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CASE STUDY
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CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, Tarlac City
CASE STUDY FORMAT
I. IntroductionII. Objectives
Nurse centeredIII. Nursing Process
A. Data Basea. Nursing health history A
1. Demographic data2. Chief complaint3. History of present illness4. Past medical history5. Family history6. Social and personal history7. Review of system
b. Nursing health history B1. General Description Of Client2. Health Perception-Health Management Pattern3. Nutritional-Metabolic Pattern4. Elimination Pattern 5. Activity-Exercise Pattern6. Sleep-Rest Pattern7. Cognitive-Perceptual Pattern8. Self-Perception – Self-Concept Pattern9. Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Pattern
c. Physical examinationd. Laboratory Findingse. Review of anatomy and physiologyf. Pathophysiology (highlight patient manifestation)
B. NCPC. Drug StudyD. Medical and Nursing ManagementE. METHOD
II. Evaluationa. Narrative evaluation of the objectivesb. Patient condition upon discharge
III. RecommendationIV. References/Bibliography
CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, tarlac city
CASE STUDY FORMATI. Introduction
a. Introduction about patient/background
Age
Gender
Address
b. Significance/relevance to the concept
c. Background knowledge
Definition
Causative agent
Clinical manifestation
Mode of transmission
d. Current/target population
e. Risk factors/contributing factors
f. Prognosis and complications
II. Nurse centered
a. Objectives
NURSING HEALTH HISTORY A
Demographic data
Patient:Date: Ward: Bed:Age: Sex: C/S: Religion:Examiner:Informant:
I. Chief complaint
I. History of present illness
II. Past medical history (include dates and complications, if any)A. Pediatric and Adult Illness
Mumps Pertussis HPNMeasles Rheumatic Heart DiseaseChicken Pox Pneumonia HepatitisRubella Tuberculosis Others
B. Immunizations/Tests
BCG HEP B For PneumoniaDPT Measles OthersOPV For Flu
C. Hospitalizations
D. Injuries
E. Transfusions
F. Obstetrics/gynecologic History
G. Medications
H. Allergies
II. Family history
AGE List:Parents, Spouse, Children
Health Status or Cause of
Death
Diseases Present in the FamilyL D
L = Living TB = Tuberculosis HPN = Hypertension OB = ObesityD = Deceased DM = Diabetes Mellitus CA = Cancer J = Jaundice
HD = Heart Disease MI = Mental Illness KD = Kidney Disease O = Others
III. Social And Personal History
Birthplace: Birthday:Education: Ethnic Background:
Age and Sexes of Children (if any):
Client’s position in the family:
ResidenceHome Environment:
OccupationNature of present occupation: (stresses, hazards, etc.)
Financial Support System:
Habits (tobacco/alcohol use, others):
Diet (meal distribution, others)
Physical Activity/Exercise, if any:
Brief Description of Average Day:
IV. Review of system
General Description:Weight Loss: __________ Fatigue: ____________ Anorexia: ____________
Night Sweats: ____________ Weakness: __________
Skin:Itch: _________________________ Bruising: ________________________Rash: ________________________ Bleeding: ________________________Lesions: ______________________ Color Change: ____________________
Eyes:Pain Itch Vision LossDiplopia Blurring Excessive TearingGlasses/Contact Lenses
Ears:Earaches Discharge Tinnitus Hearing Loss
Nose: Obstruction Epistaxis Discharges
Throat and Mouth:Sore Throats Bleeding Gums Tooth Aches Decay
Neck:Swelling Dysphagia Hoarseness
Chest:Cough Sputum: (Amount & Character) HemoptysisWheeze Pain on Respiration Dyspnea: Rest/ExertionBreast: Lumps Pain Bleeding Discharge
CVS:Chest pain Palpitation Dyspnea on exertion EdemaPND Orthopnea Others: _________________________
GIT:Food tolerance Heartburn Nausea JaundiceVomiting Pain Bloating Excessive GasConstipation Change in BM Melena
GU:Dysuria Nocturia Retention Polyuria DribblingHematuria Flank painMale: Penile Discharge Lesion Testicular pains others:Female: Menarche: (age) LMP: (date) Cycle: _____ others:
Extremities:Joint pains varicose veins ClaudicationEdema Stiffness Deformities
Neuro:Headaches Dizziness Memory Loss FaintingNumbnessTingling Paralysis: ____________ Paresis: _________Seizures Others: ______________________________
Mental Health Status:Anxiety Depression InsomniaSexual Problems Fears
NURSING HEALTH HISTORY B
a. General Description Of Client
b. Health Perception-Health Management Pattern
c. Nutritional-Metabolic Pattern
d. Elimination Pattern
e. Activity-Exercise Pattern
f. Sleep-Rest Pattern
g. Cognitive-Perceptual Pattern
h. Self-Perception – Self-Concept Pattern
i. Role-Relationship Pattern
j. Sexuality-Reproductive Pattern
k. Coping-Stress Tolerance Pattern
l. Value-Belief Pattern
PHYSICAL EXAMINATION
GENERAL SURVEY:
Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______
Skin: Color: __________ Turgor: ___________ Bruises: __________
State of Hydration: _____________
Eyes: Sclera: _____________________ Pupils: ______________________
Respiratory: Easy Breathing in Distress No Distress
VITAL SIGNS:
HR ___________ / min Temperature: ____________
BP Supine R/L arm ___________ mmHg Capillary Refill: ____________
Sitting R/L arm ___________ mmHg RR: _____________________
Standing R/L arm ___________ mmHg
Others: ______________________________
BODY POSITION/ALIGNMENT:
Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________
Alignment: Appropriate Inappropriate
MENTAL ACUITY:
Oriented coherent appropriately responsive others: ___________
Disoriented incoherent inappropriately responsive
SENSORY/MOTOR RESTRICTIONS:
Amputation deformity paresis paralysis fracture
Gait hearing disorder speech others: ______________________
EMOTIONAL STATUS:
Euphoric Depressed Apprehensive
Angry/Hostile Others: ___________________________
MEDICALLY IMPOSED RESTRICTIONS:
CBR w/out BRP_____ BR w/ BRP_____ OOB – Chair_____ Restricted Ambulation _____
OTHER HEALTH RELATED PATTERNS:
Fatigue Restlessness Weakness Insomnia Coughing
Dyspnea Dizziness Pain Others: ______________________
ENVIRONMENT:
Room Temperature: Adequate Inadequate
Lighting: Adequate Inadequate
SAFETY:
Violations of medical asepsis: ________________________________________________
Violations of safety measures: ________________________________________________
ACTIVITIES OF DAILY LIVING:
Can/Cannot perform
Feeding Brushing teeth Bathing Transferring
Dressing Combing Others: __________________________________
PHYSICAL EXAMINATION FINDINGS
HEAD/SKULL:
EYES/VISION:
EARS/HEARING:
NOSE, MOUTH AND THROAT:
NECK AND LYMPH NODES:
THORAX (CHEST AND LUNGS):Anterior:
Posterior:
HEART AND CARDIOVASCULAR SYSTEM:
ABDOMEN:
NEUROLOGICAL:
MUSCULOSKELETAL:
GENITALIA:
EXTREMETIES:
(Follow IPPA format when documenting Physical Examination findings)
LIST OF IDENTIFIED NURSING PROBLEMS
PRIORITIZATION OF NURSING PROBLEM
1. Oxygenation2. Nutrition3. Elimination4. Activity and Exercise5. Comfort and Safety6. Sexual- Reproductive7. Psychological8. Psychosocial
LABORATORY FINDINGS
Review of anatomy and physiology
Pathophysiology (highlight patient manifestation)
NCP
ASSESSMENT INTERVENTIONEVALUATION
CUES NURSINGDIAGNOSIS
SCIENTIFICEXPLANATION
PROBLEM STATEMENT
(GOAL)
NURSINGINTERVENTION RATIONALE
Drug Study
DRUG NAME/
GENERIC
CLASSI-FICATION
DOSAGE/STOCKDOSE
ACTION INDICATION CONTRAINDICATION
SIDEEFFECTS
ARVERSEREACTION
NURSING RESPONSIBILITIES
Medical Management (
Nursing Management
Discharge Planning
METHOD (Example)
M (Medications):Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset.Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.
E (Exercise/Environment):Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allow you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.
T (Treatments):Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.)
H (Health knowledge of disease):Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is
important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.
O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.
D: (Diet):Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.
Evaluationa. Narrative evaluation of the objectivesb. Patient status after discharge
Recommendation
References/Bibliography
How to Write a Case Study Paper for NursingA well-written case study paper for a nursing program requires some planning and consideration. All too often students begin writing before they complete appropriate, preliminary steps. Ideally, before you begin a paper, you should already have determined the focus and format of it. You will then follow this up with a fact-gathering step in which you will gather and collate the content of your paper. Finally, there is the construction/execution step in which you will write the paper in a standard format (such as the APA style) and edit it.A nursing case study paper contains several sections that fall into three categories:1. The status of the patient Demographic data Medical History Current diagnosis and treatment
2. The nursing assessment of the patient Vital signs and test results Nursing observations (i.e., range of motion, mental state)
3. Current Care Plan and Recommendations Details of the nursing care plan (including nursing goals and interventions) Evaluation of the current care plan Recommendations for changes of the current care plan
Patient StatusThe first portion of the case study paper will talk about the patient — who they are, why they are being included in the study, their demographic data (i.e., age, race), the reason(s) they sought medical attention and the subsequent diagnosis. It will also discuss the role that nursing plays in the care of this patient.Next, fully discuss any disease process. Make sure you outline causes, symptoms, observations and how preferred treatments can affect nursing care. Also describe the history and progression of the disease. Some important questions for you to answer are: 1) What were the first indications that there was something wrong, and 2) What symptoms convinced the patient to seek help?Nursing AssessmentWhen you are discussing the nursing assessment of the patient describe the patient’s problems in terms of nursing diagnoses. Be specific as to why you have identified a particular diagnosis. For example, is frequent urination causing an alteration in the patient’s sleep patterns? The nursing diagnoses you identify in your assessment will help form the nursing care plan.Current Care Plan and Recommendations for ImprovementDescribe the nursing care plan and goals, and explain how the nursing care plan improves the quality of the patient’s life. What positive changes does the nursing care plan hope to achieve in the patient’s life? How will the care plan be executed? Who will be responsible for the delivery of the care plan? What measurable goals will they track to determine the success of the plan?The final discussion should be your personal recommendations. Based on the current status of the patient, the diagnosis, prognosis and the nursing care plan, what other actions do you recommend can be taken to improve the patient’s chances of recovery? It is important that you support your recommendations with authoritative sources and cited appropriately per APA style guidelines.Creating a well-written nursing case study paper doesn’t need to be a grueling challenge. It can actually be very rewarding, and it’s good practice for assessing patients while out in the field, too. Keep in mind that your instructor will not only grade you on the quality of the content of your paper, but by how you apply the APA style, as well. If you find that you are spending too much time formatting your paper, consider using formatting software as a helpful tool to ensure accuracy so you don’t lose points on a well written paper because of some formatting errors.David PlautDavid Plaut is the founder of Reference Point Software (RPS). RPS offers a complete suite of easy-to-use formatting template products featuring MLA and APA style templates, freeing up time to focus on substance while ensuring formatting accuracy. For more information, log
ontohttp://www.referencepointsoftware.com/ or write to:info @ referencepointsoftware.comReference Point Software is not associated with, endorsed by, or affiliated with the American Psychological Association (APA) or with the Modern Language Association (MLA).
INTRODUCTION
Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or
Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for
older adults and those with chronic illnesses, it can also strike young, healthy people as well. It is a common illness
that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and
mortality in the country.
There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia,
bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe.
Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial
pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the
judgment of the doctor. It’s best to do everything we can to prevent pneumonia, but if one do get sick, recognizing
and treating the disease early offers the best chance for a full recovery.
A case with a diagnosis of Pneumonia may catch one’s attention, though the disease is just like an ordinary cough
and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an
appropriate care has to be done to make the patient’s recovery faster. Treating patients with pneumonia is necessary
to prevent its spread to others and make them as another victim of this illness.
ANATOMY AND PHYSIOLOGY
The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the
process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20
times per minute taking in and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each
bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each
lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs
are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways
that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called
alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated
blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled
from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of
those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances
has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each
other during breathing.
PATHOPHYSIOLOGY
Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid.
Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells can’t work properly.
Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs
in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects
patches throughout both lungs.
Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common.
Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia
pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella
pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses:
respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher
bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical
strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus
neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).
The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions
from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from
contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization,
cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as
in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to
transmissible agents.
Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes
accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles
with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H.
influenzae.
NURSING PROFILE
a. Patient’s Profile
Name: R.C.S.B.
Age: 1 yr,1 mo.
Weight:10 kgs
Religion: Roman Catholic
Mother: C.B.
Address: Valenzuela City
b. Chief Complaint: Fever
Date of Admission: 1st admission
Hospital Number: 060000086199
c. History of Present Illness
2 days PTA – (+) cough
(+) nasal congestion, watery to greenish
(+) nasal discharge
Tx: Disudrin OD
Loviscol OD
Few hrs PTA - (+) fever, Tmax= 39.3 C
(+) difficulty of breathing
(+) vomiting, 1 episode
Tx: Paracetamol
Sought consultation at ER: Rx=BPN, Salbutamol neb.
IE: T = 38.3C, CR= 122’s, RR= 30’s
(+) TPC
SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema
d. Past Illness
(-) asthma
(-) allergies
e. Family History
PMHx: (+) asthma (mother)
f. Activities of Daily Living
Sleeping mostly at night and during afternoon
Usually wakes up early in the morning (5AM) to be milkfed.
Eats a lot (hotdogs, chicken, crackers, any food given to her)
Active, responsive
BM (1-2 times a day)
Urinates in her diaper (more than 4 times a day)
Likes to play with those around her
g. Review of Systems
Neuromuscular: weakness of muscles
Integumentary: (-) cyanosis
Respiratory: tavhypnea; (+) DOB; (+) coarse crackles, (+) wheezes,
Digestive: food aversion, vomits ingested milk
DRUG STUDY
View NCP
NURSING ACTIONS
INDEPENDENT
positioning of the patient with head on mid line, with slight flexion
rationale: to provide patent, unobstructed airway , maximum lung excursion
auscultating patient’s chest
rationale: to monitor for the presence of abnormal breath sounds
provide chest and back clapping with vibration
rationale: chest physiotheraphy facilitates the loosening of secretions
considering that the patient is an infant, and has developed a strong stranger anxiety
as manifested by “white coat syndrome” , it is a nursing action to play with the patient.
rationale: to establish rapport, and gain the patients trust
DEPENDENT
administer due medications as ordered by the physician, bronchodilators, anti pyretics and anti biotics
rationale: bronchodilators decrease airway resistance, secondary to bronchoconstriction,
anti pyretics alleviate fever, antibiotics fight infection
placing patient on TPN prn
rationale: to compensate for fluid and nutritional losses during vomiting
COLLABORATIVE
assist respiratory therapist in performing nebulization of the patient
rationale: nebulization is a favourable route of administering bronchodilators
and aid in expectorating secretions, hence patient’s breathing
PHYSICIAN’S ORDER SHEET
11/19/06
Admit patient to ROC under the service of Dr. Vitan secure consent for admission and management, TPR every shift
then record. May have diet for age with strict aspiration precaution, IVF D5 0.3NaCl 500cc to run at
62-63mgtts/min.May give paracetamol 125mg 1supp/rectum if oral paracetamol is not tolerated.
11/20/06
For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use zinacef brand of cefuroxine 750mg- given ½
vial 375mg every 8hours, nebulize (Ventolin 1 nebule) every 6 hours, paracetamol drugs prn every 4hours (Temp
37.8).
11/21/06
Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF, revise Cefuroxine IV to Cefuroxine 500mg via
deep Intramuscular BID,continue management.
11/22/06
Continue management and refer.
DISCHARGE PLANNING
Take the entire course of any prescribed medications. After a patient’s temperature returns to normal,
medication must be continued according to the doctor’s instructions, otherwise the pneumonia may recur.
Relapses can be far more serious than the first attack.
Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid
relapse.
Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen
mucus in the lungs.
Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected.
It’s important to have the doctor monitor his progress.
Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs that can
cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands
thoroughly and often can help reduce the risk.
Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g.
smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.
Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.
Protect others from infection. Try to stay away from anyone with a compromised immune system. When
that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.
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ESTHER FUNMILAYO AFOLALU
06370934
NUI Galway
Bachelor of Nursing Science 3NG1
NU324 CLINICAL PRACTICE 6
Title of assignment: Case study (Brain tumour).
Module Leader: Toni Ui Chiardha
Assignment due date: 08 May 2009
Actual date of submission: 08 May 2009
Word limit for assignment: 2500 words
Actual word count: 2768 words
Brain tumours are relatively uncommon yet this particularly cancer
has a significant effect on the affected individual; low survival rates and dire
prognosis in many cases are a sad reality for most patients. These cancers
occur most frequently in older populations and are also a common cancer
seen in children. (Baumann & Zumwalt, 1989, Pelletier et al., 2002, Grant,
2004, McKinney, 2004). Smeltzer & Bare (2004 pg. 1970) described a brain
tumour as ‘a localized intracranial lesion that occupies space within the
skull...with effects occurring from compression and infiltration’. A benign
or malignant lesion can arise from anywhere in the complex brain structure
thus there are many distinct forms of primary brain tumours. The most
common and aggressive types are gliomas which arise from the glial cells of
the brain itself, different forms of gliomas include astrcoytomas,
glioblastomas, and oligodendroblastomas (Franges, 2006). Other main
types of tumours include meningiomas which are slow-growing benign
masses arising from the meninges, acoustic neuromas, pituitary adenomas
and angiomas (Smeltzer & Bare, 2004, Franges, 2006). McKinney (2004)
identified several risk factors known to be associated with developing brain
tumours, including previous head injury, disruption of the functioning of the
immunes system by viruses, allergies, infections and gradual development
of changes to the individual’s genetics, and exposure to certain chemicals,
extremely low frequency magnetic fields, and radiofrequency signals from
mobile phones.
Clinical manifestations of brain tumours are often due to the effects of
the tumour whether it is compressive as in the case of meningiomas or
related to specific effects on the area of the brain where the tumour occurs,
for example an individual with a pituitary adenoma might present with
hormonal disorders as well as generalised tumour effects (Hickey, 2003a).
General effects are mostly related to abnormalities in brain volume caused
by the tumour itself and cranial nerves impairment, these include seizures
due to disturbances of brain electrical activities, cerebral oedema,
obstruction to normal cerebrospinal fluid flow, raised intracranial
pressure(ICP), headaches and vomiting, cognitive deficits, fatigue, changes
in level of consciousness, and other focal deficits relating to specific areas
of the brain and resulting in specific symptoms such as visual, speech and
language disturbances, personality changes and coordination
problems(Belford, 2000, Hickey, 2003a, Bohan & Glass – Macenka, 2004,
Lovely, 2004). Initial diagnosis of brain tumour is based on neurological
examination and assessment of presenting symptoms; diagnosis is
confirmed by identifying the location of a tumour through computer
topography (CT scan) and magnetic resonance imagery (MRI) (Rampling et
al., 2004, Franges, 2006). Further diagnosis to evaluate tumour histology
and extensiveness are usually done through CT or MRI guided biopsy
(Hickey, 2003a, Bohan & Glass – Macenka, 2004). Treatment of the cancer
is usually aimed at precise surgery to remove or lessen the tumour so as to
relive tension effects and symptoms of raised ICP. Curative or palliative
chemotherapy many also be used, but radiotherapy remains the prevailing
treatment for most brain tumours (Hickey, 2003a, Rampling et al., 2004,
Whittle, 2004).
A diagnosis of brain tumour is worrisome for patients and their
families, the cancer affects individuals intensely in a lots of different ways;
damage to the intricate workings of the brain may result in symptoms that
not only hamper the individual physically but also pose a great threat to
whole personality and sense of self, thus holistic nursing care of the patient
is paramount (Barker, 1990, Mogensen, 2008). There are certain nursing
priorities and interventions that are distinctive for brain tumour patients;
three of which include management of seizures, management of increased
intracranial pressure and cerebral oedema and management of fatigue and
activity intolerance.
Management of seizures: Seizures commonly occur in patients with
brain tumours with up to 30% of patients presenting with seizures at
diagnosis and between 50 – 70% presenting with seizure activities as the
disease progresses (Rabbitt & Page, 1998). Seizure occurrence may be
related to the histology and location of the tumour; it’s been investigated
that slow-growing temporal and frontal lobe tumours accounts more for the
occurrence of seizures (Kilpatrick et al., 1994, Krouwer et al., 2000, Hickey,
2003a, van Breemen et al., 2007). Seizure activity in brain tumour patients
are said to be caused by tumour’s irritation of and interference with the
cells and electrochemical activity of the brain (Belford, 2000, Rabbitt &
Page, 1998, Hickey, 2003a). Managing seizures is a significant aspect of the
nursing care for these patients as seizures further complicates a diagnosis
of brain tumour by limiting quality of life, ability to perform daily activities,
independence and coping (Lovely, 2004, van Breemen et al., 2007, Tremont
– Lukats et al., 2008). Nursing interventions during a seizure are to promote
patient dignity and safety by clearing the environment, keep the bed in a
low position with side rails up and padded, it’s also important not to put
anything in patient’s mouth while teeth is clenched during a grand-mal
seizure, it’s essential to monitor airway and ventilation during a seizure and
to guide but not restrict patient movement. Following a seizure it’s
important to ensure the patient is comfortable and positioned on side, note
any resultant weakness or paralysis and the specifics of seizure
activity( duration, movements of involved body parts, papillary reaction,
level of consciousness and behavioural and psychical conditions post-
seizure) should be documented accurately (Hickey, 2003b, Carpenito –
Moyet, 2008). It’s also important to administer prescribed anticonvulsants,
paying particular attention to medication interactions, serum levels and
potential side effects (Belford, 2000). Brain tumour complications such as
increased intracranial pressure and post neurosurgical complications such
as decreased cerebral perfusion, pyrexia, hypotension, hypoxia, and
electrolyte imbalance could potentially aggravate seizures and should thus
be managed as appropriate (Barker, 1990, Hickey 2003c). Seizures can be
very upsetting for the patient and family, thus nursing interventions are also
aimed at educating patients and family members regarding coping with the
impact of seizures, recognising auras preceding seizures and taking safety
measures in the event of a seizure (Rabbitt & Page, 1998).
Management of increased intracranial pressure and cerebral
oedema: Within the confined space of the skull, three main components;
brain, cerebrospinal fluid and blood are needed to maintain adequate
intracranial pressure (0 – 15mmHg), any abnormal volume shift relating to
any one of these components would result in a compression of the
remaining two which would consequently increase intracranial
pressure(Allan, 2006). Brain tumours intervene with this complex
intracranial relationship between volume and pressure by initiating cerebral
oedema, disrupting the flow of cerebrospinal fluid and leading to collection
of fluid in the cellular space in brain (Smeltzer & Bare, 2004, National Brain
Tumor Association, 2007, Mogensen, 2008). Increased intracranial pressure
prompts further cerebral oedema which results in movement of brain tissue
though the small opening of the rigid dura, this is a particularly morbid
complication of neurological malignancies resulting in death from brain
herniation (Hickey, 2003d, Smeltzer & Bare, 2004).
Observing for signs of increased intracranial pressure are thus a vital
nursing priority in relation to care of the brain tumour patient in all stages
of the diseases, even postoperatively as complications from curative
surgical intervention may aggravate brain swelling and intracranial
pressure (Barker, 1990, Hickey, 2003c). Tension headaches with associated
nausea and vomiting are often experienced in connection with increased
intracranial pressure and are caused by stress on the pain receptive areas
in the brain (Cohen, 1995, Lovely, 2004). Other signs and symptoms include
deteriorating level of consciousness, impaired papillary function,
papilledema, abnormal motor responses, sudden onset of one-sided
weakness, respiratory difficulties, and late changes in the vital signs termed
as Cushing’s triad (hypertension, bradycardia and irregular respirations)
(Barker, 1990, Belford, 2000, Hickey, 2003d, Smeltzer & Bare, 2004, Allan,
2006). Nursing interventions include carrying out frequent neurological
examinations to monitor for the aggravation of symptoms. Head of bed
should be elevated to 30 – 45 degrees in order to optimise jugular venous
drainage which would contribute to lowering intracranial pressure (Hickey,
2003d, Carpenito – Moyet, 2008). Extreme flexion and extension of the head
and neck, straining, coughing or any other process that could illicit the
valsalva manoeuvre should be avoided as this impede jugular veins,
obstructs venous return and increases intracranial pressure. Likewise in
this regard, a relaxed stress –free environment should be provided for the
patient. Furthermore, nursing activities that could increase intracranial
pressure such as suctioning, giving a bed bath, and repositioning should not
be carried out consecutively (Belford, 2000, Hickey, 2003d, Smeltzer &
Bare, 2004, Carpenito – Moyet, 2008). During episodes of increased
intracranial pressure, oxygenation may be indicated in order to maintain
sufficient blood flow to the compromised brain, steroids(dexamethasone)
and osmotic diuretics( mannitol )are usually prescribed to reduce brain
oedema and draw out excess fluids from the brain and reduce pressure
(Hickey, 2003d).
Management of fatigue and activity intolerance: Fatigue is a
major and recurrent issue in patients with brain tumours and has wide-
ranging and crippling effect on daily living activities and functioning. It may
be a chronic symptom, a result of many factors relating to the cancer itself,
pain, the effect of treatment such as chemotherapy, radiotherapy or
anticonvulsant medications or related to depression, anaemia, infection or
impaired functional ability (Lovely, 2004, Palmieri, 2007). It is described by
Lovely (2004, p. 278) as a ‘symptom depicting weakness, exhaustion,
lethargy, inability to concentrate, malaise, sleepiness and lack of
motivation’. Activity intolerance is decreased performance in and inability
to fulfil activities of daily living due to fatigue (McFarland & McFarlane,
1997, Straight, 2002). According to National brain tumor foundation (2007)
fatigue and resultant activity intolerance is regarded as one of the worst
incapacitating effect of having a brain tumour. It could potentially lead to
worse problems concerning quality of life, ineffective coping and serious
neuropsychiatry complications such as chronic depression if not addressed
promptly (Eriksson, 1994, Lovely, 1998, Pelletier et al., 2002, Smeltzer &
Bare, 2004).
It’s thus a clinically relevant nursing priority to acknowledge and
evaluate the impact of fatigue on quality of life when caring for these
groups of patients. Nursing interventions are directed towards identifying
causes of fatigue and helping patients achieve increased activity intolerance
by attaining a balance between rests and carrying out activities within
capabilities, decreasing level of fatigue and consequently achieving more
independence in performing activities of daily living (Straight, 2002). If
fatigue is related to anaemia, it’s vital to transfuse and monitor effects of
red blood cells as prescribed to raise haemoglobin levels, also if depression
is evaluated as a cause for fatigue and activity intolerance, anti-depressants
may be prescribed and patient should be informed sufficiently regarding
this (Lovely, 2004). Other nursing interventions aimed at managing fatigue
incorporate assisting with activities as appropriate and encouraging
exercises in order to maintain muscle strength. Referring the patient to and
liaising with physiotherapy and occupational therapy would be beneficial in
assessing patient’s specific ability and developing ways to enhance activity
tolerance. During periods of non – hospitalisation, the nurse should provide
information to the patient and family regarding developing methods of
energy preservation by recognising causes of fatigue, arranging activities
around energy levels and aiming to exercise for at least 30 minutes thrice
weekly(Lovely, 2004, Palmieri, 2007). Moreover, it’s essential to encourage
the patient and reassure of appropriate means of achieving an optimal level
of activity through proper hydration, eating a nutritionally balanced diet ,
getting adequate levels of sleep, rest, and exercise and managing stress
through breathing exercises, relaxation techniques and mental stimulation
(Straight, 2002, Smeltzer & Bare, 2004).
As Graham & Cloughesy (2004) explained the histological and
pathological distinctiveness of the different classification of brain
malignancies means that pharmacological treatments and interventions
would inevitably vary. However there are two main classes of pharmacology
agents that are routinely prescribed for use in patients with brain tumour,
due to the fact that they manage symptoms that manifest fairly consistently
in patients with all types of brain tumour.
Corticosteroids are a group of pharmacological agents that behave
in the same ways as the steroid hormones produced by the adrenal glands,
they are effectively used to reduce cerebral swelling and production of
cerebrospinal fluid and relieve signs and symptoms associated with brain
tumours such as motor deficits, headaches and impaired mental states in up
to as much as two-thirds of brain tumour patients (Graham & Cloughesy,
2004, Grant, 2004, Nahaczewski et al., 2004). The main type of
corticosteroids used are glucocorticoids, which works as an inflammatory
agent and also by binding to intracellular glucocorticoids receptors and
initiating effects that stops the use of glucose by fatty tissues and
muscles(Janning & Lassiter, 2003, Nahaczewski et al., 2004).
Dexamethasone is the most commonly prescribed corticosteroid; initial dose
of 10mg is given intravenously, subsequent dosage is normally 16mg/day
and may be given either orally or intravenously, both ways acting equally
effectively in the swift and total absorption of the drug (Gerrard & Franks,
2004, Nahaczewski et al., 2004). Whilst proving to be an effective aspect of
the pharmacological treatment of brain tumour patients, dexamethasone
presents with many side effects and significant drug interactions. At least
half of patient receiving dexamethasone therapy will experience at least one
side effects, which include gastritis, endocrine hormonal imbalances giving
rise to hyperglycaemia, appetite stimulation and subsequent weight gain,
fluid and sodium retention, steroid characterised ‘moon face’ appearance,
steroid induced psychosis and other drastic neuropsychological changes,
thromboembolism, severe musculoskeletal defects due to osteoporosis and
proximal myopathy and most severely immunosuppression in the long term
resulting in profound neutopenia and increased susceptibility to infections
especially PCP(pneumocystis carinii pneumonia) (Rabbitt & Page, 1998,
Janning & Lassiter, 2003, Graham & Cloughesy, 2004, Gerrard & Franks,
2004, Mogensen, 2008).
Nursing management of side effects are related to providing
emotional support for altered body image and psychological disturbances,
monitoring for risks of infections, preventing gastrointestinal complications
by administering dexamethasone with meals and administering prescribed
histamine-2 receptor blocker or proton pump inhibitor, and educating
patients regarding blood glucose monitoring and eating a low sodium diet
(Rabbitt & Page, 1998, Nahaczewski et al. 2004, Franges, 2006). Drug
interactions induced toxicity by phenytoin and perpetuation of side effects
in patients receiving chemotherapy makes dosage monitoring a vital issue
(Graham & Cloughesy, 2004, Nahaczewski et al., 2004). If side effects
worsen, dexamethasone may need to be discontinued, gradual dose
reduction is essential as abrupt withdrawal of steroid hormones may
complicate neurological symptoms and also induce life-threatening
cardiovascular complications (Rabbitt & Page, 1998, Janning & Lessiter,
2003).
Anticonvulsants are pharmacological agents commonly prescribed
to manage seizure activity which are common occurrences in brain tumour
patients; however several studies have shown no proven benefit of
prophylactic use of anticonvulsants in the absence of seizure activity
(Rabbitt & Page, 1998, Gerrard & Franks, 2004, van Breemen et al., 2007).
There are different classes of anticonvulsants that may be used to control
seizures but phenytoin is one often prescribed. Phenytoin is part of a class
of anticonvulsants known as hydratonins and acts by inhibiting sodium
reception and movement in the brain and thus regulating brain cell’s
sensitivity to electrical discharges that causes epileptic muscle contractions
(Janning & Lassiter, 2003, Lovely, 2004).
Initial dose of phenytoin is 20mg/kg given intravenously at 50 mg/min
and subsequent dosage of 4 – 7mg/kg/d (qd – tid) is maintained , however,
due to the well-known side effects and drug interactions of phenytoin with
dexamethasone and certain chemotherapy drugs(such as nitroureas,
etoposide, and methotrexate) that occurs because all pharmacological
agents are competing for the same important metabolic P450 enzyme
pathway, it’s often a challenge to maintain therapeutic levels(10 – 20 mg/l)
of phenytoin and avoid drug toxicities in brain tumour patients (Rabbitt &
Page,1998, Krouwer et al., 2000, Graham & Cloughesy, 2004, Lovely, 2004
Tremont – Lukats et al.,2008). It is thus essential to monitor serum drug
level and signs of toxicities and other side effects which can often present
like and be mistaken for tumour dysfunction. Phenytoin’s side effects which
are perpetuated by drug toxicities especially in chemotherapy receiving
patients include neuro-cognitive deficits(ataxia, dizziness, headaches,
encephalopathy), gingival hyperplasia, suppression of the bone marrow,
liver impairment, and severe skin rashes known as Stevens Johnson
syndrome which can occur in the first few weeks following drug
commencement (Krouwer et al., 2000, van Breemen et al., 2007).
This case study reveals the complex and diverse needs of patient
presenting with a brain tumour. Diagnosis of brain tumours presents many
challenges for patients, family and health professionals. Clinical
manifestations of the illness may be subtle or associated with drastic
changes in patient’s ability to function. Successful disease management is
dependent on nurses’ knowledge of the disease and accompanying clinical
manifestations and acknowledgment of how the cancer diagnosis is
affecting patient’s functioning, coping and relationship. This is achieved by
identifying key nursing priorities, managing symptoms, observing closely
for complications and carrying out appropriate therapeutic clinical and
psychosocial nursing interventions.
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