Surgical Case Study: Cranioplasty

I. Introduction A surgery is one of the most stressful procedures a patient could undergo. There are numerous types of surgeries, each one tailored to fit a certain purpose, may it be to deliver a child ( i.e. cesarean section), remove a part ( i.e. craniectomy), to visualize and gain access to a structure within ( i.e. craniotomy) or to repair a defect ( i.e. cranioplasty). This is a case of Master Labrador, Ralph, 12 years old, who was admitted last May 2, 2008 at Cebu Doctors’ University Hospital to undergo a cranioplasty. Two years ago the patient sustained an epidural hematoma from motor-vehicular accident in Argao. He was brought to Cebu Doctors’ University Hospital last February 26, 2006 and underwent craniotomy and evacuation of epidural hematoma. He was advised to undergo a cranioplasty six months after recovery but was only able to come back for compliance due to financial reasons. A cranioplasty is a surgical repair of a cranial defect. Cranial defects may result from fractures, infections, surgical procedures ( cranial bone biopsy, craniotomy) or a cranial deformity. Indications for the procedure include protection from external trauma, alleviation of pain or seizures and cosmetics. The artificial cranium may be fashioned from the autogenous bone grafts, metal ( e.g. tantalum) or acrylic material ( e.g. methylmethacrylate). Methylmethacrylate is the preferred material for cranioplasty, except in cases of wound infection, in which autogenous grafts are better accepted. In cranioplasty, the scalp is incised over the defect. The defect may be trimmed as necessary. Methylmethacrylate is mixed according to the manufacturer’s directions. The surgeon then molds the material to fit the defect. Acrylic is removed from the polyethylene bag and allowed to harden. Excess material may be trimmed with rongeurs or power saw. A craniotome may be used to smooth the rough spots. Holes are drilled in the periphery of the acrylic plate and the cranial defect. The plate is placed over the defect and secured by the stainless steel wired passed through the holes and the wound is irrigated and closed.

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This case study was chosen because of the challenge that it posed- it involves the head and skull which contains the central processing unit of the body, a single mistake could be fatal and could turn a life upside down if not end it. At the end of this case study, the student nurse expects to expand her knowledge regarding the surgical procedure known as cranioplasty, and refine her skills in caring for a patient who has undergone the said surgical procedure.

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II. Objectives General Objectives: After 3 days of student nurse-patient interaction, the student nurse will be able to learn more about cranioplasty, effectively provide holistic caring care and inculcate positive attitude while caring for a patient who has undergone the said procedure. After 3 days of student nurse-patient interaction, the patient will be able to learn more and cope with the surgical operation cranioplasty, avoid complications that may arise post-operatively and incorporate lifestyle modifications until he returns to his optimum level of functioning. Specific objectives: After 3 days of providing holistic caring care and facilitating student nurse-patient interaction, the student nurse will be able to: 1. perform a thorough assessment of a school-age child in his present condition, and discuss the physical, social and cognitive characteristics of a school-age child 2. identify the signs and symptoms presented by the patient in relation to the causative factor of the condition 3. avoid complications which may arise from the surgical procedure 4. implement a comprehensive plan of care for the patient who has undergone cranioplasty, and 5. evaluate the interventions provided in the given span of time for efficiency and effectiveness. After 3 days of receiving holistic care and participating in student nurse-patient interaction, the patient and his significant others will be able to: 1. establish trust towards the student nurse

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2. cooperate in procedures performed to the patient for the management and treatment , such as medication administration and vital signs taking 3. manifest a decrease in the signs and symptoms associated with the surgical procedure, such as pain 4. perform, with minimal assistance from the student nurse and significant others, activities of daily living 5. terminate the therapeutic student nurse-patient interaction at the end of the given span of time

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III. Nursing Assessment 1. Personal History 1.1 Patient’s profile Name: Ralph de los Reyes Labrador Age: 12 years old Sex: Male Civil Status: Single Religion: Roman Catholic Date of admission: May 2, 2008 Room no.: 422 Complaints: Diagnosis: Physician: Dr. Milo Vergara 1.2 Family and Individual Information, Social and Health History Master Labrador, Ralph, the eldest son of Mrs. Labrador, was admitted last May 2, 2008 at 11:49am. Two years prior to admission, patient sustained an epidural hematoma from a motor-vehicular accident in Argao. He was in his grandparents; care back then. He was riding his bicycle in the highway when a bus came speeding towards his direction. He was admitted for the first time at Cebu Doctors’ University Hospital last February 26, 2006 and underwent evacuation of hematoma and craniotomy. He was in comatose for three to four days but regained consciousness and was stabilized and in good condition when discharged. Patient’s mother was advised to bring back her son six months after for a cranioplasty but they were not able to comply due to financial constraints. Few days prior to admission, they had raised enough money thus subsequent admission. Ralph is completely immunized. He had chickenpox at seven years old. He has no maintenance medications and no vitamins. Family history reveals

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hypertension on the maternal and paternal sides and bronchial asthma on the paternal side. He has no food and drug allergies. He is asthmatic. Last asthma attack was two years ago and was managed with ventolin syrup. 1.3 Level of Growth and Development 1.3.1

Normal Development Physical Changes Physiologically, the school-age years or middle years begin with the

shedding of the first deciduous tooth and end at puberty with the acquisition of the final, permanent teeth ( with the exception of wisdom teeth). The period of middle childhood is a time of gradual growth and development with more even progress in both physical and emotional aspects. School-age children’s annual average weight gain is approximately 3-5 lb. (1.3-2.2 kg); the increase in height is 1-2 inches (2.5-5 cm). Children who did not lose the lordosis and knock-kneed appearance of toddlers during the preschool period lose these now. Posture becomes erect. Their body proportions take on a slimmer look, with longer legs, varying body proportion and a lower center of gravity. The most pronounced changes that indicate increasing maturity in children are a decrease in head circumference in relation to standing height, a decrease in waist circumference in relation to height and an increase in leg length related to height. Facial proportions change as the face grows faster in relation to the remainder of the cranium. The skull and brain grow very slowly during this period and increase little in size. Maturity of the gastrointestinal system is reflected in fewer stomach upsets, better maintenance of blood glucose levels , and increased stomach capacity, which permits retention of food for longer periods. Physical maturation is evident in other body tissues and organs, as well. Bladder capacity is generally greater in girls than in boys. The heart grows more slowly during the middle years and is smaller in relation to the rest of the body than at any other period of life. Heart and respiratory rates steadily decrease and blood pressure increases during

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ages 6 to 12. Heart rate ranges from 70 to 80 beats per minute, respiratory rate 15 to 25 breaths cycles per minute, and an average blood pressure of 112/60 mmHg. Psychocosial Development Freud described middle childhood as the latency period, a time of tranquility between the oedipal phase of early childhood and the eroticism of adolescence. During this time, children experience relationships with same-sex peers following the indifference of earlier years and preceding the heterosexual fascination that occurs for most boys and girls in puberty. According to Erickson, a sense of industry or a stage of accomplishment is achieved somewhere between age 6 and adolescence. School-age children are eager to develop skills and participate in meaningful and socially useful work. Interests expand in the middle years, and with a growing sense of independence , children want to engage in tasks that can be carried through to completion. Reinforcement in the form of grades, material rewards, additional privileges and recognition provides encouragement and stimulation. Peer approval is a strong motivating power. The danger inherent in this period of development is the occurrence of situations that might result in as sense of inferiority. When the reward structure is based on evidence of mastery, children who are incapable of developing those skills are at risk for feeling inadequate and inferior. No child is able to do everything well, and children must learn that they will not be able to master every skill they attempt. Children need and want real achievement. When they have access to tasks that need to be done, that they are able to do well despite individual differences in their innate capacities and emotional development, and for which they are suitably rewarded, children achieve a sense of industry. Cognitive Development When children enter the school years, they begin to acquire the ability to relate a series of events to mental representations that can be expressed both verbally and symbolically. This is the stage Piaget describes as concrete

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operations, when children are able to use thought processes to experience events and actions. The rigid, egocentric view of the preschool years is replaced by mental processes that allow children to see things from another’s point of view. During this stage, children develop an understanding of relationships between things and ideas. They progress from making judgments based on what they see to making judgments based on what they reason. They master the concept of conversation, develop classification skills and their ability to read becomes the most significant and valuable tool for independent inquiry. Sexuality Preadolescence is the period of approximately 2 years that begins at the end of middle childhood and ends with the thirteenth birthday. Because puberty signals the beginning of the development of secondary sex characteristics, prepubescence typically occurs during preadolescence. There’s no universal age at which children assume the characteristics of prepubescence. The first physiologic signs appear at about 9 years of age and are usually clearly evident in 11-12 years old children. Boys experience little visible sexual maturation during preadolescence. Pubic hair present across pubis, penis lengthens, breast enlargement occurs and there’s dramatic linear growth spurt. 1.3.2

The Ill School-Age Child One of the biggest problems facing a school-age child with an illness or

physical challenge is time lost from school. This threatens not only academic achievement but also the child’s relationships with his or her peers. It may make him or her the “odd person out” with respect to making friends or joining gangs. Whether children are confined to home or hospitalized, helping them keep in contact with friends can help foster socialization that is important for continued development.

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In caring for a school-age child who is ill, choose short term activities that can be completed independently. Be careful not to insult a child with tasks that are obviously not age-appropriate. Master Labrador, Ralph was admitted last May 2, 2008 with the following vital signs: heart rate was 100 beats per minute, respiratory rate 25 breath cycles per minute, temperature of 36.5 degress Celsius and blood pressure of 90/60 mmHg. Upon admission he weighed 28.3 kg. Primary assessment revealed a scar at the right parieto-temporal area and on approximately 5-6 cm scar on the left periumbilical region of the abdomen. Patient was observed to be outgoing, cooperative and socially able to relate to nurses and student nurses. He had questions and wasn’t shy about them. Aside from his mother, he had his aunts to accompany him during the whole length of hospital stay.

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2. Diagnostic Results Complete Blood Count ( May 7, 2008) Hemoglobin Hematocrit WBC count Neutrophil Basophil Eosinophil Lymphocyte Monocyte Bands Atypical

Results 13.1 g/L 39.5 % 13.70 10^3/uL 45 % 0 7 47 1 0 PNDG

lymphocyte Blasts Red Cell Count MCV MCH MCHC MPV RDW Platelet

PNDG 4.9 10^6/uL 80.5 26.7 33 6.69 14.1 344

Normal Values 12-16 g/L 36-45 % 4.5-13.0 10^3/uL 25-70 % 0-3 % 0-8 % 20-65 % 0-9 % 0%

Significance normal normal normal normal normal normal normal normal normal normal

10^6/uL 78-102 fL 25-35 pg 31-36 g/L 4.50-100 cL 0-100 % 140-440 10^3/uL

normal normal normal normal normal normal normal normal

Normal Values 2.3-9.5 min. sec. 5-15 min.sec.

Significance normal normal

Normal Values sec 10-13 sec. 70-120 % < 1.2

Significance normal normal normal normal

Hematology ( May 7, 2008) Blood type: O+ Bleeding Time Clotting

Results 5’22’’ 12’13’’

Prothrombin Time (May 7, 2008) Control PRO time % activity LNR

Results 14.9 12.7 107.2 0.94

CT Scan on Head ( May 7, 2008) Impression: 1. S/P Right parietal craniotomy

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2. Focal encephalomalacic changes at the left frontal lobe. Please correlate clinically.

3. Present Profile of Functional Health Pattern ( Pre-operative) 3.1 Health Perception Ralph sees his present condition as good. He and his mother has no worries regarding his current health status. His last asthma attack was two years ago and they’re thankful it hasn’t recur since after the accident. He perceived complete immunization and is not taking any vitamins.

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3.2 Nutritional- Metabolic Pattern Patient eats three full meals of rice, fish and sometimes chicken and red meat. He eats these during breakfast, lunch and dinner. He usually eats junkfood and drinks ice juice or ice candy during snack time. He drinks up to 1.5 liters of water a day and rarely takes in fruit juices, milk or coffee. He does not take any vitamins or food supplements. Upon admission, his weight was 28.3 kg. 3.3 Elimination Pattern Ralph does not have any problem in urinary elimination ( oliguria, polyuria, dysuria, retention, etc.) as far as he could remember. He is able to urinate up to a maximum of seven times a day, with around 60 mL of urine per voiding. He defecates brown, semiformed stool often every other day. He does not use laxatives nor diuretics. 3.4 Activity-Exercise Pattern Patient plays table tennis at school. He has no difficulty performing activities of daily living. He does not experience shortness of breath during playing. Upon pre-operative assessment, his vital signs were: temperature of 36.5 degrees Celsius; pulse rate of 84 brats per minute; respiration of 20 breath cycles per minute and blood pressure of 90/60 mmHg. 3.5 Cognitive/Perceptual Pattern Ralph speaks mostly in Cebuano. He knows Tagalog and claims to be proficient in English. He is able to read and write. He has no hearing aids or eyeglasses; however he reports that he cannot hear well with his right ear. He can sense heat, cold, sharpness, and dullness. He can determine rough and smooth surfaces, as well as application of pressure on all extremities. Patient reports that since the accident, he has short-term memory lapses and there are times that he has difficulty summoning the right word/name for an event/object. 3.6 Rest/Sleep Pattern

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Prior to hospitalization, the patient sleeps at around 8pm and wakes up at 7 am the next day. He has no difficulty falling and staying asleep. Upon hospitalization, patient is able to sleep at 9-9:30 pm, and sometimes 10 pm due to vital signs taking and other routine procedures. His mother stated that the patient is unusually restless during the night and is probably anxious about the upcoming procedure.He usually takes short nap at home, usually after arriving from school. 3.7 Self-Perception Pattern Ralph is well-adjusted. He stated that he is somewhat anxious for tomorrow’s surgery but his mother has helped calm him down. He expressed his desire to go home and play with his siblings 3.8 Role-Relationship Pattern Ralph speaks well, with coherent thoughts, and facial expressions with gestures that are appropriate. He lives with this mother in Argao and has two siblings, all boys and all younger than him, His parents are separated. His mother stated that Ralph is hard-headed and often, wants to go his own way. 3.9 Sexuality and Reproductive Pattern Ralph is in the prepubescence period. He admits to having noticed growth of hair under the axilla and pubic hair across the pubis but other than that he refuses to divulge details. 3.10Coping-Stress Tolerance Pattern Ralph plays basketball after school. Whenever he feels down, he watches television or play with his brothers at home. 3.11Value-Belief System Ralph is a Roman Catholic and is taught by his mother to pray and attend mass every Sunday. He stated that he is thankful to God for not taking him two years ago. He jokingly said that the accident may be a wake-up call for him to stop being hardheaded and a burden to his mother.

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4. Present Profile of Functional Health Pattern (Post-operative) 4.1 Health Perception Ralph considers his present state of health as well but recuperating. He and his mother both know that as long as he takes care of himself and follow the doctor’s orders he will heal in time and prevent complications of the surgery. 4.2 Nutritional-Metabolic Pattern The patient was to have diet as tolerated upon full awakening as ordered by his doctor. He still eats the same meal at breakfast, lunch and dinner. He eats bread and crackers for snacks. He drinks 1200- 1680 ml of water a day. He still does not take any vitamins or food supplements. After the operation, his weight was slight decreased to 28 kg. He was prescribed Oxacillin 750 g IVTT every 6 hours, an antibiotic as prophylactic management to prevent infection and Mefenamic acid 500 g 1 cap every 8 per orem for pain management. 4.3 Elimination Pattern Ralph still does not have urinary elimination problems after the surgical operation.He voids 5-6 times per day, with around 60 ml of urine per voiding. He defecates brown, semi-formed stools every other say. He doe not use laxatives nor diuretics. 4.4 Activity-Exercise Pattern The patient does not do any strenuous physical activities, avoids leaning over and straining too much for fear of post-operative complications. Upon return to the ward, his vital signs are: temperature of 37 degrres Celsius, respiratory rate of 18 breaths per minute, pulse rate of 85 beats per minute and blood pressure of 90/60 mmhg. 4.5 Cognitive-Perceptual Pattern Patient was drowsy after the surgical operation but regained alertness after several hours of sleep. No significant sensorineural changes have been noted. His cognitive functioning is intact. 4.6 Rest-Sleep Pattern No significant changes in sleep pattern has been noted post-operatively. He tales interspersed naps in the morning and afternoon.

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4.7 Self-perception Pattern Ralph is relieved now that the operation is over. He knows that if he follows his medication regimen and stays in the hospital for a few days to recuperqate, he will eventually heal and return to his usual level of functioning. 4.8 Role-relationship Pattern Patient expressed his longing to be home and play with his brothers. His hospital stay has started to bore him already. 4.9 Coping-stress tolerance Pattern The patient has no other option left now to cope with stress except talking with his mother and aunts and watching television. 4.10 Value-Belief system Ralph prays fervently for healing. He expressed his gratitude to the Lord for keeping him safe during and after surgery. 5. Pathophysiology and Rationale 5.1 Normal Anatomy and Physiology Structure Protecting the Brain The brain is contained in the rigid skull, which protects it from injury. The major bones of the skull are the frontal, temporal, parietal and occipital bones. These bones join at the suture lines.

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Figure 1. The Human Skull The meninges, the fibrous connective tissues that cover the brain and spinal cord, provide protection, support and nourishment to the brain and spinal cord. The layers of the meninges are the dura, arachnoid and pia mater. Dura mater- the outermost layer; covers the brain and the spinal cord. It is tough, thick, inelastic, fibrous, and gray. There are four extensions of the dura: the falx cerebri, which separates the two hemispheres in a longitudinal plane; the tentorium, which is an unfolding of the dura that forms a tough, membranous shelf; the falx cerebelli, which is between the two lateral lobes of the cerebellum; and the diaphragm sellae, which provides a roof for the sella turcica. The tentorium supports the hemispheres and separates them from the lower part of the brain. When excess pressure occurs in the cranial cavity, brain tissue may be compressed against the tentorium or displaced downward, a process called herniation. Between the dura mater and the skull in the cranium, and between the periosteum and dura in the vertebral column, is the epidural space, a potential space. Arachnoid- the middle membrane; an extremely thin, delicate membrane that closely resembles a spider web. It appears white because there is no blood supply. It contains the choroids plexus which is responsible for the cebrospinal fluid production. Subdural space is between the dura and arachnoid layer and subarachnoid space is between the arachnoid and pia layers and contains the cerebrospinal fluid. Pia mater- the innermost membrane; a thin, transparent layer that hugs the brain closely and extends into every fold of the brain’s surface. Figure 2.

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5.2 Schematic Diagram Predisposing Factor

Precipitating Factor

Congenital anomalies Bone infection Tumor in the head Family history of brain cancer stroke

Motor-vehicular accidents Craniotomy Craniectomy Cranial bone biopsy

Signs and Symptoms

Defect in the cranial bone as shown in the CT scan; in the patient’s case defect was on the right pariental bone Softness of the area of defect upon palpation Scar on the area of previous 17patient’s case, surgery ; in the scar on the right parietal area of the scalp

Surgical Management Cranioplasty to repair the cranial bone defect

Medical Management

Nursing Management

Antibiotic therapy to prevent infection

Elevate head of bed 30 degrees Encourage deep breathing exercises

Analgesia for pain management

Promote cleanliness and proper handwashing Encourage increased fluid intake Teach divertional activities to help manage pain

Optimum Level of Functioning

5.3 Cranioplasty secondary to a Craniotomy to Evacuate an Epidural Hematoma A cranioplasty, as mentioned earlier, is a surgical repair of a defect of the cranium. Cranial defects result from fractures, infections, surgical procedures or a congenital deformity. Ralph Labrador is a 12 year old child who had undergone craniotomy two years ago to evacuate an epidural hematoma. He was supposed to come back 6 months after a complete recovery from the previous surgical procedure but was not able to due top financial constraints. An epidural hematoma results from arterial bleeding into the space between the dura and the inner table of the skull. It is often caused by a fracture o fthe temporal

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bone, which houses the meningeal artery. Epidural hematomas may be characterized by the presence of a “lucid interval” that lasts for minutes during which the client is talking and walking. This follows a momentary unconsciousness that occurred within minutes of injury. Following the lucid interval, the symptoms progress rapidly with potential catastrophic intracranial pressure elevation and structural changes. An epidural hematoma is a neurosurgical emergency. Ralph Labrador obtained the epidural hematoma from a motor-vehicular accident two years ago and he underwent craniotomy to evacuate the epidural hematoma and save his life. Post surgery he was in coma for 4 days. He woke up the next day confused . Two years post-surgery, he and his mother noticed a change in his academic performance level and short-term memory lapses. He also has difficulty hearing with his right ear and complains of having difficulty summoning the right word for a certain event or object. After a severe traumatic brain injury, the patient is always expected to exhibit abnormalities secondary to the injury obtained. The previously mentioned deficits exhibited by Ralph Labrador all belong to the temporal lobe’s function. The temporal lobe is responsible for the complicated memory patterns and is the auditory center for sound interpretation. It is also in this lobe that the Wernicke’s area for speech is found. This association area plays a significant role in higher-level brain function. It enables processing of words into coherent thought and recognition of the idea behind written or printed languages.

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Cranioplasty was performed to repair the cranial defect on Ralph’s right parietal bone, a defect obtained from the emergency surgical procedure performed on him two years ago. This cranioplasty will help protect his brain from the traumatic injuries in the future and reinforce the function of his skull. Figure 3. Hematoma

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5.4 Signs and Symptoms Classical Signs

Clinical Signs Pre-operative

Post-operative

Rationale

Defect in the cranial

Manifested; defect

Not manifested

bone as shown in

on right parietal

the CT scan was a

the CT scan

bone

remnant of the

The defect shown on

previous surgery the patient may have undergone. -pg. 1050; MedicalSurgical Nursing by Ignatavicius Scar on the area of

Manifested; on right

Manifested

previous surgery

parietal area of scalp

The defect shown on the CT scan was a remnant of the previous surgery the patient may have undergone. -pg. 1050; Medical-

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Surgical Nursing by Ignatavicius Softness of the area

Manifested; on right

Not observable

of defect upon

parietal area of scalp

palpation

In craniotomy, a burr hole is made to serve as an opening through which blood or fluid may be evacuated. Cranioplasty is often done after. -pg. 367 Pocket Guide to the Operating Room by Goldman

IV. Nursing Interventions 1. Care Guide for Patients who have undergone cranioplasty Nutrition and Fluids Clients should be assisted to take in at least 2,500 ml of fluids a day unless conditions contraindicate this amount. Although there is no evidence that excessive doses of vitamins or minerals enhance wound healing, adequate amounts are extremely important. The nurse should ensure that clients receive sufficient protein, vitamins C,A,B, B5 and Zinc. Because an inadequate intake of calories, protein, vitamins and iron is believed to be a risk factor for pressure ulcer development, nutritional supplements should be considered for nutritionally compromised patients. Monitor weight regularly to help assess nutritional status. Preventing Infection

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There are two main aspects of controlling wound infection: preventing microorganisms from entering the wound and preventing transmission of blood borne pathogens to or from the client to others. Standard precautions include wearing of gloves when touching blood and body fluids and when handling items soiled with blood or body fluids; and washing thoroughly of hands after removing gloves. Head dressing should be inspected each day post-operatively until it is removed on the third post-operative day. Head dressings should not be disturbed for the first 24 hours unless inordinate bleeding requires that they must. Health care professionals and significant others should touch or change the dressing only when wearing sterile gloves and using sterile instrument.

Positioning The head of the bed is elevated 30 degrees to decrease intracranial pressure. To promote healing, patient should be positioned to keep pressure off the wound. Patient should be assisted to be as mobile as possible to enhance circulation. Deep breathing exercises while sitting is also advised to prevent accumulation of respiratory secretions.

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Seen patient , Mast. Ralph Labrador,sittin g on bed watching

television without IV. He is 12 years old and is for cranioplasty.

Actual state Of patient’s condition

A. Psychologic deficit: Anxiety -restlessness -client reported increased feeling of tension or as mother stated: “overexcitement” -client does foot shuffling -”kulbaan gamay” as verbalized by the patient

Brunswick Lens Model (Pre-operative)

B. Physiologic deficit: disturbed sleep pattern - client now sleeps late than his usual bed time -mother stated tat client is unusually restless during the night probably due to anxiety -client reported increased feeling of tension or as mother stated: “overexcitement” C. Knowledge deficit I.Anxiety:restlessness related to fear of -patient frequently asks questions unknown outcomes of surgery II.Disturbed sleep pattern: sleeping later regarding the procedure than his bedtime related to fear of -patient is only 12 years old -none of the family members is unknown outcome of surgery III. Knowledge deficit : frequent asking of in the medical field and none questions regarding the surgical procedure could give a simple explanation cranioplasty related to lack of of what he is about to go through explanation from significant others cues

Nursing Diagnoses

Measures to: A. reduce Anxiety -acknowledged fear -encouraged patient to verbalize feelings -spent some time with the patient -encouraged guided imagery -provided touch, massage B improve Sleep Pattern - clustered nursing activities - minimized fluid intake during night time -restricted intake of caffeinecontaining foods and fluids -supported continuation of patient’s bedtime rituals - encouraged patient to verbalize feelings C. improve knowledge on cranioplasty -evaluated capabilities and readiness to learn -reviewed information regarding injury process and after effects -showed the patient a picture of the skull and brain and explained in simple terms the surgical procedure

98 % resolu -tion Of Psychologi c

and physiologic problems experienced by the patient

Nursing Actions Desired Outcome Objectives Goal After 8 hrs. of student nurse –patient interaction, After 3 days of student the patient will be able to : 1. demonstrate decrease in anxiety as evidenced by nurse-patient interaction, patient will be able to attain decrease in restless ness optimum level of 2.improve sleep pattern as shown by sleeping functioning during his usual bedtime 3.verbalize purpose of the procedure

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Brunswick Lens Model (Post-operative)

Seen patient , Mast. Ralph Labrador,sittin g on bed watching

television without IV. He is 12 years old and is for cranioplasty.

Actual state Of patient’s condition

A. promote comfort -positioned patient so that his affected side will not receive much pressure -perforemded massage but not on affected part -encouraged deep breathing exercises -promoted rest -administered medications per doctor’s order

A.Physiologic Overload:Alteration in comfort -intermittetn pain on right parietal area of head; pain started hours after arriving from the OR;it is described as mildly stinging, aggravated by sudden head movement, relieved by rest and treated with Mefenamic acid 1 cap q8h po -patient rated pain as 5 in a pain scale 0f 0-10 wherein 0 stands for no pain and 10 as most painful

B.Risk for ineffective breathing pattern -patient has bronchial asthma and has undergone surgery for hours under general anesthesia -respiratory rate 18 breaths per minute C.Risk for infestion -patient is post-cranioplasty with head dressing reinforced with sterile pads

cues

Measures to:

I.Alteration in comfort:pain related to disruption of tissue integrity secondary to surgical procedure II.Risk for ineffective breathing pattern related to post-operative cerebral edema III.Risk for infection related to wound obtained during surgery

Nursing Diagnoses

98 % resolu -tion Of

B maintain respiratory function -placed patient in a semi-prone position -suctioned trachea -elevated head of bedas prescribed physiologic -administered nothing per orem until active problems coughing and swallowing reflexes returned experienced by C. maintain vital signs within normal range the patient -monitored site for signs of infection -instructed patient to report presence of salty taste -instruceted patient to avoid coughing, blowing nose -used aseptic technique when handling dressings -administered prophylaxis per doctor’s order

Nursing Actions

Desired Outcome Goal 1. demonstrate decrease in pain sensation as evidenced by a painAfter 3 days of student nurse-patient interaction, scale rating as 1 in a pain scale of 0-10 2.maintain adequate respi.function as evidenced by respi.rates in patient will be able to attain normal levels optimum level of 3.exhibit absence of infection as evidenced by vital signs in functioning normal range After 8 hrs. of student nurse –patient interaction, the patient will be able to :Objectives

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Patient’s name: Ralph Labrador

Age: 12 years old

Physician: Dr.Vergara Nilo

Room no. : 422

Sex: Male

Date: May 8, 2008

Nursing Care Plan (pre-operative) Needs/Problems

Nursing

Scientific

Objectives of

Diagnosis Anxiety:

Basis Anxiety or

Care After 8 hours of

restlessness

fear of the

student nurse-

I. Anxiety

related to

unknown is

patient

-restlessness

fear of

real.

interaction, the

-client reported

unknown

Feelings

patient will be

increased feeling

outcome of

are real and

able to:

of tension or as

surgery

changes in

1.demonstrate a

mother stated:

vital signs

decrease in

“overexcitement”

may

anxiety as

-client does foot

suggest the

evidenced by a

feelings so they can be

shuffling when the

degree of a

decrease in

discussed and dealt

nurse and his

patient’s

restless ness

with.-

mother talked to

anxiety

him about the

before a

b.encourage patient to

-It is helpful to bring out

upcoming surgery

certain

verbalize feelings

feelings so they can be

Cues A. Physiologic deficit:

Nursing Actions

Rationale

Measures to:

1. reduce anxiety a. acknowledge fear

-It is helpful to bring out

pg.745,NCPs,Doenges

procedure.

discussed and dealt

It is helpful

with-

To bring

pg.745,NCPs,Marilyn 26

out these

c.spend some time

Doenges

feelings out

with the patient

-continuous support may

in the open

help patient regain

so they can

internal locus of control-

be

d.encourage guided

pg.746,NCPs,Doenges

discussed

imagery

-promote release of

and dealt

endorphins and reduce

with

anxiety-

- pg.

e. provide

pg.745,NCPs,Doenges

745,NCPs,

touch,massage

-aids in meeting basic

Marilyn

human need decreasing

Doenges

sense of isolationpg.745,NCP,Doengespg.745,NCPs,Doenges

Patient’s name: Ralph Labrador

Age: 12 years old 27

Physician: Dr.Vergara Nilo

Room no. : 422

Sex: Male

Date: May 8, 2008

Nursing Care Plan (pre-operative) Needs/Problems

Nursing

Scientific Basis

Objectives of Care

Nursing Actions

Cues B.Physiologic

Diagnosis Disturbed

The effect of the

After 8 hours of

deficit:

sleep pattern:

change in sleep

student nurse-

sleeping later

patterns in

patient interaction,

II. Disturbed sleep

than his

children prior to

the patient will be

pattern

bedtime

and after an

able to:

related to fear

elective surgery

2.improve sleep

of unknown

has not been

pattern as shown by

outcome of

evaluated

sleeping during his

2. improve sleep

surgery

objectively.

usual bedtime

pattern

Rationale

Measures to:

Sleep in hospital

a. cluster nursing

- to give client

may influence

activities

time to rest with

biological

less disturbance-

processes related

pg.744,NCPs,Do

to circadian

enges

rhythm. It is

b. minimize fluid

- to prevent

reasonable to

intake during night

frequent urination

assume that

time

during the night

hospitalized

when patient is

children have

supposed to sleep 28

disturbed sleep

pg.744,NCPs,Do

patterns prior to

enges

and following

c. restricted intake of

- Caffeine

elective surgery.

caffeine-containing

lengthens the

We hypothesize

foods and fluids

time it takes to

that melatonin

fall asleep,

will improve

reducing your

sleep patterns

total sleeping

prior to and

time-pg.5; Get

following

Z’s now;

surgery, by

Geoffrey

reducing sleep

Burchfield

latency and

d.supported

-Children need a

extending total

continuation of

familiar and

sleep time. We

patient’s bedtime

pleasant routine

also hypothesize

rituals

and these are

that this

bedtime rituals

improvement

which can help

will have

children sleep on

positive impact

time- pg.37; Get

on anesthetic

Z’s now;

stress measures

Geoffrey

and on recovery.

Burchfield 29

-pg.50,Beyond the Relaxation Response by

e. - encouraged

- The source of

patient to verbalize

uneasiness or

feelings

anxiety, which is often a cause of

Herbert Benzon

sleep disturbance, is not always known or recognized. It is helpful to bring out feelings so they can be discussed and dealt with.pg.745,NCPs,Do enges

Patient’s name: Ralph Labrador

Age: 12 years old

Physician: Dr.Vergara Nilo

Room no. : 422

Sex: Male

Date: May 8, 2008

Nursing Care Plan (pre-operative) 30

Needs/Problems

Nursing

Scientific Basis

Objectives of Care

Nursing Actions

Rationale

Cues C.Knowledge

Diagnosis Knowledge

An anxious

After 8 hours of

deficit:

deficit:

patient could use

student nurse-

frequent

some emotional

patient interaction,

asking of

support and an

the patient will be

-patient frequently

questions

explanation of

able to:

asks questions

regarding the

what he is about

3.verbalize in his

about the procedure

surgical

to go through.

own level of

-patient is only 12

procedure

They need a

understanding the

2. improve

-permits

years old

related to lack

simple

purpose and

knowledge on

presentation of

-none of the family

of simple

explanation,

prognosis of the

cranioplasty

material based on

members is in the

explanation

appropriate for

procedure he is

a. evaluate

individual needs

medical field and

from

their level in

about to undergo

capabilities and

pg.225,NCPs,Doe

none could give a

significant

order to alleviate

readiness to learn

nges

simple explaination

others

their anxiety.-

-aids in

of what he is about

pg.50,Beyond the

establishing

to go through

Relaxation

realistic

Measures to:

Response by

b. review information

expectations and

Herbert Benzon

regarding injury

promotes

process and after

understanding of

effects

current situation and nedds-

31

pg225,NCPs,Doe nges c. show the patient a

-provides a visual

picture of the skull

stimuli for

and the brain and

learning-

explain in simple

pg.225,NCPs,Doe

terms the surgical

nges

procedure

atient’s name: Ralph Labrador Room no. : 422

Age: 12 years old Sex: Male Nursing Care Plan (post-operative)

32

Physician: Dr.Vergara Nilo Date: May 8, 2008

Needs/Problems

Nursing

Scientific Basis

Objectives of Care

Nursing Actions

Rationale

Cues Physiologic

Diagnosis I.Alteration in

Naked nerve

After 8 hours of

overload:

comfort:pain

endings found in

student nurse-

I.Alteration in

related to

the tissue are

patient interaction,

comfort

disruption of

called pain

the patient will be

tissue

receptors.Once

able to:

intermittetn pain on

integrity

an injury/break

1.demonstrate

right parietal area

secondary to

in the skin

decrease in pain

of head; pain

surgical

occurs, they send

sensation as

started hours after

procedure

nerve impulses

evidenced by a pain that his affected side

arriving from the

and chemicals to

scale rating as 1 in

will not receive much nerve triggering

OR;it is described

the brain

a pain scale of 0-10

pressure

as mildly stinging,

indicating the

pg.368,NPG,Doe

aggravated by

presence of pain

nges

sudden head movement, relieved by rest and treated with Mefenamic acid 1 cap q8h po -patient rated pain

-pg.210, Essentials of

Measures to:

1. promote comfort a. position patient so

-to avoid stimulation of the pain sensation-

b. perform

-serves as a

massage but not on

distraction

affected part

technique-

human anatomy

pg.315-316,MCN

and physiology

by Adelle

by Elaine Marieb

Pelliteri

as 5 in a pain scale

c.promote adequate

-rest promotes

0f 0-10 wherein 0

rest

healing and

33

stands for no pain

growth-

and 10 as most

pg.211,NCPs,

painful

Doenges -alleviates painpg.212;NCPs;Do enges

Patient’s name: Ralph Labrador Room no. : 422

Age: 12 years old Sex: Male Nursing Care Plan (post-operative) 34

e. administer

-alleviates pain-

medications per

pg.212;NCPs;

doctor’s order

Doenges

Physician: Dr.Vergara Nilo Date: May 8, 2008

Needs/Problems

Nursing

Scientific Basis

Objectives of Care

Nursing Actions

Cues II.Risk for

Diagnosis Risk for

After surgery the

2. maintain

2.maintain

ineffective

ineffective

frequency of

adequate

respiratory function

breathing pattern

breathing

post-operative

respiratory function

Rationale

pattern related complications

as evidenced by a

a. place patient in a

-the position

-patient has

to post-

monitoring is

respiratory rate at

semi-prone/ lateral

facilitates

bronchial asthma

anesthesia

based on the

normal range

position

respiratory gas

and has undergone

complications

patient’s clinical

exchange-

surgery for hours

status. Causes of

pg.2184;

under a general

anesthesia-

med.surg;

anesthesia

related death are

-respiratory rate of

usually linked to

b. suction trachea and Brunner and

18 breath cycles per

the respiratory

pharynx

minute

system. These

-removes

include

secretions

insufficient

pg.2184;

intubation or

med.surg;

proper

Brunner &

ventilation which

Suddarth

Suddarth

results in hypoxia, which

c. elevate head of bed -provides

is a deficiency of

20-30 degrees as 35

adequate lung

oxygen reaching

prescribed and

expansion

the tissues of the

promote purse-lip

pg.2184;

body.

breathing exercises

med.surg;

Complications

Brunner &

are mostly

Suddarth

related to General

d. administer nothing

-prevents

Gaseous-state

by mouth until active

aspiration

anesthesia and

coughing and

-page 2154; Med

may include

swallowing reflexes

Surg; Brunner &

laryngospasm,

are demonstrated

Suddarth

bronchospasm, aspiration, intubation injury, pulmonary edema, respiratory arrest .-pp. 378381,Stoelting, R.K, Pharmacology & Physiology in 36

Anesthetic Practice

Patient’s name: Ralph Labrador Room no. : 422

Age: 12 years old Sex: Male Nursing Care Plan (post-operative) 37

Physician: Dr.Vergara Nilo Date: May 8, 2008

Needs/Problems

Nursing

Scientific Basis

Objectives of Care

Nursing Actions

Cues III.Risk for

Diagnosis Risk for

The patient

3. exhibit absence

3. maintain vital

infection

infection

undergoing

of infection as

signs within the

related to

neurosurgery is

evidenced by vital

normal range

-patient is post-

wound

at risk for

signs within the

cranioplasty with

obtained

infection related

normal range

head dressing

during

reinforced with

surgery

sterile pads

Rationale

a. monitor site for

-these signs

to brain

redness, tenderness,

indicate infection

exposure, bone

bulging, separation,

at the site-

exposure and

foul odor

med.surg;

presence of IV

Brunner

lines for fluid administration.

b. instruct patient to

-this can be

Risk is increased

report presence of

caused by CSF

for those who

post-nasal drip or

leaking down the

undergo lengthy

salty taste

throat

intracranial

pg.2188;

procedures.-page

med.surg;

2187; Med.Surg.

Brunner &

Ng.; Brunner and

Suddarth

Suddarth

38

c. instruct patient to

-can cause CSF

avoid coughing,

leakage by

sneezing or blowing

creating pressure

nose

on operative site pg.2188; med.surg; Brunner & Suddarth

d. use aseptic

-prevent

technique when

contamination

handling dressings

and infection -page 2188; Med Surg; Brunner & Suddarth

e. administer

-prevent

prophylaxis per

infection--page

doctor’s order

2188; Med Surg; Brunner & Suddarth

Patient’s name: Ralph Labrador Room no. : 422

Age: 12 years old Sex: Male

Physician: Dr.Vergara Nilo Date: May 8, 2008

Drug Therapeutic Record Drug / Dose

Classification /

Indications /

Principle of Care 39

Treatment

Evaluation

/ Frequency / Route Mefenamic acid 500 g 1 cap every 8 per orem

Contraindications / Side-effects Classification: Indications: 1. Advise patient 1. Keep a record and - nonsteroidal anti- mild to moderate and significant monitor frequency, inflammatory drugs pain others that drug is location, duration, ;analgesic only for short term character, onset and Mechanism:- Mefenamic Contraindications: use and may intensity of pain. acid binds the - hypersensitivity aggravate condition 2 Perform back prostaglandin synthetase to the drug if use is prolonged. massage, and not on the receptors COX-1 and 2. Tell patient to injured site. COX-2, inhibiting the Side-effects: take drug as 3. Perform deep action of prostaglandin CNS: dizziness, prescribed and not breathing exercises. synthetase. As these vertigo, headache, to increase dose or 4. Provide adequate rest. receptors have a role as a somnolence dosage interval 5. Provide distractions major mediator of Gastrointestinal: unless ordered. to take patient's mind off inflammation and/or a nausea, vomiting 3. Advise the the pain. role for prostanoid Genitourinary: patient to inform 6. Discourage signaling in activityurinary retention, the prescriber if constrictive clothing. dependent plasticity, the urinary frequency taking OTC drugs symptoms of pain are Respiratory: since interactions temporarily reduced. respiratory may occur. depression Source: pp. 405-406; Nursing Drug Handbook 2006, 26th Edition; Lippincott, Williams and Wilkins

Oxacillin 750 g IVTT every 6 hours

Mechanism

Classification: - anti-infective narrow spectrum beta-lactam antibiotic of the

Indications: - treatment and prophylaxis for infections of the respiratory tract,

1. Check for allergies to the drug. 2. If large doses are given, therapy is prolonged, or patient 40

1. Monitor vital signs. 2. Tell patient to take the entire quantity prescribed

The patient was able to verbalize a decrease in pain sensation on a pain scale of 0-10, with 0 as “no pain” and 10 as “most painful,” from 5, “moderate pain” to 3, “tolerable pain.”

No evidence of suppuration on superficial wounds. The patient has

penicillin class. Mechanism: - inhibits cell wall synthesis, promoting cell wall / osmotic instability; usually bactericidal

EENT, skin, soft tissue, GIT, biliary, abdominal bone and joints, UTI Contraindications: - hypersensitivity to penicillins, lactation, renal insufficiency

is at high risk, monitor for signs and symptoms of super infection. 3. Tell patient not to confuse drug with other penicillins that sound alike. 4. Instruct patient to report discomfort at IV insertion site. 5. Advise patient to notify prescriber about loose stools or diarrhea.

even if he feels “better.” 3. Encourage bed rest. 4. Advise patient to take a well-balanced diet. 5. Promote proper hand washing, hygiene, and environmental sanitation.

manifested a normal temperature 36.8 degrees celsius; skin is warm to touch, noted with sweating, with no flushing and no chills.

Side-effects: Central Nervous System: headache, dizziness Cardiovascular: phlebitis Gastrointestinal: pseudomembranous colitis, nausea, vomiting, diarrhea, abdominal cramps th Source: pg. 168; MIMS, 108 Edition and pp. 105-107; Nursing Drug Handbook 2005, 25th Edition; Lippincott, Williams and Wilkins

41

Patient’s name: Ralph Labrador

Age: 12 years old

Physician: Dr.Vergara Nilo

Room no. : 422

Sex: Male

Date: May 8, 2008

SOAPIE No. 1 S-

“Kulbaan gamay,” as verbalized by the patient

O-

client does foot shuffling when the nurse and his mother talkied to him about the procedure; client is restless

A- Anxiety: restlessness related to fear of unknown outcome of surgery P-

to reduce anxiety

I-

acknowledged fear; encouraged patient to verbalize feelings ; spent time with the patient; encouraged guided imagery; provided touch, massage

E-

“Mahadlok ko okay wala akong mama ana gud. Dili siya makasud kuyog nako ingon ang nurse ganina,” as verbalized by the patient

42

Patient’s name: Ralph Labrador

Age: 12 years old

Physician: Dr.Vergara Nilo

Room no. : 422

Sex: Male

Date: May 8, 2008

SOAPIE No. 2 S-

“5 ang kasakit,” as verbalized by the patient referring to the pain scale 0-10 wherein 0 stands for “no pain” and 10 for “most painful”

O-

client tries to move slowly; client barely moves/ turns head

A-

Alteration in comfort: acute pain related to disruption of skin, tissue, muscle and blood vessel integrity secondary to the surgical procedure

P-

to promote comfort

I-

positioned patient so that affected side will not receive much pressure; performed massage but not on affected side; encouraged deep breathing exercises; promoted adequate rest; administered medication per doctor’s order

E- “Din a kayo sakit. 1 na,” as verbalized by the patient referring to the pain scale 0-10 wherein 0 stands for “no pain” and 10 for “most painful”

43

Patient’s name: Ralph Labrador

Age: 12 years old

Physician: Dr.Vergara Nilo

Room no. : 422

Sex: Male

Date: May 8, 2008

Play Therapy Developmental Change School age (6-12 years)

Type of Play Competitive

Objective of play After 15-20

Implemental Play “Questions and

Evaluation Patient was able

-the period in which the

quiet games

minutes of

Ladder”

to follow the rules

child’s body proportions

and activities

student nurse-

take on a slimmer look,

-although

patient

Materials needed:

was able to

with longer legs, varying play at this

interaction, the

-a snake ladder

answer the

body proportion and a

stage is

patient will be

board

student nurse’s

lower center of gravity.

highly active,

able to:

-2 chips with

review questions.

Freud described this

school-age

different colors

He lost the game

period as a time of

children also

1. follow the rules -cards containing

but he stated that

tranquility between the

enjoy quiet

of the game

he enjoyed it just

Oedipal phase of early

solitary

2. demonstrate his questions

like the way he

childhood and eroticism

games or

reading skills and

Mechanics of the

enjoyed the

of adolescence. During

games they

sportsmanship

game:

original snake and

this time children

can play with

3. learn more

1. student nurse

ladder game.

experience relationships

their best

about cranioplasty will serve as the

with same sex peers

buds. School

through the

patient’s playmate

following the

age children

student nurse

2. each of them

indifference of earlier

become

4. express how he

will have a chip

years and preceding the

fascinated

feels towards the

that’ll represent

heterosexual fascination

with complex

upcoming surgery

them on the s & L

that occurs for most

board, card or

board

boys and girls in

computer

3. the patient gets

puberty.-pg.356-380;

games.

to choose

Fundamentals of

Adherence to

questions from

Nursing; Barbara Kozier

the rule is

cards that he can

44

of the game. He

different

fanatic.- pg.

ask the SN;

Psychosocial task:

479; Wong’s

questions vary

industry vs. inferiority

pediatric

from personal to

Nursing by

inquiries about

Hocken berry

the surgery

Industry- or stage of accomplishment; they

4. the SN gets to

are eager to develop

question patient

skills and participate in

as a review if the

meaningful and socially

patient listened to

useful work; they

the SN’s answers

acquire a sense of

5. success in

personal and

anwering

interpersonal

advances the chip

competence

to the next level ;

Inferiority-when the

failure will lead to

reward structure is based

falling from the

on evidence of mastery,

ladder

children who are incapable of developing skills are at risk for feeling inadequate; they must learn that they will not be able to master every skill they attempt.

V. Evaluation and Recommendation 45

Healthy children and adults often heal and recover more quickly than older people who are more likely to have chronic diseases that hidner healing. Emotional support from significant others has also proved to be helpful in shortening recovery time for the patient. Being a 12 year-old, without any significant medical condition that could possibly hinder healing and with a supportive mother and aunts, the patient has a better prognosis.

Up to this point, the best recommendation in this case would be to encourage the patient and his significant others to follow all the doctor’s orders and take in the prescribed medications for an appropriate menght of time. Regarding the deficits manifested by the patient after the accident, the significant other is advised to show more patience in dealing with Ralph and if possible, forewarn the teacher of his difficulty in hearing with his right ear and short memory lapses because these may have been affecting his academic performance in school.

46

VI. Evaluation and Implication of the Case Study to:

Nursing Practice This case study nurtures the student nurse’s ability to integrate knowledge, attitude and skills taught in the classroom, into the actual clinical set-up. It provides the student nurse a comprehensive view about the field of medical diseases and their surgical intervention and broadens knowledge in giving holistic care to the patient. It benefits not only the patient and significant others but the student nurse as well. Nursing Education This case study is as vital as classroom teaching as a clinical exposure in nursing education as it broadens the student nurse’s knowledge even more. It is an additional force in promoting nursing education as it better helps the nurse understand the disease condition and updates one’s knowledge about the management of the disease . Nursing Research This case study enhances the student nurse’s research ability as one strives to have a comprehensive and thorough investigation about the case. The student nurse utilizes the maximum resources available and is able to use them effectively in making good and comprehensive research. This case study can be used as a source for further researches.

VII. Bibliography 47

Brunner and Suddarth; Medical-Surgical Nursing; 10th edition; JB. Lippincott Company,2008

Doenges,Moorehouse, et al; Nurse’s Pocket Guide: Diagnosis, Intervention and Rationale; 9th edition; FA Davis Company, 2004

Doenges,Moorehouse, et al; Nursing Care Plans: Guidelines for individualizing patient care; FA Davis Company, 2004

Grolier Incorporated; Grolier Encyclopedia of Knowledge; Academic American Encyclopedia, 1998

Hockenberry, Marilyn J., et al; Wong’s Essential of Pediatric Nursing; 7th edition; Mosby Inc. 2005

Kozier, Barbara, et al; Fundamentals of Nursing; 7th edition; Pearson Education, Inc, 2004

Marieb, Elaine N.; Essentials of Human Anatomy and Physiology; 7th edition; Pearson Education, Inc, 2003

Smeltzer, Suzanne C., et al; Medical-Surgical Nursing; 10th edition; JB Lippincott Company, 2004

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