Aklan Polytechnic College - College of Nursing

BRAIN TUMOR

A Case Study

Presented

to

The Faculty of the College of Nursing

Aklan Polytechnic College

Kalibo, Aklan

In Partial Fulfilment

Of the Requirements in

Related Learning Experience

Submitted by:

Bolido, Jill Cheastine C.

Castro, Roselyn V.

Dela Torre, Rochelle Andrea P.

Llamera, Clint B.

Pedro, Nori Fe

Relor, Leoni Beth R.

Tumbokon, Rosemary R.

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OBJECTIVES

General Objective:

After the case study, we the nursing students will be able to acquire new knowledge,

enhance basic skills, and develop desirable attitudes towards the care of a patient with Brain

Tumor through the utilization of the nursing process.

Specifically, we will be able to:

Knowledge

 Define terminologies related to Brain Tumor;

 Discuss and explain the pathophysiology, etiology, clinical signs, and symptoms,

incidence rate, diagnostic procedures and management of a patient with Brain Tumor;

 Discuss the Anatomy and Physiology of the brain;

 Identify and explain the drugs used to treat Brain Tumor;

 List nursing responsibilities in caring for a patient with a Brain Tumor;

Skills

 Assess and classify gathered data relevant to the patient’s condition;

 Formulate nursing diagnosis specific to the identified health problem;

 Plan care specific to the patient’s identified health problems;

 Implement the plan of care to the patient;

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 Evaluate the effectiveness of nursing care rendered;

 Formulate a Concept Map;

 Identify the deviation of laboratory results and its significance;

Attitude

 Acknowledge the patient’s expression of feelings and emotion;

 Observe courtesy at all times to the patient and to all the members of the health care team;

 Establish rapport and promote cooperation through nurse-patient interaction;

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INTRODUCTION

Living creatures are made up of cell. The adult body normally forms new cells only when

they are needed to replace old or damaged ones. Infants and children create new cells to

complete their development in addition to those needed for repair. A tumor develops when they

are not needed.

A brain tumor is a mass of unnecessary cells growing in the brain or central spine canal.

There are two basic kinds of brain tumors - primary brain tumors and metastatic brain tumors.

Primary brain tumors start and end to stay, in the brain. Metastatic brain tumors begin as cancer

elsewhere in the body and spread to the brain.

When doctors describe brain tumors, they often use the words, “benign”, or “malignant.”

Those descriptions refer to the degree of malignancy or aggressiveness of a brain tumor. It is not

always easy to classify brain tumors as “benign” or “malignant” as many factors other than

pathological features contribute to the outcome.

A tumor that starts in the brain is a primary brain tumor. Primary brain tumors are

grouped into benign tumors and malignant tumors.

A benign brain tumor consists of very slow-growing cells, usually has distinct borders

and rarely spreads. When viewed under a microscope, these cells have an almost normal

appearance. Surgery alone might be an effective treatment for this type of tumor. A brain tumor

is composed of benign cells but located in a vital area, can be considered life-threatening –

although the tumor and its cells would not be classified as malignant.
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A malignant brain tumor is usually rapid-growing, invasive and life-threatening.

Malignant brain tumors are sometimes called brain cancer. However, since primary brain tumors

rarely spread outside the brain and spinal cord, they do not exactly fit the general definition of

cancer. Malignant brain tumors that are cancerous can spread within the brain and spine. They

rarely spread to other parts of the body. They lack distinct borders due to their tendency to send

“roots” into nearby normal tissue. They can also shed cells that travel to distant parts of the brain

and spine by way of cerebrospinal fluid. Some malignant tumors, however, do remain localized

to a region of the brain or spinal cord.

Cancer cells that begin growing elsewhere in the body and then travel to the brain form

metastatic brain tumors. For example, cancers of the lung, breast, colon, and skin(melanoma)

frequently spread to the brain via the bloodstream or a magnetic-like attraction to other organs of

the body. All metastatic brain tumors are, by definition, malignant and can truly be called, “brain

cancer.”

INCIDENCE RATE:

Brain and other nervous system cancer is the 10th leading cause of death for men and

women. It is estimated that 17,760 adults (9,910 men and 7,850 women) will die from primary

cancerous brain and CNS tumors this year.

A primary brain or spinal cord tumor is a tumor that starts in the brain or spinal cord.

This year, an estimated 23,820 adults (13,410 men and 10,410 women) in the United States will

be diagnosed with primary cancerous tumors of the brain and spinal cord. Brain tumors account

for 85% to 90% of all primary CNS tumors.

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The 5-year survival rate tells you what percent of people live at least 5 years after the

tumor is found. Percent means how many out of 100. The 5-year survival rate for people with a

cancerous brain or CNS tumor is approximately 34% for men and 36% for women. However,

survival rates vary widely and depend on several factors, including the type of brain or spinal

cord tumor (https://www.cancer.net/cancer-types/brain-tumor/statistics; Date Retrieved:

03/2019).

In the Philippines between the year 2010 and 2015, a total of 262 medical records of

adult patients with brain tumor were successful retrieved.

RISK FACTORS:

Age. Brain tumors are more common in older adults, although people of any age can develop a

brain tumor.

Gender. In general, men are more likely than women to develop a brain tumor. However, some

specific types of brain tumors, such as meningioma, are more common in women.

Home and Work Exposures. Exposure to solvents, rubber, or vinyl chloride may increase the

risk of developing a brain tumor. However, there is not yet scientific evidence that supports this

possible link.

Family History. About 5% of brain tumors may be linked to hereditary genetic factors or

conditions, including Li-Fraumeni syndrome, neurofibromatosis, nevoid basal cell carcinoma

syndrome, tuberous sclerosis, Turcot syndrome, and von Hippel-Lindau syndrome. Scientists

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have also found “clusters” of brain tumors within some families without a link to these known

hereditary conditions. Studies are underway to try to find a cause for these clusters.

Infection with the Epstein-Barr virus(EBV) increases the risk of CNS lymphoma. EBV is

more commonly known as the virus that causes mononucleosis or “mono”. In other research,

high levels of a common virus called cytomegalovirus(CMV) have been found in brain tumor

tissue. The meaning of this finding is being researched. Several types of other viruses have been

shown to cause brain tumors in research on animals. More data are needed to find out if exposure

to infections, other viruses, or allergens increase the risk of a brain tumor in people. Of note,

studies have shown in patients with a history of allergies or skin conditions have a lower risk of

glioma.

Electromagnetic Field. Most studies evaluating the role of electromagnetic fields, such as

energy from power lines or from cell phone use, show no link to an increased risk developing a

brain tumor in adults. Because of conflicting information regarding risk in children, the World

Health Organization(WHO) recommends limiting cell phone use and promotes the use of a

hands-free tablet for both adults and children.

Race and Ethnicity. In the United States, white people are more likely to develop meningioma

than black people. Also, people from northern Europe are more than twice as likely to develop a

brain tumor as people in Japan.

Ionizing Radiation. Previous treatment to the brain or head with ionizing radiation, including x-

rays, has been shown to be a risk factor for a brain tumor.

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Head Injury or Seizures. Serious head trauma has long been studied for its relationship to brain

tumors. Some studies have shown a link between head trauma and glioma. A history of seizures

has also been linked to brain tumors, but because a brain tumor can cause seizures, it is not

known if seizures increase the risk of brain tumors, if seizures occur because of the tumor, or if

anti-seizure medication increases the risk.

N-nitroso compounds. Some studies of diet of vitamin supplementation seem to indicate that

dietary N-nitroso compounds may increase the risk of both childhood and adult brain tumors.

Dietary N-nitroso compounds are formed in the body from nitrites or nitrates found in some

cured meat, cigarette smoke, and cosmetics. However, additional research is necessary before a

definitive link can be established.

CLINICAL MANIFESTATIONS:

Symptoms of a brain tumor can be general or specific. A general symptom is caused by

the pressure of the tumor on the brain or spinal cord. Specific symptoms are caused when a

specific part of the brain is not working well because of the tumor. For many people with a brain

tumor, they were diagnosed when they went to the doctor after experiencing a problem, such as a

headache or other changes.

General symptoms include:

Headaches, which may be severe and worsen with activity or in the early morning.

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Seizures. People may experience different types of seizures. Certain drugs can help prevent or

control them. Motor seizures, also called convulsions, are sudden involuntary movements of a

person’ muscles.

Personality and memory changes

Nausea, Fatigue, Drowsiness

Sleep problems, Memory problems

Changes in ability to walk or perform daily activities

Symptoms that may be specific to the location of the tumor include:

Pressure or headache near the tumor

Loss of balance and difficulty with fine motor skills

Changes in judgment, including loss of initiative, sluggishness, and muscle weakness or

paralysis is associated with a tumor in the frontal lobe of the cerebellum.

Partial or complete loss of vision is caused by the tumor in the occipital lobe or temporal lobe of

the cerebrum.

Changes in speech, hearing, memory, or emotional state, such as aggressiveness and problems

understanding or retrieving words can develop from a tumor in the frontal and temporal lobe of

the cerebrum.

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Altered perception of tough or pressure, arm or leg weakness on 1 side of the body, or confusion

with left and right sides of the body are linked to a tumor in the frontal or parietal lobe of the

cerebrum.

Inability to look upward can be caused by a pineal gland tumor.

Lactation, which is the secretion of breast milk, and altered menstrual periods in women, and

growth in hands and feet in adults are linked with a pituitary tumor.

Difficulty in swallowing, facial weakness or numbness, or double vision is a symptom of a tumor

in the temporal lobe, occipital lobe, or brain stem.

COMPLICATIONS:

Serious and sometimes life-threatening complications can develop with brain cancer.

 The obstructed flow of cerebrospinal fluid from the third ventricle may cause sudden death.

 A cerebral hernia is a progressive, fatal condition in which the brain is forced through an

opening in the skull.

 Hemorrhagic stroke produces a sudden loss of vision and/or speech, unconsciousness, and

paralysis

DIAGNOSTIC EVALUATIONS:

MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can

be used to measure the tumor’s size. A special dye called a contrast medium is given before the

scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill or
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liquid to swallow. MRIs create more detailed pictures than CT scans and are the preferred way to

diagnose a brain tumor. The MRI may be of the brain, spinal cord, or both, depending on the

type of tumor suspected and the likelihood that it will spread in the CNS. There are different

types of MRI. The results of a neuro-examination, done by the internist or neurologist, help

determine which type of MRI to use.

Tissue Sampling/Biopsy/Surgical Removal of a Tumor. A sample of the tumors tissue is

usually needed for the final diagnosis. A biopsy is the removal of a small amount of tissue for

examination under a microscope and is the only definitive way a brain tumor can be diagnosed.

A pathologist then analyzes the sample/s. A pathologist is a doctor who specializes in

interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose a disease. A

biopsy can be done as part of the surgery to remove the entire tumor. Or surgery may be done as

a separate procedure if completely removing the tumor is not possible because of its location or a

patient’s health.

CT Scan. A CT scan takes pictures of the inside of the body using x-rays taken from different

angles. A computer combines these pictures into a detailed 3-dimensional image that shows any

abnormalities or tumors. A CT scan can help find bleeding and enlargement of the fluid-filled

spaces in the brain, called ventricles. Changes to the bone in the skull can also be seen on a CT

scan, and it can be used to measure a tumor’s size. A CT scan may also be used if the patient

cannot have an MRI, such as if the person has a pacemaker for his or her heart. Sometimes, a

contrast medium is given before the scan to provide better detail on the image. This dye can be

injected into a patient’s vein or given as a pill or a liquid to swallow.

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Positron Emission Tomography (PET) or PET-CT Scan. A PET scan is used at first to find

out more about a tumor while a patient is receiving treatment. It may also be used if the tumor

comes back after treatment. A PET scan is usually combined with a CT scan, called a PET-CT

scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan

is a way to create pictures of organs and tissues inside the body using various substances, such as

sugars or proteins. A small amount of a radioactive substance is injected into the patient’s body.

This substance is taken up by cells that are actively dividing. Because tumor cells are more likely

to be actively dividing, they absorb more of the radioactive substance. A scanner then detects

this substance to produce images of the inside of the body.

Cerebral Arteriogram, also called Cerebral Angiogram. A cerebral arteriogram is an x-ray,

or a series of x-rays, of the head that shows the arteries of the brain. X-ray are taken after special

dye called a contrast medium is injected into the main arteries of the patient’s head.

Lumbar Puncture or Spinal Tap. A lumbar puncture is a procedure in which a needle is used

to take a sample of cerebrospinal fluid(CSF) to look for tumor cells, blood or tumor markers.

Tumor markers or biomarkers are substance found in higher than normal amounts in the blood,

urine, spinal fluid, plasma or other bodily fluids of people with certain types of tumors. Typically,

a local anesthetic is given to numb the patient’s lower back before the procedure.

Myelogram. The doctor may recommend a myelogram to find out if a tumor has spread to the

spinal fluid, or other parts of the brain, or the spinal cord. A myelogram uses a day injected into

the CSF that surrounds the spinal cord. The dye shows up on an x-ray and can outline the spinal

cord to help the doctor look for a tumor. This is rarely done; a lumbar puncture is more common.
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Molecular Testing of the Tumor. Your doctor may recommend running laboratory tests on a

tumor sample to identify specific genes, proteins, and other factors, such as tumor markers,

unique to the tumor. Some biomarkers may help the doctors determine a patient’s prognosis,

which is the chance of recovery.

Neurological, Vision, and Hearing Tests. These tests help determine if a tumor is affecting

how the brain functions. An eye examination can detect the changes to the optic nerve, as well as

changes to a person’s field of vision.

Neurocognitive Assessment. This consists of a detailed assessment of all major functions of the

brain, such as storage and retrieval of memory, expressive and receptive language abilities,

calculation, dexterity, and the overall well-being of the patient. These tests are done by a licensed

clinical neuropsychologist. This specialist will write a formal report to compare with future

assessments or identify specific problems that can be helped through treatment.

Electroencephalography(EEG). An EEG is a non-invasive test in which electrodes are attached

to the outside of a person’s head to measure the electric activity of the brain. It is used to monitor

for possible seizures.

Evoked Potentials. Evoked potentials involve the use of electrodes to measure the electric

activity of nerves and can often detect acoustic schwannoma, a non-cancerous brain tumor. This

test can be used as a guide when removing a tumor that is growing around the important nerves.

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MEDICAL MANAGEMENT:

Chemotherapy. It is the use of one drug or a combination of drugs to kill cancer cells. In

malignant brain tumors, chemotherapy is typically used after surgery to kill any remaining

cancer cells. In malignant brain tumors, chemotherapy is typically used after surgery. The

chemotherapy used to treat cancer depends on the type and stage of cancer. Chemotherapy is

given in an outpatient setting. It can sometimes be taken by mouth or maybe given intravenously.

Corticosteroids. These are used to lower swelling in the brain, which can lessen the pain from

swelling without the need for prescription pain medications. These drugs may also help improve

neurological symptoms by decreasing the pressure from the tumor and swelling in the healthy

brain tissue.

Anti-Seizure Medicines. These help control seizures, and there are several types of drugs

available. They are prescribed by your neurologist.

SURGICAL MANAGEMENT:

Biopsy. It is a surgical procedure done to remove a small sample of small brain tissue for

examination under a microscope. It is usually performed at the same time as the surgery to

remove a brain tumor. A biopsy can be performed as a separate procedure if the tumor cannot be

removed without damaging critical parts of the brain or the patient is a surgical candidate.

Extended Bifrontal Craniotomy. It is a traditional skull base approach used to target difficult

tumors towards the front of the brain. It is based on the concept that it is safer to remove extra

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bone than to unnecessarily manipulate the brain. The extended bifrontal craniotomy involves

making an incision in the scalp behind the hairline and removing the bone that forms the contour

of the orbits and the forehead. This bone is replaced at the end of the surgery. Temporarily

removing the bone allows surgeons to work in the space between and right behind the eyes

without having to unnecessarily manipulate the brain.

Supra-Orbital or Eyebrow Craniotomy. In this procedure, neurosurgeons make a small

incision within the eyebrow to access tumors in the front of the brain or around the pituitary

gland. This approach is used instead of endonasal endoscopic surgery when a tumor is very large

or close to the optic nerve or vital arteries.

Retro-Sigmoid or Keyhole Craniotomy. It is a minimally-invasive surgical procedure

performed to remove brain tumors. This procedure allows for the removal of skull base tumors

through a small incision behind the ear, providing access to the cerebellum and brainstem.

Neurosurgeons may use this approach to reach certain tumors, such as meningiomas and acoustic

neuromas(vestibular schwannomas).

Orbitozygomatic Craniotomy. It is a traditional skull base approach used to target difficult

tumors and aneurysms. It is based on the concept that it is safer to remove extra bone than to

unnecessarily manipulate the brain. The orbitozygomatic surgery involves making an incision in

the scalp behind the hairline and removing the bone that forms the contour of the orbit and cheek.

This bone is replaced at the end of the surgery. Temporarily removing this bone allows the

surgeon to reach deeper and difficult parts of the brain while minimizing severe damage to the

brain.
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Translabyrinthine Craniotomy. It is a procedure that involves making an incision in the scalp

behind the ear, then removing the mastoid bone and some of the inner ear bone (specifically the

semicircular canals which contain receptors for balance). The surgeon then finds and removes

the tumor or as much of the tumor as possible without the risk of severe damage to the brain.

MRI – Guided Laser Ablation. It is a minimally-invasive neurosurgical technique for a number

of diseases, including brain tumors. The treatment uses lasers to target and destroy the tumor.

The procedure can help surgeons address the most serious brain tumors, including glioblastoma

multiforme(GBM) and brain tumors that are located close to sensitive structures in the brain,

making them hard to access through traditional open surgery (craniotomy). MRI-guided laser

ablation can reduce pain after surgery and shorten recovery time compared to that associated

with craniotomy.

Neuroendoscopy. It is a minimally-invasive surgical procedure in which the neurosurgeon

removes the tumor through small holes (about the size of a dime) in the skull or through the

mouth or nose. Neuroendoscopy enables the surgeons to access areas of the brain that cannot be

reached with traditional surgery and to remove the tumor without cutting or harming the other

parts of the skull. It is performed using an endoscope, a small telescope-like device equipped

with a high-resolution video camera and eyepiece on the end to allow the neurosurgeon to

navigate and access the tumor.

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ANATOMY AND PHYSIOLOGY

The brain is an amazing three-pound organ that controls all functions of the body,

interprets information from the outside world, and embodies the essence of the mind and soul.

Intelligence, creativity, emotion, and memory are a few of the many things governed by the

brain. Protected within the skull, the brain is composed of the cerebrum, cerebellum, and

brainstem.

The brain receives information through our five senses: sight, smell, touch, taste, and hearing -

often many at one time. It assembles the messages in a way that has meaning for us and can store

that information in our memory. The brain controls our thoughts, memory and speech, movement

of the arms and legs, and the function of many organs within our body.

The central nervous system (CNS) is composed of the brain and spinal cord. The peripheral

nervous system (PNS) is composed of spinal nerves that branch from the spinal cord and cranial

nerves that branch from the brain.

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The brain has three main parts: the cerebrum,

cerebellum, and brainstem.

Cerebrum: is the largest part of the brain and is

composed of the right and left hemispheres. It

performs higher functions like interpreting touch,

vision, and hearing, as well as speech, reasoning,

emotions, learning, and fine control of movement.

Cerebellum: is located under the cerebrum. Its

function is to coordinate muscle movements,

maintain posture, and balance.

Brainstem: acts as a relay center connecting the

cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as

breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing,

vomiting, and swallowing.

Right brain – left the brain

The cerebrum is divided into two halves: the right and left

hemispheres. They are joined by a bundle of fibers called the

corpus callosum that transmits messages from one side to the

other. Each hemisphere controls the opposite side of the

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body. If a stroke occurs on the right side of the brain, your left arm or leg may be weak or

paralyzed.

Not all functions of the hemispheres are shared. In general, the left hemisphere controls speech,

comprehension, arithmetic, and writing. The right hemisphere controls creativity, spatial ability,

artistic, and musical skills. The left hemisphere is dominant in hand use and language in about

92% of people.

Lobes of the brain

The cerebral hemispheres have distinct fissures,

which divide the brain into lobes. Each

hemisphere has 4 lobes: frontal, temporal, parietal,

and occipital. Each lobe may be divided, once

again, into areas that serve very specific functions.

It’s important to understand that each lobe of the

brain does not function alone. There are very

complex relationships between the lobes of the

brain and between the right and left hemispheres.

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Frontal lobe

 Personality, behavior, emotions

 Judgment, planning, problem-solving

 Speech: speaking and writing (Broca’s area)

 Body movement (motor strip)

 Intelligence, concentration, self-awareness

Parietal lobe

 Interprets language, words

 Sense of touch, pain, temperature (sensory strip)

 Interprets signals from vision, hearing, motor, sensory and memory

 Spatial and visual perception

Occipital lobe

 Interprets vision (color, light, movement)

Temporal lobe

 Understanding language (Wernicke’s area)

 Memory

 Hearing

 Sequencing and organization

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Skull

The purpose of the bony skull is to protect the brain from injury. The skull is formed from 8

bones that fuse together along suture lines. These bones include the frontal, parietal (2), temporal

(2), sphenoid, occipital and ethmoid. The face is formed from 14 paired bones including the

maxilla, zygoma, nasal, palatine, lacrimal, inferior nasal conchae, mandible, and vomer.

The brain is protected inside the skull. The skull is formed from eight bones.

Inside the skull are three distinct areas: anterior fossa, middle fossa, and posterior fossa (Fig. 9).

Doctors sometimes refer to a tumor’s location by these terms, e.g., middle fossa meningioma.

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Number Name Function

A view of the cranial nerves at the base of the skull with the brain removed. Cranial nerves

originate from the brainstem, exit the skull through holes called foramina, and travel to the parts

of the body they innervate. The brainstem exits the skull through the foramen magnum. The base

of the skull is divided into 3 regions: anterior, middle and posterior fossae.

Similar to cables coming out the back of a computer, all the arteries, veins, and nerves exit the

base of the skull through holes, called foramina. The big hole in the middle (foramen magnum) is

where the spinal cord exits.

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Cranial nerves
I Olfactory Smell

The brain communicates with the body through

II Optic Sight
the spinal cord and twelve pairs of cranial

nerves (Fig. 9). Ten of the twelve pairs of III Oculomotor moves eye, pupil
cranial nerves that control hearing, eye

movement, facial sensations, taste, swallowing IV Trochlear moves eye

and movement of the face, neck, shoulder and

V Trigeminal face sensation
tongue muscles originate in the brainstem. The

cranial nerves for smell and vision originate in

VI Abducens moves eye
the cerebrum.

VII Facial moves face, salivate

The Roman numeral, name, and main function

of the twelve cranial nerves:

VIII vestibulocochlear hearing, balance

IX glossopharyngeal taste, swallow

X Vagus heart rate, digestion

XI Accessory moves head

XII Hypoglossal moves tongue

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HEALTH ASSESSMENT

Demographic data

Name: A.Q.S

Age: 49 years old

Birth Date: Oct. 24, 1969

Birt Place: Kalibo, Aklan

Gender: Male

Height: 5’6

Weight: 56 kgs

Marital Status: Married

Current Address: Santan Road, Andagao, Kalibo, Aklan

Nationality/Race: Filipino

Religion: Jehovah’s Witness

Educational Attainment: High school Graduate

Occupation: Tricycle Driver

Monthly Family Income: 20,000

Admitting Physician: Dr. MGT S. S

Attending Physician: Dr. MGT S. S

Date and time of Admission: August 29, 2019, at 11:10 am

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Chief Complaint: “gasinakit anang eawas ag gapanghina imaw dina na makaya” as verbalized
by the wife

Admitting Vital Signs:

Temperature – 36.4ºC/axilla Pulse Rate- 106 bpm

RR – 26 cpm BP- 100/70mm/Hg

O2 Sat-96%

Informant

Primary: None

Secondary: Wife

Other Sources: Client’s Chart

Admitting Diagnosis: Soft tissue mass (L) Fronto Temporal Area, Stage IV

History of Present Illness

According to the patient’s wife, her husband works as a tricycle driver, every day he

drives us together with our daughter to my work and her school. Before he was diagnosed, he

often experiences having dizziness and body malaise when picking passengers with his tricycle,

however, he ignored all those symptoms and takes over the counter drugs like paracetamol,

alaxan, mefenamic, planax to relieve the pain every after a meal.

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On April 2019 Mr. A.Q.S complained to his wife of body malaise and felt that the lump

on his left occipital part of his head is getting bigger, so they decided to have a check-up at

MMG and after series of tests, the doctor referred to consult either at Ilo-Ilo or Manila for further

evaluation. They decided to go to PGH at Manila, from there another series of tests was done to

him while waiting for the results he stayed at his brother’s home and according to his wife he

urinated blood, and after 2 months she decided to go back home.

On July 6, he was admitted at PHCand after the doctor read his results, in there he was

diagnosed with Brain Cancer with right-sided paralysis and after 6 days he was discharged with

pain medications to take.

On August 29, 2019, while he was at home in Adagaohe complaints of severe pain

especially in his head, so his wife decided to call MDDRMO to take them to DRSTMH via

ambulance. When they arrived at the Emergency room at around 11:00 a.m. they gave Mr. A.Q.S

Paracetamol IM for his pain he underwent a thorough examination and was admitted by Dr.S.

Past Health History

Immunization

The patient’s wife does not have any idea if his husband is completely immunized.

Childhood Illness

“uwa ako ka syod kung ano ang ana mga masakitdati” as verbalized by his wife

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Allergies

According to his wife, the patient is allergic to dried fish

Medication

The patient's wife claimed that whenever his husband gets a common illness like cough,

fever, and colds she just takes over the counter drugs such as Biogesic 500 mg, Mefenamic acid

500 mg, and Neozep tablet.

Previous Hospitalization

According to his wife when his husband did a check-up at Medway, they found out that

there was a mass on his lung, he was admitted by then, however, no biopsy was done and the

doctor only gave medications for 6 months for him to take.

Surgeries

Patient’s wife reports no history of surgery.

Serious Injuries or Accidents

Patient wife reports no history of serious injury and accidents.

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Family Genogram

Mr. M.Q.S
80 yrs. old Mrs. S.P.Q
Alive and Hypertensive

Mr. A.Q.S Mr. L.Q.S Mr. A.Q.S Mr. Ms. A.Q.S Mr.
55yrs.oldALIVE 53yrs.oldALIVE 50yrs.oldALIVE A.Q.S49yrs.oldP 46yrs.oldALIVE R.Q.S44yrs.oldAL
AND WELL AND WELL AND WELL ATIENT AND WELL IVE AND WELL

Mrs. A.P.S 45
yrs. Old Alive
and WELL

Mr. RJ.P.S 26 Mr. R.P.S 25 Ms. A.P.S 19 Ms. A.P.S 8

yrs.oldALIVE AND WELL yrs.oldALIVE AND WELL yrs.oldALIVE AND WELL yrs.oldALIVE AND WELL

Legend:

Patient’s Parents

Patient’s Siblings

Patient

Patient’s Wife

Patient’s Children

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Mr. A.Q.S’sparents are married with 6 children. His father Mr. M.Q.S80 years old alive

and well, her mother Mrs. R.P.Qdeceased. Our patient Mr. A.Q.S is the 4th child among the

siblings. He has4 children. His 1st child isMr. RJ.P.S 26 years old alive and well. His 2nd child,

Mr. R.P.S,25 years old is alive and well, his 3rdchild Ms. A.P.S 19 years old is alive and well,

and youngest Ms. A.Q.S years old is alive and well. His siblings, Mr. A.Q.S 55 years, Mr. L.Q.S

53 years old, Mr. A.Q.S 50 years old, Ms. A.Q.S 46 years old, and Mr. R.Q.S 44 years old are

alive and well.

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PSYCHOSOCIAL HISTORY

Health Beliefs and Practices

The patient’s wife claimed that they don’t believe in traditional healers like “albularyo”

but whenever they get sick they usually seek medical help to the doctor.

Sleep and Rest Pattern

According to the patient’s wife he usually sleeps at around 1 A.M and wakes up at 4 A.M

every morning. He also takes a nap at noon for 2 hours

Elimination Pattern

He defecates every day to a brownish, well-formed stool and voids more than 4-5 times a

day and his urine is yellowish in color.

Activities of Daily Living

Patient’s wife stated before his husband was diagnosed, during weekdays Mr. A.Q.S

usually wakes up at 4 am. He takes his breakfast by having coffee and porridge before dropping

off his wife at work via tricycle he will then do his routine route at Kalibo to drive and pick up

some passengers, then at lunchtime, he will pick up his 2 children at school before going home to

take their lunch. He will then take a few minutes nap when he gets enough rest he will then drop

off his children at school then do his routine route again at Kalibo. he will drop Then at around

8am to 9am, he will start to drive his tricycle to pick up passengers. In the evening, they usually

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eat dinner together and before he sleeps he will read his bible every night. Sometimes when his

eldest child works too late he picks her up from work.

Nutritional Pattern

The patient eats regularly three times a day. According to his wife, his breakfast consists

of coffee and porridge while during lunch and dinner he eats fish and vegetable. He also

consumes fruits like banana, mango, orange or any available fruits in his house. He prefers to

drink soda than water.

Role/Relationship Pattern

Mr.A.Q.S lives with his wife and 4 children. They have a good relationship and

communication with each other. He seeks advice from his wife when it comes to decision

making but he has the final decision

Sexuality Pattern

“ Kouwa pa imawsakit hay, mgatatlobesessaisangdumingo”. as verbalized by his wife.

Values and Belief Pattern

Mr. A.Q.S is a devoted Jehovah’s Witnesses. He is one of the shepherds in their church.

Every Saturday he goes to people’s houses with his wife to spread the word of their religion and

during Sunday’s and Thursday he goes to church with his family.

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Social History

He has a good relationship with his neighbors.

REVIEW OF SYSTEM

General Survey

On August 30, 2019, at 7 am received patient a 49-year-old male lying on bed not on

respiratory distress, he appears weak and restless wearing black undershirt, on diapers and black

shocks with IVF of PNSS 1L X 60cc per hour @ left cephalic vein infusing well with GCS 12.

Vital signs were as follow:

T: 36.4 ºC/axilla. CR: 106 bpm

RR: 26 cpm BP: 100/70 mmHg

INTEGUMENT

Skin

 Skin is brown in color, smooth and warm to touch.

 Presence of mole in right arm and chest area.

 He uses soap for his skincare and takes a bath every day before he was diagnosed, he

hasn’t bathed since that day.

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Hair

 Hair is black in color and evenly distributed covering the whole scalp

 Hair is curly, dry and presence of dandruff

 Present of mass in the left side of his scalp during inspection and palpation.

Nails

 Fingernails are trimmed upon inspection.

 Nail beds are pale pink in color without clubbing.

 Has a good capillary refill that returns in 2 seconds.

Head

 Head is oval in shape

 Presence of mustache and beard.

 No presence of pimples, wrinkles, and scars

 Mass felt in left side of his head upon palpation.

 Not able to turn head from left to right with or without resistance.

Eyes

 Eyes are symmetric, outer canthus of the eye is aligned to the auricles.

 Eyebrows are black in color and fairly distributed.

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 Eyelashes appeared to be equally distributed and curled slightly outward.

 Eyelids have no presence of discharges or discoloration and close symmetrically.

 The sclera is clear, the iris is black in color flat and round.

 Pupils are equally round and reactive to light and accommodation.

 Not able to perform 6 cardinal eye movements.

Ears

 Ears are symmetric; auricles are aligned at the outer canthus of the eyes.

 Pinna recoils when folded.

 No mass and tenderness upon palpation.

 Left is able to hear the clicking sound of a pen 2 feet away from him.

 Cleans his ears once a week.

Nose and sinuses

 The nose is intact, aligned, symmetrical without discharge or redness.

 Both nares are patent.

 No tenderness upon palpation on sinuses.

Mouth and Pharynx

 Teeth are incomplete; 2 lower right molar and 1 upper left molar extracted.

 Lips are dry and dark in color.

 The uvula is intact and hangs in the midline.

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 Brushes his teeth once a day.

Neck

 The neck is in the midline and has the same color as the body.

 Not able to perform a full range of motion (ROM).

 No masses, swelling, and venous distention observed.

 The trachea is in the midline.

Breast and Axilla

 The areola is dark brown in color nipple is everted.

 No palpable lumps and lesions upon palpation and inspection.

 Axilla has presence of hair, no lesion, masses, and rashes present.

Lungs

 Respiration is 26 cpm no use of accessory muscle upon breathing.

 No crackles or abnormal sounds heard upon auscultation.

 Does not smoke or use tobacco.

Heart

 No jugular distention observed.

 No mass and tenderness with palpation on heart landmarks

 Heartbeats 106 bpm.

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Gastrointestinal

 The abdomen is round in shape.

 The umbilicus is in the midline and inverted.

 Patient eliminates to every other day to brown well-formed stool

 Abdominal distention upon inspection ( 36 cm).

Peripheral vascular

 Arms are equal in size, no swelling, and no clubbing of fingernails.

 Capillary refill time less than 2 seconds.

 Legs are warm to touch bilaterally and no ulcers or edema noted.

 No apparent varicosities or superficial thrombophlebitis noted.

 Right upper and lower extremities were paralyzed.

 Left-arm and legs are slightly weak.

Genitourinary

 No history of reproductive disease or disorders claim by the patient wife

 The patient consumes 4 diapers a day.

 The patient’s wife claims that her husband has presence of pubic hair

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Musculoskeletal

 Patient has right sided paralysis

 Symmetrical muscles on the both sides of the body.

Neurologic

 GCS 13 (E4, V3, M5), Confused with time, place and person.

 He is barely cooperative and attentive all throughout the assessment.

 Not able to answer concretely all questions being asked.

CRANIAL NERVES

CRANIAL NERVES RESULT

Not able to identifies the smell of calamanci
Cranial Nerve – I (Olfactory)
and vinegar.
The patient was not able to read printed
Crania Nerve – II (Optic )
writing held at a distance of 12 inches.
Intact. Pupils equally round and reactive to
Cranial Nerve – III,IV& VI (Oculomotor,
light and accommodation, not able to perform
Trochlear, and Abducens)
6 cardinal eye movements.
Able to sense and distinguish the point of
Cranial Nerve – V (Trigeminal Nerve)
pencil only on cheeks, left arm, and left leg.
The patient is not able to follow the
Cranial Nerve – VII (Facial) instruction to smile, frown, wrinkle the
forehead, show teeth, puff out cheeks, pursed

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lips, raise eyebrows, and close eyes against

resistance.
Cranial Nerve – VIII (Acoustic nerve) Able to hear clicking sounds of a pen.
Cranial Nerve IX and X (Glossopharyngeal
Intact. The patient is able to swallow.
&Vagus)
The patient was not able to shrug shoulders
Cranial Nerve XI (Accessory Nerve)
but able to nod his head to the up and down.
The patient is not able to follow instruction to
move his tongue side to side and protrude.
Cranial Nerve XII (Hypoglossal)

Sensory Function Test

 Mr. A.Q.S was able to feel touch, pain, and temperature only on his head and left
side of his body.
 The patient was not able to follow the 6 cardinal eye movements.
 The patient was barely able to identify the shapes and letters drawn in his hand.

Glasgow Coma Scale

Response
6- Obeys command fully

5- Localizes pain

4- Withdraws from pain

I.MOTOR RESPONSE 5 ( Localizes pain)
3-Abnormalflexion
(decorticate)

2-Extensor response
(decerebrate)

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1- No response
5- Alert and oriented

4- Confused, yet coherent

speech
II. VERBAL RESPONSE
3- Inappropriate words 3 (Inappropriate words)

2- Incomprehensible sounds

1- No sounds

4- Spontaneous eye-opening

II. EYE OPENING 3- Eyes open to speech

4 (Spontaneous eye-
opening)
2- Eyes open to pain

1- No eye-opening
Score: 12

DIAGNOSTIC/LABORATORY TEST

Laboratory Test#1: Hematology

Indication: To evaluate the characteristics of blood components.

Date Performed: August 29, 2019

Test Result Normal Values Significance

Hemoglobin 129 g/L 120-160 g/L Normal

Hematocrit 0.38 Vol. fr 0.41-0.47 Vol. fr Slightly decrease, due

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tobrain tumor

Red Blood cell 3.80 L 4.60-6.20 x1012/L Decrease, due to

presence of brain
tumor

White blood cell 14.0 4.50-11.00 x1012/L Increase, due to

infection

Neutrophil 0.81 0.36-0.68 Increase, due to

infection

Segmenter 0.81 Normal

Lymphocyte 0.19 0.24-0.44 Decrease, due to

presence of brain
tumor

Laboratory Test#2: Ultrasound

Indication: To evaluate kidneys, liver, gallbladder, pancreas, spleen and abdominal aorta.

Date Performed: July 9,2019

WHOLE ABDOMEN ULTRASOUND

The liver is enlarged with a craniocaudal span of 16cm, increased parenchymal echogenicity

with heterogeneous echopattern. There are multiple hypoechoic and cystic nodules with

peripheral hypodensity in the right and left hepatic lobe. There are also cystic nodules with thin

walls largest in the right measuring 2.6 x 2.4 cm and largest in the left is 2.0x 2.0 cm. There is a

solid nodule with peripheral hypodensity at the left hepatic lobe measuring 1.4 x 1.0 cm. The

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common bile duct and intrahepatic ducts are not dilated the former measuring 0.5 cm. The

gallbladder is not visualized, probably contracted.

The intrahepatic vessels and inferior vena cava are unremarkable.

There is no fluid noted at the Morison’s pouch.

Pancreas and spleen are normal in size and tissue echogenicity. No focal lesion is seen.

Both kidneys are normal in sizes with increased parenchymal echogenicity with fairly defined

corticomedullary demarcations. The central echo complexes are intact.

Right kidney measures 9.4 x 4.9 x 5.0 x 1.6 cm (Lx AP x W x Cortical Thickness).

There are multiple cystic foci noted, largest measuring 2.2 x 1.7 cm at the superior pole.

Left kidney measures 10.6 x 6.0 x 5.5 x 1.4cm (L x AP x W x Cortical Thickness)

There are multiple high-intensity echoes noted, largest measuring 0.7 cm at the inferior pole.

Ureters are not delineated sonographically.

The urinary bladder is well distended with smooth walls. No intraluminal echoes noted.

The prostate gland is normal in size and measures 2.3 x 3.9 cm (L x W x AP) with an

approximate weight

Of 18.3 grams. Prostatic capsule is intact. No focal lesions are seen.

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Negative for ascites.

IMPRESSIONS:

 ENLARGED LIVER WITH DIFFUSE PARENCHYMAL DISEASE

 T/C SIMPLE HEPATIC CYST, CYST METASTASES, AND SOLID METASTATIC

NODULES

 NON-VISUALIZED GALLBLADDER, PROBABLY CONTRACTED

 DIFFUSE RENAL PARENCHYMAL DISEASE, BILATERAL

 SIMPLE RENAL CYSTS, RIGHT

 NON-OBSTRUCTING NEPHROLITHIASIS, LEFT

 SONOGRAPHICALLY NORMAL COMMON BILE DUCT, PANCREAS, SPLEEN,

URINARY BLADDER

AND PROSTATE GLAND

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Laboratory Test#3: Ultrasound

Indication: To assess tumor masses

Date Performed: May 1, 2019

MASS ULTRASOUND

A well-defined hypoechoic complex-predominantly solid soft tissue mass is observed at the left

Parieto-temporal measuring approx. 8.72cm x 2.53cm.

Incidental note of focal destruction (approx. 1.35 cm) of the outer table, Parieto- Temporal bone.

IMPRESSION:

COMPLEX- PREDOMINANTLY SOLID TISSUE MASS, LEFT PARIETO- TEMPORAL

AREA

FOCAL DESTRUCTION, OUTER TABLE, LEFT PARIETO- TEMPORAL BONE.

Laboratory Test#4: Radiology

Indication: To assess cardiopulmonary disease

Date Performed: August 29, 2019

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ROENTOLOGICAL REPORT

There are suspicious densities in the periphery of the right upper lung.

The heart is normal in size.

The aorta is prominent.

Both hemidiaphragm, costophrenic sulci, and visualized bones are intact.

IMPRESSION:

Suspicious densities, periphery of the right upper lung. Spot view of the right upper lung

is suggested for further evaluation.

Prominent aorta.

Laboratory Test#5: MRI of the Brain without Contrast

Indication: To assess the inner structure of the brain and tumors.

Date Performed: June 17, 2019

Clinical Information: a 5-month history of an enlarging left parietal mass. S/P punch biopsy of a

left nasopharyngeal mass showing non-keratinizing squamous cell CA (05/20/19)

Findings:

Correlation is made with the CT 05/07/19, done at an outside institution.

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There is an expansile causing extensive cortical destruction of the left parietal and occipital

bones, with an enhancing multiseptated, multiloculated soft tissue component, measuring 9.1 x

5.2 x 9.7 cm (AP/T/CC). The intracranial component appears predominantly extradural, although

there are small portions of the dura that are equivocal for dehiscence. There is moderate

comprehension of the adjacent parietal and posterior temporal lobes and left cerebellar

hemisphere, with no evident edema or abnormal parenchymal enhancement. There is resultant

compression of the left lateral ventricle and left to right midline shift of about 6 mm. There are

punctate signal abnormalities involving the parietal white matter bilaterally, with no associated

mass effect, consistent with chronic small vessel ischemic changes. No other parenchymal

abnormalities are demonstrated in the cerebral hemispheres or posterior fossa structures. There is

no evidence of hydrocephalus.

Partially visualized is an ill-defined, heterogeneously enhancing mass involving the left

nasopharyngeal mucosa and pharyngeal space, involving the left medial and, to lesser extent,

pterygoid muscles, the left longus capitis muscle, and the prevertebral space. It also extends

inferiorly to the left oropharynx and soft palate. It invades the left side of sella and left cavernous

sinus, mildly displacing the left medial temporal lobe, and encroaches on the distal-most portion

of the left orbital apex. It further involves the petrous apex., clivus and left occipital condyle. The

distal cervical, petrous and cavernous portions of the left ICA are encased. This corresponds to

known nasopharyngeal malignancy. There is non-enhancing fluid signal involving the left

mastoid air cells, consistent with obstructive mastoid disease. Abnormal signal and enhancement

is seen involving the left side of the atlas, as well as the odontoid process, which may represent

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osseous metastasis. There are partially visualized prominent and enhancing left level II cervical

lymph nodes.

IMPRESSION:

1. Expansile lesion causing extensive cortical destruction of the left parietal occipital bones,

with an enhancing multiseptated, multiloculated soft tissue component, with features and

mass effects. Consistent with a malignant neoplasm, probably metastasis from biopsy-

proven malignancy.

2. Mild chronic small vessel ischemic changes involving the parietal white matter bilaterally.

3. No other brain parenchymal abnormalities demonstrated.

4. Partially visualized ill-defined, heterogeneously enhancing left nasopharyngeal mass,

corresponding to the biopsy proven malignancy.

5. Non-enhancing fluid signal involving the left mastoid air cells, consistent with

obstructive Mastoid disease.

6. Abnormal signal and enhancement involving the left side of the atlas, as well as the

odontoid process, which may represent osseous metastasis. Partially visualized prominent

and enhancing left level II cervical lymph nodes.

Laboratory Test#6: X-ray

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Indication: To assess cardiopulmonary disease

Date Performed: July 6, 2019

X-RAY RESULT:

There is haziness in the right paracardiac area

Heart is not enlarged.

Aorta is prominent.

The pulmonary vascular markings are exaggerated

Trachea is at midline

Hemidiaphragms and costophrenic angles are intact.

Soft tissues and osseous structures are unremarkable.

IMPRESSION:

 PNEUMONIA VS VESSEL CROWDING, RIGHT PARACARDIAC AREA

 PROMINENT AORTA

 PLEASEE CORRELATE CLINICALLY

Laboratory Test#7: Clinical Chemistry

Indication: To evaluate different compounds in blood and urine.

Date Performed: August 29, 2019

EXAMINATION RESULT REFERENCE RANGE

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CREATININE 58.2 80.00-115.00 umol/L

UREA NITROGEN 3.22 2.83-7.17 mmol/L

SGPT 35.4 4.00- 36.00 U/L

SODIUM 132.1 135.00- 148.00 mmol/L

POTASSIUM 3.00 3.50-5.30 mmol/ L

Laboratory Test#8: Ultrasound

Indication: To assess the size, location, and shape of the kidneys and related structures such as

ureters and bladder and to detect cysts, tumors, obstructions and infection within the kidneys.

Date Performed: June 28, 2019

URINARY- TRACT SONOGRAPHY: Right kidney is normal in size but with 2.3 X 1.3 – cm

and 2.2 x 1.7-cm cysts at the lower pole and cortex, respectively. Left kidney is normal in size

but hyperechoic. Right and left kidney measure 10.2 x 3.6cm and 10.6 x 4.7-cm respectively.

Calices, pelves and ureters are not dilated. Urinary bladder is physiologically distended with

normal anechoic lumen. Remainder is unremarkable.

IMPRESSION:

Renal cysts, multiple, right.

Parenchymal renal disease left.

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INCIDENTAL NOTE: Hepatic cysts, left.

Laboratory Test#9: Radiology

Indication: To assess the bones of the skull, facial bones, the nose and sinuses.

Date Performed: May 1, 2019

RADIOLOGY REPORT

Skull APL views reveal no gross evidence of fracture.

Cranial sutures are intact.

Note of a lytic change at the left temporal area.

The visualized facial bones appear unremarkable

IMPRESSION: *AS DESCRIBED

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DRUG STUDY

Medication No. 1

Generic name: Clonidine Hydrochloride

Brand name: CATAPRES

Drug classification: Antihypertensive

Dosage/Route/Frequency: 150 mg/tab 1-tab SL now

Mechanism of Action: Stimulate alpha-adrenergic receptor in the CNS, which results in

decreased sympathetic outflow inhibiting cardio acceleration and vasoconstriction centers.

Indication: It is indicated in the treatment of hypertension.

Side effects:

CNS:headache, dizziness, drowsiness, insomnia, sedation

GI: constipation, nausea, vomiting

EENT: dry eyes

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Adverse effect:

CV: hypotension, bradycardia, congestive heart failure, edema, palpitations, Raynaud’s

phenomenon, tachycardia

DERMA: alopecia, angioneurotic edema, hives, pruritus, rash, and urticaria

GENITOURINARY: decreased sexual activity, difficulty in micturition, erectile dysfunction,

loss of libido, nocturia, and urinary retention

Nursing Responsibilities:

1. Assess client’s vital sign especially blood pressure before and after giving the medication.

Rationale: To monitor the therapeutic effectiveness of the drug

2. Advice the patient to take exactly as prescribed and not to stop abruptly.

Rationale: Withdrawal symptoms and severe hypertension may occur.

3. Advise the patient to take clonidine at bedtime.

Rationale: To minimize side and adverse effects.

4. Monitor BP carefully when discontinuing clonidine.

Rationale: Hypertension usually returns within 48hrs.

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Medication# 2

Generic name: Nalbuphine Hydrochloride

Brand name: NUBAIN

Drug classification: Synthetic opioid agonist-antagonist analgesic

Dosage/Route/Frequency: 5mg /IVTT/q8h

Mechanism of Action: Binds to oblate receptors in the CNS, alters the perception of the

responses to painful stimuli of white producing generalized CNS depression.

Indication: For the relief of moderate to severe pain.

Side effects:

CNS: Restlessness, confusion, faintness, nervousness

EENT: dry mouth,

GI: nausea, vomiting

Adverse effect:

CNS: hallucination, dysphoria

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EENT: Blurred vision

CARDIO: Hypertension, hypotension, bradycardia, tachycardia

RESPI: Depression, dyspnea, asthma

Others: Speech difficulty

Nursing Responsibilities:

1. Assess for hypersensitivity to the drug.

Rationale: To prevent allergic and hypersensitivity reactions

2. Assess type, location, and intensity of pain before and after 30 min. of IV administration.

Rationale: To monitor drug effectiveness

3. Assess blood pressure, pulse, and respiration before and periodically during

administration.

Rationale: To provide prompt nursing interventions accordingly

4. Assess previous analgesic history.

Rationale: Antagonistic properties may induce withdrawal symptoms in patient

physically dependent on opioids.

5. Instruct folks to increase patient’s fluid intake.

Rationale: Constipation is often severe with maintenance therapy

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Medication#3

Generic name: Ketorolac

Brand name: TORADOL

Drug classification: Non-steroidal anti-inflammatory agents

Dosage/Route/Frequency: 30mg IVTT q6h (ANST)

Mechanism of Action: Inhibits prostaglandin synthesis, producing peripherally mediated

analgesia. Also has antipyretic and anti-inflammatory properties.

Indication: Short-term management of pain,

Side effects:

CNS: drowsiness, abnormal thinking, dizziness, headache

CV: edema, pallor, vasodilation

Respi: dyspnea

GI: Diarrhea, dry mouth, dyspepsia

Derm: Sweating

Adverse effect:

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CV: Edema, pallor

GI: GI bleeding

GU: Renal toxicity

Derm:Exfoliative dermatitis

Nursing Responsibilities:

1. Assess for hypersensitivity to the drug.

Rationale: prevent allergic/hypersensitivity reactions

2. Monitor BP upon administration.

Rationale: drug may cause vasodilation

3. Instruct patient to take the medication exactly as ordered.

Rationale: To provide a therapeutic effect.

4. Explain to the patient’s folks to avoid activities requiring alertness until response to the

medication is known.

Rationale: Because this drug may cause drowsiness or dizziness.

Medication No. 4

Generic Name: Parecoxib

Brand Name: DYNASTAT

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Drug Class: COX-2 selective inhibitor

Dosage/ Route/ Frequency: 40mg IVTT single dose

Drug action: Inhibitcyclooxygenase COX enzymes which are involved in the synthesis of

prostaglandins and thereby reduce pain and inflammation.

Drug indication: Management of acute pain and post-operative pain.

Side effects:

CNS: dizziness

CV: Bradycardia

GI: vomiting, nausea&constipation

Dermatologic: Rash

Adverse Effects:

CV: hypertension aggravated, hypotension postural

CNS: insomnia, agitation

Dermatologic: rash, pruritus, diaphoresis

GU: oliguria

MS: arthralgia, back pain

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Nursing Responsibilities with Rationale:

1. Assess for hypersensitivity.

Rationale: To prevent an allergic reaction.

2. Check the patency of the IV line prior to drug administration.

Rationale: To ensure the delivery of the drug.

3. Administer the drug slowly.

Rationale: To prevent irritation of the IV site.

4. Advise folks to increasepatient’s fluid intake.

Rationale: To prevent constipation.

5. Advise folks that the patient needs to avoid activities that requires alertness.

Rationale: To promote client’s safety because this drug may cause dizziness

Medication 5

Generic Name: Tramadol Hydrochloride

Brand Name: ULTRAM

Drug Class: Opioid analgesic

Dosage/ Route/ Frequency: 1 tabIVTT q6h RTC

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Drug action: Binds to the opioid receptor and inhibits the reuptake of serotonin and

norepinephrine the CNS.

Drug indication: Moderate to moderately severe pain

Side effects:

CNS: dizziness, headache, somnolence

EENT: Visual disturbances

GI: constipation, nausea, dry mouth, anorexia, flatulence

Adverse Effects:

CNS: anxiety, confusion, seizure, CNS stimulation, euphoria, nervousness

CV: vasodilation

GI: abdominal pain, diarrhea, dyspepsia, flatulence, vomiting

GU: urine retention,

Dermatologic: pruritus, sweating

Nursing Responsibilities with Rationale:

1. Explain to the patient’s folks the indication and classification of the drug.

Rationale: To promote awareness and cooperation.

2. Prepare medication exactly as ordered.

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Rationale: To achieve the intended effect of the drug

3. Monitor patient’s vital sign especially blood pressure.

Rationale: This drug may cause hypotension.

4. Monitor client closely after administration of the drug.

Rationale: To provide prompt intervention to untoward adverse reaction of the drug.

5. Advise patient’s folks to increase his oral fluid intake.

Rationale: To prevent constipation.

Medication# 6

Generic name: Celecoxib

Brand name: CELEBREX

Drug classification: Nonsteroidal anti-inflammatory

Dosage/Route/Frequency: 400 mg1 tab OD

Mechanism of Action: Inhibits prostaglandin synthesis by selectively inhibiting enzyme an

enzyme needed for biosynthesis.

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Indication: For acute pain and foe inhibition of inflammatory response.

Side effects:

CNS: Headache, drowsiness, weakness,dizziness

Respi: Chest pain

GI: Diarrhea,abdominal pain, bloating, constipation

Adverse effect:

Derma: skin rash

CV: Heart problem

GI: Stomach bleeding, liver problem, kidney problem

Nursing Responsibilities:

1. Assess for hypersensitivity in Celecoxib.

Rationale: To prevent an allergic reaction.

2. Instruct the patient’s folks to take the medication with a full stomach.

Rationale: To prevent GI upset.

3. Encourage the patient’s folks to increase fluid intake.

Rationale: To prevent dehydration.

4. Establish safety measures if CNS or visual disturbances occur.

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Rationale: To prevent injury and promote safety

CONCEPT MAP

1.CHRONIC
PAIN

1.RISK FOR
IMPAIRED SKIN
INTEGRITY

4.IMPAIRED VERBAL
COMMMUNICATION
2.
IMPAIRED
PHYSICAL
MOBILITY BRAIN TUMOR

3. CHRONIC
CONFUSION

LEGEND:

 Straight arrow: Denotes direct relationship from medical

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diagnosis/chief complaint

 Broken arrow: Denotes Risk Nursing Diagnosis

 Dotted Arrow: Denotes linking relationship between or among

NURSING CARE PLAN

Nursing Diagnosis No. 1

Nursing Diagnosis:Risk for Impaired Skin Integrity related to prolonged bed rest

Subjective cues: “ indiimawmakatagiliddahilgareklamoimawngagasakit” as verbalized by the

wife.

Objective cues:

 Limited ROM

 Paralysis of right upper and lower extremities

General objectives: To prevent skin breakdown

Specific objective: Within 8 hours of nursing intervention, the patient’s andfolks will be able to:

 Enumerate techniques/ measures to prevent skin breakdown, such as the importance of

maintaining clean, dry and moisturize skin, and use of pressure-relieving devices such as

pillows and gel mattress.

Nursing Responsibilities:

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1. Inspect skin surfaces and pressure points routinely

Rationale: To prevent pressure sores

2. Provide protection by use of pads, pillows, foam mattress and so forth

Rationale:To increase circulation and mimic or eliminate tissue pressure

3. Change continents pad or diapers frequently

Rationale: To minimize contact irritants

4. Emphasize the importance of adequate nutritional and fluid intake

Rationale:to maintain general good health and skin turgor

5. Apply lotion if not contraindicated

Rationale: To prevent friction and shear

 Evaluation: Goalsmet. The folks were able to enumerate techniques/ measures to prevent

skin breakdown, such as the importance of maintaining clean, dry and moisturize skin,

and use of pressure-relieving devices such as pillows and gel mattress.

Nursing Diagnosis No. 2

Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular impairment as

evidenced by inability to move purposefully within the physical environment, including bed
mobility, transfers, and ambulation.

Subjective cues: “ umpisanga nag uli kami halinsapanaygahininggalat a imaw” as verbalized by

his wife

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Objective cues:

 Limited range of motion

 Limited movement

 Difficulty turning

 Paralysis of right upper and lower extremities

General objectives: To maintain good body mechanics and prevent and correct deformities

Specific objectives: Within 8 hours of nursing intervention, the folks of the patient will be able

to:

 Assist patient to do passive ROM exercises to avoid muscle atrophy.

 Verbalize non-pharmacologic methods to prevent complications of immobility such as

bed sores with the use of pillows, foams and gel mattress in bony prominences

Nursing Responsibilities:

1. Assess mobility level prior to any activity and other interventions.

Rationale: To ensure patient safety.

2. Educate patient and family the importance of changing position every 2hours and assist

her in a comfortable position.

Rationale: To promote circulation to all body tissues and prevent complications of

immobility.

3. Advise folks to provide foam, mattresses, and pillows

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Rationale: To promote comfort and decrease pressure on the skin

4. Assist in passive ROM exercises on all extremities and joints using slow and smooth

movements.

5. Rationale: To permit enhance circulation, maintain muscle tone and prevent muscle

atrophy.

6. Place items within easy reach.

Rationale: To promote patient’s independence and convenience.

 Evaluation: Goals met. The folks were able to verbalize non-pharmacologic methods to

avoid muscle atrophy such as the use of pillows, foams and gel mattress in bony

prominences

Nursing Diagnosis No. 3

Nursing Diagnosis:Chronic confusion related to neurological impairment as evidence by brain

tumor.

Objective cues:

 Inappropriate words

 Disorientated to person, time and place

General objectives:To remain safe and free from harm

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Specific objective: Within 8 hours of nursing intervention, the patient’s folks will be able to:

1. Verbalize understanding of disease process, prognosis, and clients’ needs

2. Identify and participate in interventions to deal effectively with the situation

Nursing Responsibilities:

1. Explain to the patient the disease process, prognosis and the client’s needs of the patient.

Rationale: To facilitate understanding and promote active cooperation in patient’s care.

2. Orient patient to person, time and environment as needed.

Rationale: Reality orientation techniques help improve patient’s awareness of self and

environment.

3. Monitor the patient for non-verbal communication, such as facial grimacing, smiling,

pointing, crying, and so forth; encourage the use of speech when possible.

Rationale: Indicates that feelings or needs are being expressed when speech is impaired.

Excessive mumbling, striking out, or non-verbalization clues may be the only method left

for the patient to express discomfort.

4. Ask family members about their ability to provide care for the patient.

Rationale: To identify the family’s need for assistance

5. Instruct family to utilize distraction techniques, such as soothing music, going for a walk,

or looking at picture albums if the patient has delusions.

Rationale: Distraction may be effective if a stressful situation occurs.

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6. Remove competing stimuli, and provide a calm, unhurried atmosphere for

communication.

Rationale: Reduces unnecessary noise and distraction and allows the patient time to

decrease frustration

Evaluation: Goals met. The patient’s folks verbalize understanding of disease process,

prognosis, and clients needs and able to identify and participate in interventions to deal

effectively with the situation

Nursing Diagnosis No. 4

Nursing Diagnosis:Chronic pain related to disease process as evidenced by irritability,

restlessness and sleep disturbance.

Subjective cues: “gahambaeimaw it agayagay ag gakurisompagnakabatyagimaw it sakit” as

verbalized by his wife.

Objective cues:

 Irritability

 Facial grimace

 Restlessness

General objectives: To promote physical comfort.

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Specific objective: Within 8 hours of nursing intervention, the patient’s folks will be able to:

 Demonstrates the use of different relaxation skills and diversional activities such as deep-

breathing techniques and etc.

 Comply with the pain management regimen as ordered.

Nursing Responsibilities:

1. Assist the patient in a comfortable position.

Rationale: To alleviate pain.

2. Provide quiet and well-ventilated environment.

Rationale: Relaxing environment can promote rest and aid in fast recovery.

3. Provide the patient with adequate rest periods.

Rationale: To facilitate comfort and relaxation.

4. Instruct patient’s folks to use relaxation technique and deep breathing exercise.

Rationale: To distract attention and reduce the tension that increases the intensity of

pain.

5. Administer pain medications as ordered.

Rationale: to relieve pain

 Evaluation: Goals met. The folks were able to demonstrate the use of

different relaxation skills and diversional activities such as deep-breathing techniques and

etc. and comply with the pain management regimen as ordered.

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Nursing Diagnosis: No. 5

Nursing Diagnosis:Impaired Verbal Communication related to neurosensory impairment as

evidenced by inappropriate verbalization of words.

Subjective cues: “gapinalapongimaw it hambaepagitstoryakamo” as verbalized by his wife

Objective cues:

 Inappropriate words

 Dysphasia

General objectives:To maintain a therapeutic communication

Specific objective: Within 8 hours of nursing intervention, the patient will be able to:

 Use form of communication to get needs met and relate effectively with people and

environment.

Nursing Responsibilities:

1. Assess whether patient has other communication impairment like hearing, vision and

literacy.

Rationale: Presence of other problems influences plan for alternative communication

2. Pre-arrange for obtaining immediate help

Rationale: To decrease patient’s anxiety about inability to speak appropriately

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3. Allow sufficient time for communication

Rationale: Loss of speech and stress and alternative communication can cause frustration

and block expression.

4. Provide non-verbal communication like touching

Rationale: To communicate concerns and meets need for contact with others.

Evaluation:Goals met. The patient was able to use form of communication like touching to get

needs met and relate effectively with people and environment.

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