the skull will be remove. The procedure will give the surgeon access to the affected portion of the brain and will remove the tumor – or as much of it as possible and the bone that was taken out at the start of the procedure will then be replaced. The location of the meningioma will determine how accessible it is to the surgeon. If it can't be accessed via surgery, radiation therapy is likely applied as radiation can shrink the tumor or can avoid the tumor from growing any larger. In addition, radiation is also a toll that can kill cancer cells if the tumor is malignant and can also be used on the parts of a tumor the surgeon was unable to remove.

B. Actual/Doctors Order November 12, 2016 @ 2:10 pm Dr. Paglomutan  Please admit under neuro ward  

   



Justification/Rationale

Pt. requires pre-op nursing care routine for further investigation in preparation for surgery. secure consent Pt. must give permission before receiving any type of medical treatment or surgery. DAT To determine whether pt. food intake will not lead to any complications and if the pt. needs further monitoring for further lab tests IVF PLR To hydrate the pt. appropriately. To shift fluids Labs attach to chart + clearance To make sure that pt. is cleared and ready for the procedure secure 3 U PRBC + 1 U ff. up stand by To prevent blood loss during the procedure on OR Secure mech vent neuro for Helps pt. to breathe after the surgery. reservation for possible post OR admission Inform neuro of this admission Neuro will check the clinical history and health standing of the patient based on available documentation ensuring that pt is eligible for the procedure

November 13, 2016 @ 9:11 AM Dr. Malasig  DAT

 NVS q4  Still for OR scheduling  Refer for unusualities

November 14, 2016

Justification/Rationale To determine whether pt. food intake will not lead to any complications and if the pt. needs further monitoring for further lab tests To obtain baseline data for comparison Pt is being prepared for the procedure Further evaluation and management

Justification/Rationale

@ 7:00 AM Dr. Malasig  Secure referral from IM neuro for evaluation and management  Still for OR schedule  DAT

Pt should be fit for the operating procedure to prevent intra and post-op complications Pt is being prepared for the procedure

 NVS q4

To determine whether pt. food intake will not lead to any complications and if the pt. needs further monitoring for further lab tests To obtain baseline data for comparison

 Refer unusualities

For further evaluation and management.

November 15,2016 @ 5:45 AM Dr. Malasig  Follow up referral to IM neuro

Justification/Rationale

 For OR scheduling

Ensuring that evaluation and management are in order As per elective procedure standard

 NVS q4

To obtain baseline data for comparison

 Refer

For further evaluation and management

November 15,2016 @ 3:40 PM Dr. Dillera  Thank you very much for referral  Patient seen and examined  History recorded  Noted surgical plans  Start dexamethasone 4mg IVTT q6h

November 16,2016 @ 2:07 AM

Justification/Rationale Pt has been evaluated and examined. documentation is done and plans has been established. To control edema

Justification/Rationale

Dr. Paglomutan  For OR scheduling  DAT  PLR 1 L @100cc/hour  Labs CBC, Na, K, Ca,  Refer November 17,2016 @ 7:00 AM Dr. Paglomutan  For OR scheduling  DAT

For elective procedure In preparation for the elective procedure, pt. is required to DAT To hydrate the patient appropriately Pt lab result must be monitored ensuring that pt. is eligible for the procedure For further evaluation and management Justification/Rationale

 Continue meds

To update the OR schedule Pt is allowed to DAT in preparation for the procedure, once procedure is done pt. food intake will be as per medical advised To continue therapeutic regimen

 Refer unusualities

For further evaluation and management

November 17,2016 @ 2:30 PM Dr. Dillera  Continue meds  Secure OR scheduling

To continue therapeutic regimen To confirm the elective procedure as scheduled

 Refer back as necessary

For any unusualities referral is advised

 Diazepam PRN for seizure

To treat seizure

 Secure CBC, PC, Na, K, Ca, Crea, Mg

As per standard of operating procedure, pt. lab results must be checked and documented to make sure that there will be no intra and postop complications

November 18,2016 @ 7:00 AM Dr. Paglomutan

Justification/Rationale

Justification/Rationale

 For scheduling

 NVS q4

To schedule the procedure as per OR availability To determine whether pt. food intake will not lead to any complications and if the pt. needs further monitoring for further lab tests To obtain baseline data for comparison

 Refer for unusualities

For further evaluation and management

 DAT

November 19,2016 @ 10:00 AM Dr. Paglomutan  Still for OR scheduling  Continue meds

No available slot for the procedure For therapeutic regimen

 NVS q4

To obtain baseline data for comparison

 Refer November 19,2016 @ 9:00 PM Dr. Paglomutan  clonidine 150 mcg IVTT now

For further evaluation and management

November 20, 2016 @ 9:00 PM Dr. Paglomutan  For OR scheduling

November 21,2016 @ 7:00 AM Dr. Malasig  Still for OR scheduling  DAT

Justification/Rationale

To address the issue of hypertension

Justification/Rationale Due to unavailability of OR slot

Justification/Rationale

 Continue meds.

No slot available for OR procedure To determine whether pt. food intake will not lead to any complications and if the pt. needs further monitoring for further lab tests For therapeutic regimen

 Refer

Should requires, to address clinical issues early

November 22,2016 @ 7:00 AM Dr. Paglomutan  Schedule patient for craniotomy Excision of tumor tomorrow 11/23/16  Secure consent  Inform OR/AROD

 NPO post-midnight  Meds: ceftriaxone 1g IVTT q8h ranitidine 50 mg IVTT q8h or 6 on NPO

Justification/Rationale Schedule for elective procedure has finally confirmed Pt. must give permission before receiving any type of medical treatment or surgery. To prepare OR bed, prepare the surgical equipment, ensuring that standby response team is available As required to prevent aspiration intra-op Ceftriaxone is given before surgery to prevent infections that may develop after the operation. Ranitidine to prevent ulcer while patient is on NPO diet.

 ff. up procurement of PRBC & FFP  Refer

To make sure that it is available as per needed For further evaluation and management

Anesthesia Pre-Op Orders November 22,2016 @ 5:15 PM

Justification/Rationale

Dr. Toledo Thank you for this referral  Pt. seen and examined

As per standard operating procedure

 History and physical examination reviewed  Meds: 1 omeprazole 40 mg 1 tab @ 12 mn  IVF: D5LR 1L @100cc/hr PNSS 1L @ KVO (bloodset)  ensured patency of IVF PTOR  VS en route to OR  NPO post-midnight  refer

To determine the appropriate type of anesthesia to be given to the pt. For prophylaxis of acid aspiration prior to surgery To hydrate the patient appropriately To supply glucose to the brain since the pt is on NPO To prevent any complications. To be monitored strictly as per clinical and operating standard To prevent aspiration inra-operatively Pt needs to be assess by other specialty to double check pt’s eligibility to the procedure

Anesthesia Post-Op Orders November 23,2016 @ 12:45 PM

Justification/Rationale

Dr. Toledo  To PACU then neuro ICU  NPO

 IVF: PNSS 1L @ KVO  Sterofundin @ 140 cc/hr  Meds: 1) paracetamol 1g IVTT x 6 days @ PACU 2) nalbuphine 5 mg IV q6h PRN for severe pain 3) omeprazole 40 mg IV OD

 Mod to HBR  to secure 2 U FFP + 3 U PRBC  Labs: CBC & PG S , NA, K, Crea  Transfuse blood once available

To recover pt. from anesthesia When the body awakens after anesthesia, the digestive system also needs some time to adjust. Filling the belly with solid foods shortly after surgery may cause to feel nauseous and might lead to vomiting. To hydrate the pt. appropriately For fluid replacement Paracetamol for mild to moderate pain and fever Nalbuphine for moderate to severe pain. Omeprazole to help decrease the chance of developing an ulcer while the pt is on NPO diet. This position helps maximize lung expansion For possible blood loss after the procedure Pt lab result must be monitored to check for any complication The soonest possible per patient necessity

 Hook to mech vent IV: 350 RR: 18 I:R: 1:25 F102: 100%

To help the patient breathe

 Keep pt. warm & thermoregulated

General anesthesia can cause pt.’s core body temperature to drop several degrees, retaining body heat will prevent hypothermia. To prevent aspiration

 Suction secretions PRN  WOF unusualities  Refer November 23,2016 @ 3:30 PM Dr. Toledo

For further evaluation and management

  epinephrine infusion to 15 cc/hr  300 cc voluven now

For bradycardia Relief of respiratory distress For treatment and prophylaxis of hypovolemia

November 23,2016 @ 4:30 PM Dr. Toledo ABE Uncompensated Metabolic Acidosis  Give NaHCO3 50 meQs IV bolus now

To treat metabolic acidosis

 incorporate 50 meQs NaHCO3 on 1L sterofundin - HOLD  Refer

For further evaluation and management

November 23,2016 @ 10:00 PM Dr. Toledo  Drips Levophed drip (2mg/kg) @ 10 cc/hr Dobutamine drip (18mg/kg) @10 cc/hr Epinephrine drip (25mg + 18 cc PNSS) @ 9 cc/hr

Justification/Rationale Levophed to restore blood pressure control in certain acute hypotensive states Dobutamine to treat heart failure caused by surgery Epinephrine to relieve respiratory distress

 Refer

November 23,2016 Dr. Guiani P0515 PRBC & FFP  Shift sterofundin to voluven 500 cc to run @ 160 cc/hr  to secure 3 units of PRBC & transfuse w/in 2 hrs each  for repeat CBC, Plt, creatinine, Na, K, Ca + Mg now

For further evaluation and management

Justification/Rationale

For fluid replacement For possible blood loss after the surgery To monitor any changes of the laboratory results

 Vit. K 1 amp now then q8hr x 3 doses

To help heal excision after surgery

 continue levophed as ordered

To restore blood pressure control in certain

 D/C epinephrine & dobutamine  Start dopamine drip @ 5 mcg/kg  Revision of mech vent set OP F102: 100 I:E: 1:3 IV: 375 AC MDOE RR: 16  For repeat ABG 1 hour after post revision

acute hypotensive states Patient is not in respiratory distress Dopamine is indicated for the correction of hemodynamic imbalances

To check how well the lungs are able to move oxygen into the blood and removes carbon dioxide from the blood.

 thanks

November 24,2016 @ 5:00 AM Dr. Toledo  Transfer available PRBC & FFP

Justification/Rationale To replace blood loss

 Request CBC & PLT for transfusion

Lab results must be checked to make sure that there will be no complications while doing the BT

 Refer to IM neuro  Cont. meds

For evaluation For fast recovery

 refer November 24,2016 @ 6:20 AM Dr. Toledo  to secure another 5 U PRBC of pts blood type and transfuse to run 4 hrs each after proper crossmatching  Transfuse 1 U FFP for every 2 U PRBC  Furosemide 20 mg IV post BT 2 U with BP precautions

For further evaluation and management

 Mod to HBR  Maintain on mech vent  Suggest NGT insertion

To replace blood loss FFP is Indicated to replace labile plasma coagulation factors Furosemide is a loop diuretic. It works by helping the kidneys to remove fluid from the body. This position promotes lung expansion To help the patient breathe To drain gastric contents, decompress the stomach, obtain a specimen of the gastric

contents, or introduce food into the GI tract.  WOF unusalities  refer November 24,2016 @ 7:15 AM Dr. Clarion  Please insert NGT & start OTF 1,800 kcal/day x 6 divided feedings November 24,2016 @ 3:20 PM Dr. Clarion  ceftriaxone 2q IVTT q12/hr November 24,2016 @ 7:30 PM Dr. Clarion  Pt self extubated  cont. meds  possible soft diet tomorrow

November 25,2016 @ 7:00 AM Dr. Paglomutan  trans out to ward

 repeat CBC with blood 1 U PRBC transfuse  moderate high back rest  soft diet & DAT

For further evaluation and management

To introduce food in the GI tract since the patient is still unconscious

Ceftriaxone is given to prevent infections that may develop after the operation.

Pt doesn’t need to be intubated For fast recovery soft diet until the gastrointestinal tract can tolerate/digest solid food.

Patient is now recovering from the procedure and now she is going to trans out to neuro for further management and evaluation To replace blood loss To promote lung expansion Client can now tolerate any food she desires that is nutritious as orderes To prevent infection Patient recovered from hypovolemia For faster recovery To hydrate the patient appropriately

 daily dressing  D/C voluven  Cont. meds  Cont. IVF November 25,2016 @ 7:35 AM Dr. Toledo  Pls ff. up blood availability & transfuse To replace blood loss in 4 hrs

 Mod to HBR  Deep breathing exercises  Refer November 25,2016 @ 6:45 PM Dr. Malasig  trans out neuro ward

This position facilitate lung expansion This exercises helps the patient to breathe For further management and evaluation

Patient at this time is stable

Chapter VII LABORATORY FINDINGS Date: November 16, 2016 @ 10:15 PM TEST

RESULT

REFERENCE

INTERPRETATION

RANGE

HEMATOLOGY CBC + PLT Hemoglobin Hematocrit RBC Count WBC Count

134.0 0.39 4.48 12.12

115-155 0.36-0.48 4.20-6.10 5.0-10.0

High

91

55-75

High

9.0

20-35

Low

 Monocytes

0

2-10

Low

 Eosinophils

0

1-8

Low

Differential Count  Neutrophils

 Lymphocytes

 Basophils 0 0-1 Platelet Count 393 150-400 MCH 29.9 25.60-32.20 (mean corpuscular hemoglobin) MCHC 34.5 32.20-35.50 (mean corpuscular hemoglobin concentration) MCV 86.6 79.40-94.80 (mean corpuscular volume) Date: November 17, 2016 @ 11:48 PM TEST

HEMATOLOGY

RESULT

REFERENCE RANGE

Within normal range Within normal range Within normal range There is an increase in WBC to fight the inflammation During tumor development, neutrophils appear to be one of the first inflammatory cell types on the scene Low lymphocytes indicates that the body is low on infection resistance Low monocytes indicates an increased risk for infections Low eosinophils indicates that the body is low on infection resistance Within normal range Within normal range Within normal range

Within normal range

Within normal range

INTERPRETATION

CBC + PLT Hemoglobin Hematocrit RBC Count WBC Count

127.0 0.37 4.20 16.59

115-155 0.36-0.48 4.20-6.10 5.0-10.0

High

91

55-75

High

 Lymphocytes

8.0

20-35

Low

 Monocytes

1.0

2-10

Low

 Eosinophils

0

1-8

Low

0 371 30.2

0-1 150-400 25.60-32.20

During tumor development, neutrophils appear to be one of the first inflammatory cell types on the scene Low lymphocytes indicates that the body is low on infection resistance Low monocytes indicates an increased risk for infections Low eosinophils indicates that the body is low on infection resistance Within normal range Within normal range Within normal range

34.3

32.20-35.50

Within normal range

88.11

79.40-94.80

Within normal range

REFERENCE

INTERPRETATION

Differential Count  Neutrophils

 Basophils Platelet Count MCH (mean corpuscular hemoglobin) MCHC (mean corpuscular hemoglobin concentration) MCV (mean corpuscular volume)

Within normal range Within normal range Within normal range There is an increase in WBC to fight the inflammation

Date: November 23, 2016 @ 9:29 PM TEST

RESULT

RANGE

HEMATOLOGY CBC + PLT Hemoglobin

32.0

115-155

Low

Hematocrit

0.1

0.36-0.48

Low

RBC Count

1.07

4.20-6.10

Low

WBC Count

25.54

5.0-10.0

High

91

55-75

High

4.0

20-35

Low

5 0

2-10 1-8

Low

0 59 29.9

0-1 150-400 25.60-32.20

It is common for neutrophils to be high after surgery because this cells help mop up regular body cells that were damaged during surgery. Low lymphocytes indicates that the body is low on infection resistance Within normal range Low eosinophils indicates that the body is low on infection resistance Within normal range Within normal range Within normal range

33.7

32.20-35.50

Within normal range

88.8

79.40-94.80

Within normal range

Differential Count  Neutrophils

 Lymphocytes

 Monocytes  Eosinophils

 Basophils Platelet Count MCH (mean corpuscular hemoglobin) MCHC (mean corpuscular hemoglobin concentration) MCV

Low hemoglobin results indicates postoperative anemia Low hematocrit results indicates postoperative anemia Low RBC count results indicates postoperative anemia It is common for WBC counts to be high after surgery, because this cell initiates healing after the tissue damaged.

(mean corpuscular volume) Date: November 25, 2016 @ 6:09 PM TEST

RESULT

REFERENCE RANGE

INTERPRETATION

Hemoglobin

87.0

115-155

Low

Hematocrit

0.25

0.36-0.48

Low

RBC Count

2.94

4.20-6.10

Low

WBC Count

19.35

5.0-10.0

High

96

55-75

High

3.0

20-35

Low

5 0

2-10 1-8

Low

0 60 29.6

0-1 150-400 25.60-32.20

HEMATOLOGY CBC + PLT

Differential Count  Neutrophils

 Lymphocytes

 Monocytes  Eosinophils

 Basophils Platelet Count MCH

Low hemoglobin results indicates postoperative anemia Low hematocrit results indicates postoperative anemia Low RBC count results indicates postoperative anemia It is common for WBC counts to be high after surgery, because this cell initiates healing after the tissue damaged. It is common for neutrophils to be high after surgery because this cells help mop up regular body cells that were damaged during surgery. Low lymphocytes indicates that the body is low on infection resistance Within normal range Low eosinophils indicates that the body is low on infection resistance Within normal range Within normal range Within normal range

(mean corpuscular hemoglobin) MCHC (mean corpuscular hemoglobin concentration) MCV (mean corpuscular volume)

35.2

32.20-35.50

Within normal range

84

79.40-94.80

Within normal range

Date: November 16, 2016 @ 10:17 PM TEST RESULT

REFERENCE RANGE

CLINICAL SIGNIFICANCE

39.00-113.00 3.6-5.1 136.00-144.00

Within normal range Within normal range Within normal range

REFERENCE RANGE

CLINICAL SIGNIFICANCE

1.75-2.39 39.00-113.00 3.6-5.1 0.74-1.03 136.00-144.00

Within normal range Within normal range Within normal range Within normal range Within normal range

CLINICAL CHEMISTRY Creatinine Potassium Sodium

58.09 mmol/L 3.56 mmol/L 140 mmol/L

Date: November 17, 2016 @ 11:10 PM TEST RESULT CLINICAL CHEMISTRY Calcium Creatinine Potassium Serum Magnesium Sodium

2.37 mmol/L 58.51 mmol/L 3.87 mmol/L 0.94 mmol/L 139.60 mmol/L

Arterial Blood Gas Test Date: November 23, 2016 @ 3:36 PM Measured test

Result

Units

pH@37 PCO2@37 PO2@37 Temp Calculated Test BE-ecf BE-b HCO3 TCO2 SO2b A a/A PO2/F102

7.282 29.0 489.9 37.0 -13.1 -10.8 16.1 13.8 14.7 100.0 113.9 4.3 2344.2

PCO mmHg mmHg deg mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmHg mmHg mmHg

Reference range (-) (-) (-) (-)

Analyzer

Reference range (-) (-) (-) (-)

Analyzer

pHox pHox pHox

Date: November 23, 2016 @ 8:54 PM Measured test

Result

Units

pH@37 PCO2@37 PO2@37 Temp Calculated Test BE-ecf BE-b HCO3 TCO2 SO2b A a/A PO2/F102

7.410 26.3 385.5 36.9 8.0 -5.5 20.0 16.8 17.6 100.0 117.5 3.3 1844.5

PCO mmHg mmHg deg mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmHg mmHg mmHg

pHox pHox pHox

Cranial CT Scan with Contrast FINDINGS: Multiple and IV-contrast enchanced axial CT images of the head were obtained. No adverse reactions are observed. A well-defined enhancing mass with slightly increased attenuation to the brain parenchyma is noted in the left fronto parietal convexity measuring 4.5 x 5.4 x 5.0 cm (CCAPW) with perilesional low density edema. The left lateral ventricle is compressed. No abnormal distinct changes appreciated in the brain and brainstem parenchyma. No abnormally enhancing areas. Midline structures are displaced to the right by about 0.7 cm. Sella, orbits, paranasal sinuses and petromastoids are unremarkable. Calvarium and visualized facial bones are intact with no evidence of fracture. Extracalvarial soft tissues are unremarkable. No other significant findings. IMPRESSIONS: Consider meningioma, left frontoparietal convexities with mass effect.

Chapter VII NURSING THEORY “Environmental Theory” By: Florence Nightingale The Environmental Theory by Florence Nightingale defined Nursing as “the act of utilizing the environment of the patient to assist him in his recovery.” It involves the nurse’s initiative to configure environmental settings appropriate for the gradual restoration of the patient’s health, and that external factors associated with the patient’s surroundings affect life or biologic and physiologic processes, and his development. This particularly correlates with the patient’s case since one of the most important factors that aids not only in the healing process but also the preventive aspect is the environment. By manipulating the environment of the patient such as ventilation, light and warmth, the body can repair itself quickly compared to a poor environment.

“Self-care Deficit Theory” By: Dorothea Orem Orem’s theory defined nursing as “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness.” It focuses on each individual’s ability to perform self-care, defined as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being.” Self-care deficit delineates when nursing is needed. Nursing is required when an adult (or in the case of a dependent, the parent or guardian) is incapable of or limited in the provision of continuous effective self-care. As in the case of the patient, she is unable to take care of herself such as doing his activities of daily living like taking a bath, urinating, defecating and ambulating due to her inability to see clearly. Thus comes the role of the nurse to fill in the gap and assist the patient in doing such activities as much as possible.

“Nursing Need Theory” By: Virginia Henderson The Nursing Need Theory was developed by Virginia A. Henderson to define the unique focus of nursing practice. The theory focuses on the importance of increasing the patient’s independence to hasten their progress in the hospital. Henderson’s theory emphasizes on the basic human needs and how nurses can assist in meeting those needs. The nurse’s task in every patient is to assist them in achieving optimal health. However, nurses are not always beside their patients and can’t assist or help them round the clock. Thus, it is one of the nurse’s responsibilities for the patient to not only achieve optimal health but also in gradually attaining independence during the healing process. With the patient’s case, the nurse slowly allows him to do minor tasks such as eating all by herself as long as she can tolerate or do so. The nurse also gave instructions to the patient and her husband on what must be done after they are discharged from the hospital. This allows the continuation of care through independence attained by the patient and his significant others.

CHAPTER IX NURSING ASSESSMENT Date of assessment: November 18, 2016 Time: 9:05 am REVIEW OF SYSTEMS: NEUROLOGICAL Patient Leila appears conscious and responsive. She is oriented to time, place and person. The patient though suffered seizures. EYE/VISION The patient’s pupils are equal and reactive to light and accommodation. She cannot see properly on both eyes though. Patient Leila stated that she only sees shadows. EARS/HEARING Both ears appear normal without the presence of discharges, impacted cerumen and foreign objects upon thorough inspection using a pen light. The patient can hear normally without any difficulty. NOSE Nose is patent with no lesions and abrasions. Nasal mucosa is pink, moist and intact. Nostrils are patent with no signs of nasal flaring. No discharges and foreign objects observed. MOUTH/TONGUE/TEETH/SPEECH The buccal mucosa is pink and has no evident signs of infection. No lesions present on tongue and buccal mucosa. Teeth are complete with no dentition although there are small signs of tooth decay. The patient has also no difficulty in speaking and pronounces words correctly.

THROAT/NECK The throat is pink with normal tonsils and adenoids. Patient can swallow without any problems and has no signs of infection. The neck appears normal but has some enlarged lymph nodes upon palpation. RESPIRATORY SYSTEM The patient had respiratory distress. Upon auscultation, crackles were heard. Clear secretions were noted. MUSCULOSKELETAL SYSTEM The extremities have decreased range of motion. The patient still needs some assistance in doing activities of daily living such as going to the comfort room. No tremors or spasms observed on the muscles. INTEGUMENTARY SYSTEM No abrasions were noted on the skin. Other parts of the skin are intact and no evident signs of dehydration was noted. Hair is well kempt and has dandruff. CIRCULATORY SYSTEM The patient has no signs of cyanosis as evidenced by pinkish conjunctiva and mucosa. Upon pressing the nails, redness goes back within 3 seconds which indicates that capillary refill is good. The patient has also no signs of cardiovascular diseases with a pulse rate within normal range of 80 beats per minute. GASTROINTESTINAL Bowel sounds were heard indicative of normal peristalsis. The patient has not experienced any loose bowel movement and has no signs of indigestion. Upon palpation, no pain was noted. Percussion of the abdomen yielded a resonant sound.

GENITOURINARY The patient has a normal urinary frequency of about 3 every 8 hours. She also has no difficulty in urinating. PRESENT BEHAVIOR The patient is alert and responsive. She answers the group’s questions immediately and appropriately. She is also cooperative and open minded to several nursing interventions that the group advised and done. SOCIO-ECONOMIC STATUS Currently, the patient is a housewife. Her husband works as a carpenter and earns 300 pesos a day. After working as a carpenter, in the evening her husband drives their tricycle to earn extra income of 250 per night. According to them, their financial income is enough to sustain their daily needs. FAMILY CONCERN The family is concerned on patient Leila’s condition since it requires an invasive procedure and there are chances of poor prognosis. LATEST VITAL SIGNS: BP-130/80 mmHg PR-80 bpm RR-18 cpm Temp-37.2 oC GCS: Best eye response: 4 Best verbal response: 4 Best motor response: 6 Total: 14

Chapter X NURSING MANAGEMENT A. Nursing Care Plan DATE/ TIME

Nov. 18, 2016 @ 8:00 am

CUES

NEEDS

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS OBJECTIVES CRITERIA

NURSING INTERVENTIONS

Subj: “Pag muubo ko naay plema maapil”

A C T I V I T Y

Ineffective airway clearance r/t increased mucous production secondary to bacterial infection

Normally the lungs are free from secretions. Pneumonia bacteria are invading the lung parenchyma thus ,producing inflammatory process. And these responses leading to filling of the alveolar sacs with exudates leading to consolidation

Within 8 hours of nursing interventions, the patient will be able to show signs of effective airway clearance as evidenced by:

1. Obtained and monitor vital signs 2. Established rapport 3. Elevated head of bed

Obj. -productive cough noted -whitish secretions noted -nasal flaring -orthopnea noted

E X E R C I S E P A T T E R N

Kozier and Erb’s Fundamental s on Nursing

-decreased cough frequency -decreased sputum -absent nasal flaring -absent orthopnea

4. Encouraged to increase OFI 5. Provided back tapping 6. Encouraged to perform deep breathing and coughing exercises 7. Encouraged to have adequate bed rest

RATIONALE

1. To obtain baseline data 2. To gain cooperation 3. To ease respiratory discomfort 4. To loosen secretions 5. To loosen secretions 6. To increase exertional effort 7. To promote healing

EVALUATION

“GOAL MET” Within 8 hours of nursing interventions, the patient was able to show signs of effective airway clearance as evidenced by: -decreased frequency of cough -decreased sputum production -absent nasal flaring -absent postural discomfort

DATE/ TIME

Nov. 18, 2016 @ 9 AM

CUES

NEEDS

Subjective: “sakit kaayo akong ulo”, as verbalized by the patient

C O G N I T I V E P E R C E P T U A L

Objective: -Pain scale of 7/10 -Facial grimace noted -Guarded behavior noted -Restlessness noted -Irritability noted - VS of: T: 38.5 PR: 115 RR: 28 BP: 130/70

P A T T E R N

NURSING DIAGNOSIS

Acute pain related to increase intracranial pressure

SCIENTIFIC BASIS

GOALS OBJECTIVES CRITERIA

NURSING INTERVENTIONS

Inflammation especially inside the meninges triggers the vascular system to release prostaglandin s which are neurotransmitters of pain

Within 4 hours of nursing interventions the patient will be able to report pain is relieved as evidenced by:

1. Establish rapport 2. Monitor and record Vital Signs 3. Position the client: head of bed elevated with body in central position 4. Encourage diversional activities: listening to music, 5. Encourage use of relaxation techniques: deep breathing, imaging. 6. instruct client to avoid going to the bathroom 7. Encourage to have adequate rest periods

Kozier & erb’s fundamental of nursing

•Verbalization of decrease pain from 7/10 to 4/10 •Demonstrates use of relaxation skills: deep breathing •Appears relax and able to sleep/rest appropriately

RATIONALE

1. To gain cooperation 2. To obtain baseline data for comparison 3. To decrease ICP 4. To help pt. divert his attention to other matters than pain felt 5. To reduce tension 6. To decrease ICP 7. To promote wellness and prevent fatigue

EVALUATION

“GOAL MET” Within 4 hours of nursing interventions the patient reported pain is relieved by: •Verbalization of: “3/10 nalang ang kasakiton nurse” •Demonstrated ways to relieve the pain: deep breathing •Appeared relax and able to rest appropriately.

DATE/ TIME

Nov. 19, 2016 @ 10:00 AM

CUES

Sub. “init kaayo akong pamati nurse.” as verbalized by the pt. Obj. Temp: 39.1°c RR:32 cpm PR: 127 bpm BP: 130/80 mmHg -pallor -flushed skin -dry mucous membranes -chills -malaise

NEED S

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS OBJECTIVES CRITERIA

NURSING INTERVENTIONS

RATIONALE

N U T R I T I O N A L M E T A B O L I C

Hyperthermi a related to secondary infection

Pyrogens cause a rise in body temperature, it also acts as antigen triggering immune system responses. The hypothalamu s reacts to raise the set point and the body respond by producing heat.

Within 4 hours of nursing interventions, client will be able to report and show manifestations that fever is relieved as evidenced by:

1. Establish rapport with the client. 2. Monitor vital signs 3. Provide TSB 4. Encourage to increase OFI 5. Promote bed rest 6. Maintain IVF as indicated by physician 7. Administer medications as order by physician such as paracetamol or any antipyretic drugs 8. Monitor I & O

1. Promotes cooperation in the nursing care. 2. Helps to identify the development of the client’s VS 3. To reduce body temperature through the process of conduction 4. Water regulates body temp. 5. To promote relaxation 6. To replenish fluid losses during shivering chills 7. To treat underlying causes 8. To know the fluid balance of the body.

P A T T E R N

Fundamental s of Nursing -Harry & Perry

Verbalization of feeling well VS within normal range Absence of muscular rigidity/chills Absence of flushing

EVALUATION

“GOAL MET” Within 4 hours of nursing interventions, client was able to report and show manifestations that fever was relieved as evidenced by: Verbalization of the client: “dili na init akong pamati ate nurse.” VS of: Temp= 36.7°c RR= 25 cpm PR= 92 Absence of muscular rigidity/chills Normal complexion of skin

DATE/TIME

CUES

NEEDS

NURSING DIAGNOSIS

Nov.24,2016 @ 8:30am

Subjective: “Dili gyud nako kaya mubangon o maglihoklihok maam kay luya pa kayo ko”, as verbalized by the patient.

A C T I V I T Y E X E R C I S E

Activity Intolerance r/t to body weakness as evidenced by insufficient to endure a desired activity such as ambulation.

Objective: -Limited range of motion noted -Limited ability to perform gross or motor skills noted -Difficulty turning side to side -Slowed movement noted Uncoordinate d and tremors noted

P A T T E R N

SCIENTIFIC BASIS

Most activity intolerance is related to generalized weakness and debilitation secondary to post-operative procedure. Fundamentals of Nursing -Harry & Perry

GOALS OBJECTIVES CRITERIA

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Within the 8 hours of nursing interventions, the patient will :

1.Establish rapport 2. Monitor and record Vital Signs 3. Increase oral fluid intake. 4. Determine any side effects of any drug given to patient before proceeding with doing the planned activities. 5.Plan for progressive increase of the activity level/participatio n in exercise training as tolerated by the client such as: a. Performing ROM exercise daily. b. Turning to side lying position. 6. Discuss ways/activities

1.To gain cooperation 2. As baseline data 3. To maintain hydration 4. To provide special precaution for the drug’s side effect 5. To promote activity enhancing situation a. Exercise maintain muscle strength and joint ROM. b. To prevent pressure ulcer 6. To promote patient’s tolerance in executing desired or required activities. 7. To reduce fatigue 8. Acknowledgem

“GOAL MET” Within the 8 hours of nursing interventions, the patient enhanced her physical activity as evidenced by:









Show eagerness and participation in enhancing physical activity Demonstrate activities necessary in enhancing present condition. Verbalize understandin g of the management regimen, and safety procedures given. Maintain position of function and skin integrity as evidence by absence

a. Patient showed eagerness and participation in enhancing physical activity independently such as: *turning to side lying position every2 hours as tolerated b. Demonstrated activities suitable for enhancing her condition such as deep breathing exercises. c. The patient was able to verbalize,” dapat jud diay maningkamot kog lihok-lihok bisag ingun ani akong kahimtang aron di musamot ang kakapoy ug kaluya sa akong lawas”

of contactures, footdrop, decubitus and so forth.

that could enhance activity tolerance, such as walking moderately. 7. Plan care to fully balance rest periods with activities such as an hour at least of planned activities as tolerated. 8. Encourage verbalization of feelings regarding limitations. 9. Give positive reinforcement during activity. 10. Give safety needs such as raising the side rails. 11. Assist the patient in standing or walking. 12. Permit patient to execute task at his or her own pace as tolerated. 13. Encourage patient to maintain positive attitude, suggest use of relaxation

ent that living with activity intolerance is both physically and emotionally difficult coping 9. To promote patient’s confidence in doing the activities. 10. Helps avoid accidental injuries or falls 11. Assistance provides the patient safety 12. To help promoting patient’s independency and boost her self esteem. 13. Enhance sense of well being.

techniques such as breathing exercise.

DATE/TIME

CUES

NEEDS

Nov.24,2016

Subjective: “Sigehan niyag gunit iyang samad sa ulo maam”, as verbalized by the patient’s significant others.

H E A L T H

@ 10:30am

Objective: -Penrose drain -Surical site with dressing

P E R C E P T I O N H E A L T H M A N

NURSING DIAGNOSIS

Risk for Infection r/t surgical incision

SCIENTIFIC BASIS

GOALS OBJECTIVES CRITERIA

NURSING INTERVENTION S

RATIONALE

EVALUATION

An individual with an incision that will serves as portal of entry is at risk to be invaded by an opportunistic or pathogenic agent such as virus, fungus, bacteria, protozoa, or other parasite from endogenous or exogenous sources.

Within the 8 hours of nursing interventions, the patient will be able to reduce the risk of infection as evidence by:

1.Establish rapport 2. Monitor and record Vital Signs 3. Assess affected area for redness, swelling, or soaked dressing 4. Assist physician on regular provision on wound dressing 5. Maintain aseptic technique when changing dressing/ caring wound 6.Encourage to wear clean loose clothing/coverin g 7.Observe for reddened areas or any purulent

1.To gain cooperation 2. Fever may indicate infection 3. To check for skin integrity, monitor progress of healing and identify need for further management 4. To promote fast healing 5.To prevent contaminatio n 6.Reduce likelihood of worsening skin breakdown 7. To monitor improvement of wound

“GOAL MET” Within the 8 hours of nursing interventions, the patient will be able to reduce the risk of infection as evidence by:

-VS within normal limits -remains free from the symptoms of infection -identifies the symptoms of infections such as purulent dressing and fever -Patient is able to clean the wound properly and

-VS within normal limits BP , temp , RR , PR -remains free from the symptoms of infection -identifies the symptoms of infections such as purulent dressing and fever -Patient is able to clean the wound properly and apply dressing -demonstrate appropriate hygienic measures such as hand washing, bathing, hair and nail care. Changing the bed linens.

A G E M E N T P A T T E R N

apply dressing -demonstrate appropriate hygienic measures such as hand washing, bathing, hair and nail care. Changing the bed linens. -swelling decrease in size

drainage and institute treatment per doctor’s order 8. Encourage patient to engage in ambulation within room perimeter as tolerated. 9. Administer antibiotic as ordered. 10. Encourage to verbalized any untoward feelings such as discomfort or pain, changes noted on the affected area. 11. Provide safety precautions such as raising the bed rails. 12.Encourage to increase OFI 13. Keep linens clean and dry and wrinklefree. 14. Encourage to maintain proper hygiene. 15. Encourage adequate rest to boost immune

condition. 8.To improve circulation. 9. To prevent bacterial infections 10. To allow continuous monitoring. 11. To prevent further injury and trauma. 12. For hydration and faster wound healing. 13. To prevent growth of microorganis m. 14. To maintain cleanliness. 15. Physical and emotional stress increase the clients need for rest.

system

B. Drug Study

DATE/ TIME ORDERED

Nov. 15, 2016 @ 3:40 PM

BRAND NAME

Sodium phosphate

GENERIC NAME Dexamethason e

ACTION

INDICATION

Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat and carbohydrate metabolism

Cerebral edema associated with brain tumor, craniotomy or head injury

ROUTE/ DOSAGE/ TIME INTERVAL

IVTT, 4 mg q6 hrs

HALF LIFE 190 mins.

DRUG INTERACTION

-Increased risk of hypokalaemia when used concurrently with potassiumdepleting drugs such as amphotericin B and loop diuretics. Reduces efficacy of isoniazid, salicylates, vaccines and toxoids. -Increased activity of dexamethasone and cyclosporin when used together. Concurrent use with aspirin or

ADVERSE EFFECT

CNS: euphoria, insomnia, vertigo, headache, depression. CV: hypertension, edema, arrythmias, thromboembolism. EENT: cataracts, glaucoma.

PRECAUTION CONTRAINDICAT IONS

Hypersensitivity to drug; active untreated infections; ophthalmic use in viral, fungal disease of the eye.

NURSING RESPONSIBILITES

  



GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea, vomiting. GU: increase urine



Determine whether patient is sensitive to other corticosteroids Monitor intake and output of patient Assess then for level of consciousness changes and headache during the therapy. Observe the patient for peripheral edema, steady weight gain, rales or crackles or dyspnea. Notify the physician immediately if these clinical manifestations are noted. Administer with meals

ethanol may lead to increased GI side effects.

CLASSIFICATION

ABSORP TION

Antiinflammatory glucocorticoid

Wellabsorbed

EXCRETION Urine

DATE/ TIME ORDERED

Nov. 15, 2016 @ 3:40 PM

BRAND NAME

Valium

GENERIC NAME diazepam

ACTION

It increases neuronal membrane permeability to Cl ions by binding to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron w/in the CNS and enhancing the GABA inhibitory effects resulting in hyperpolarisati on and

INDICATION

Treatment of status epilepticus/ uncontrolled seizures

ROUTE/ DOSAGE/ TIME INTERVAL

IVTT, 10 mg PRN

HALF LIFE Rapid (initial), 1 or 2 days (terminal)

glucose, and calcium levels 

Metabolic: hypokalemia, hyperglycemia Musculoskeletal: muscle weakness

to minimize GI irritation. Teach patient signs and symptoms of adrenal insufficiency; fatigue, muscle weakness, join pain, fever, anorexia.

Skin: Delayed wound healing

DRUG INTERACTION

-May significantly enhance CNS depressant effect w/ antivirals, narcotic analgesics, antihistamines, antihypertensives, muscle relaxants -May decrease clearance w/ antibacterials -May increase serum level w/ disulfiram. -May reduce therapeutic effect w/ theophylline. -Reversible deterioration of parkinsonism w/ levodopa.

ADVERSE EFFECT

CNS: Dizziness, drowsiness, lethargy, hangover, headache, depression EENT: blurred vision RESP: respiratory depression

PRECAUTION CONTRAINDICATIO NS

Contraindicated to patient w/ acute angle closure glaucoma, preexisting CNS depression, coma, severe or acute resp insufficiency, sleep apnoea syndrome, myasthenia gravis, severe hepatic impairment.

NURSING RESPONSIBILITES

 



CV: hypotension



GI: Constipation,



Monitor BP, PR,RR frequently during IV therapy. Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis. Prolonged high-dose therapy may lead to psychological or physical dependence. Observe depressed patients closely for suicidal tendencies Observe and record intensity, duration

CLASSIFICATION

stabilisation.

ABSORPTIO N

EXCRETION Urine

Benzodiazepin e, Anxiolytic Antiepileptic, Skeletal muscle relaxant (centrally acting)

DATE/ TIME ORDERED

Nov. 19, 2016 @ 9:00 PM

BRAND NAME

Catapres

GENERIC NAME clonidine

Well-absorbed

diarrhea, nausea, vomiting



DERM: Rashes Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances

ACTION

INDICATION

ROUTE/ DOSAGE/ TIME INTERVAL

DRUG INTERACTION

ADVERSE EFFECT

PRECAUTION CONTRAINDICATI ONS

Clonidine stimulates α2adrenocepto rs in the brain stem which results in reduced sympathetic outflow from the CNS, and a decrease in peripheral resistance, heart rate, BP and renal vascular

treatment of hypertension, either alone or with diuretic or other antihypertensive agents.

IVTT, 150 mcg now

-Increased hypotensive effect w/ other antihypertensive s -Reduced antihypertensive effect and induced orthostatic hypotension w/ TCAs or neuroleptics w/ α-receptor blocking properties. -Reduced therapeutic effect w/

CNS: Drowsiness, sedation, dizziness, headache, fatigue, insomnia, hallucinations, delirium, nervousness, restlessness, anxiety, depression,

Contraindicated with hypersensitivity to clonidine or any adhesive layer components of the transdermal system.

HALF LIFE 6-24 hr

CV: CHF, orthostatic hypotension, palpitations, tachycardia, bradycardia, Derma: Ras, hives, urticaria, hair thinning and alopecia, pruritus, dryness, burning of the eyes, pallor GI:

Use cautiously with severe coronary insufficiency, recent MI, cerebrovascular disease; chronic renal failure; pregnancy, lactation.

and location of seizure activity. The initial dose of diazepam offers seizure control for 15-20 min after administration

NURSING RESPONSIBILITES

Assess blood pressure and apical pulse before initial dose. If systolic blood pressure is