CENTRAL LUZON DOCTORS HOSPITAL EDUCATIONAL INSTITUTION San Pablo, Tarlac City

CASE STUDY FORMAT

I. Introduction II. Objectives Nurse centered III. Nursing Process A. Data Base a. Nursing health history A 1. Demographic data 2. Chief complaint 3. History of present illness 4. Past medical history 5. Family history 6. Social and personal history 7. Review of system b. Nursing health history B 1. General Description Of Client 2. Health Perception-Health Management Pattern 3. Nutritional-Metabolic Pattern 4. Elimination Pattern 5. Activity-Exercise Pattern 6. Sleep-Rest Pattern 7. Cognitive-Perceptual Pattern 8. Self-Perception Self-Concept Pattern 9. Role-Relationship Pattern 10. Sexuality-Reproductive Pattern 11. Coping-Stress Tolerance Pattern 12. Value-Belief Pattern c. Physical examination d. Laboratory Findings e. Review of anatomy and physiology f. Pathophysiology (highlight patient manifestation) B. NCP C. Drug Study D. Medical and Nursing Management E. METHOD II. Evaluation a. Narrative evaluation of the objectives b. Patient condition upon discharge III. Recommendation IV. References/Bibliography

CENTRAL LUZON DOCTORS HOSPITAL EDUCATIONAL INSTITUTION San Pablo, tarlac city

CASE STUDY FORMAT

I. 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: Age: Examiner: Informant: I. II. III. Chief complaint History of present illness Past medical history (include dates and complications, if any) A. Pediatric and Adult Illness Mumps Measles Chicken Pox Rubella Pertussis Rheumatic Pneumonia Tuberculosis HPN Heart Disease Hepatitis Others Ward: C/S: Bed: Religion :

Sex:

B. Immunizations/Tests BCG DPT OPV HEP B Measles For Flu For Pneumonia Others

C. Hospitalizations D. Injuries E. Transfusions F. Obstetrics/gynecologic History G. Medications

H. Allergies

II.

Family history AGE L D List: Parents, Spouse, Children Health Status or Cause of Death Diseases Present in the Family

L D HD

= = =

Living Deceased Heart Disease

TB DM MI

= = =

Tuberculosis Diabetes Mellitus Mental Illness

HPN CA KD

= = =

Hypertension Cancer Kidney Disease

OB J O

= = =

Obesity Jaundice Others

III.

Social And Personal History Birthplace: Education: Age and Sexes of Children (if any): Clients position in the family: Residence Home Environment: Occupation Nature 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: Birthday: Ethnic Background:

IV.

Review of system
General Description: Weight Loss: __________ Fatigue: ____________ Weakness: __________ Bruising: ________________________ Bleeding: ________________________ Color Change: ____________________ Vision Loss Excessive Tearing Anorexia: ____________

Night Sweats: ____________ Skin:

Itch: _________________________ Rash: ________________________ Lesions: ______________________ Eyes: Pain Diplopia Glasses/Contact Lenses Ears: Earaches Nose: Obstruction Throat and Mouth: Sore Throats Neck: Swelling Chest: Cough Wheeze Breast: CVS: Chest pain PND GIT: Food tolerance Vomiting Constipation GU: Dysuria Nocturia Hematuria Flank pain Male: Penile Discharge Female: Menarche: (age) Extremities: Joint pains Edema Heartburn Pain Change in BM Palpitation Orthopnea Discharge Epistaxis Bleeding Gums Dysphagia Itch Blurring

Tinnitus Discharges Tooth Aches Hoarseness

Hearing Loss

Decay

Sputum: (Amount & Character) Hemoptysis Pain on Respiration Dyspnea: Rest/Exertion Lumps Pain Bleeding Discharge Dyspnea on exertion Edema Others: _________________________ Nausea Bloating Melena Retention Lesion LMP: (date) Polyuria Testicular pains Cycle: _____ Dribbling others: others: Jaundice Excessive Gas

varicose veins Stiffness

Claudication Deformities

Neuro: Headaches Dizziness Memory Loss Fainting Numbness Tingling Paralysis: ____________ Paresis: _________ Seizures Others: ______________________________

Mental Health Status: Anxiety Sexual Problems

Depression Fears

Insomnia

NURSING HEALTH HISTORY B General Description Of Client

Health Perception-Health Management Pattern

Nutritional-Metabolic Pattern

Elimination Pattern

Activity-Exercise Pattern

Sleep-Rest Pattern

Cognitive-Perceptual Pattern

Self-Perception Self-Concept Pattern

Role-Relationship Pattern

Sexuality-Reproductive Pattern

Coping-Stress Tolerance Pattern

Value-Belief Pattern

PHYSICAL EXAMINATION
GENERAL SURVEY: Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______ Skin: Eyes: Color: __________ Turgor: ___________ Pupils: Bruises: __________ ______________________ No Distress Temperature: ___________ mmHg ___________ mmHg ___________ mmHg ____________ State of Hydration: _____________ Sclera: _____________________ Easy Breathing in Distress Respiratory: VITAL SIGNS: HR ___________ / min BP Supine R/L arm Sitting R/L arm Standing R/L arm Capillary Refill: ____________ RR: _____________________

Others: ______________________________ BODY POSITION/ALIGNMENT: Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________ Alignment: MENTAL ACUITY: Oriented Disoriented Amputation Gait EMOTIONAL STATUS: Euphoric Angry/Hostile Depressed Apprehensive Others: ___________________________ coherent incoherent deformity appropriately responsive inappropriately responsive paresis speech paralysis fracture others: ___________ Appropriate Inappropriate

SENSORY/MOTOR RESTRICTIONS: hearing disorder others: ______________________

MEDICALLY IMPOSED RESTRICTIONS: CBR w/out BRP_____ BR w/ BRP_____ OOB Chair_____ Restricted Ambulation _____ OTHER HEALTH RELATED PATTERNS: Fatigue Dyspnea ENVIRONMENT: Room Temperature: Lighting: SAFETY: Adequate Adequate Inadequate Inadequate Restlessness Dizziness Weakness Pain Insomnia Coughing Others: ______________________

Violations of medical asepsis: ________________________________________________ Violations of safety measures: ________________________________________________ ACTIVITIES OF DAILY LIVING: Can/Cannot perform Feeding Dressing Brushing teeth Combing Bathing Transferring 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. 2. 3. 4. 5. 6. 7. 8. Oxygenation Nutrition Elimination Activity and Exercise Comfort and Safety Sexual- Reproductive Psychological Psychosocial

LABORATORY FINDINGS

Review of anatomy and physiology

Pathophysiology (highlight patient manifestation)

NCP ASSESSMENT CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PROBLEM STATEMENT (GOAL) INTERVENTION EVALUATION NURSING INTERVENTION RATIONALE

Drug Study

DRUG NAME/ GENERIC

CLASSIFICATION

DOSAGE/ STOCK DOSE

ACTION

INDICATION

CONTRA INDICATION

SIDE EFFECTS

ARVERSE REACTION

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. Dont increase or skip doses. Dont 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.

Evaluation a. Narrative evaluation of the objectives b. Patient status after discharge Recommendation References/Bibliography

How to Write a Case Study Paper for Nursing

A 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 3. Current Care Plan and Recommendations
Vital signs and test results Nursing observations (i.e., range of motion, mental state) 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 Status

The 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 Assessment
When you are discussing the nursing assessment of the patient describe the patients 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 patients sleep patterns? The nursing diagnoses you identify in your assessment will help form the nursing care plan.

Current Care Plan and Recommendations for Improvement

Describe the nursing care plan and goals, and explain how the nursing care plan improves the quality of the patients life. What positive changes does the nursing care plan hope to achieve in the patients 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 patients 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 doesnt need to be a grueling challenge. It can actually be very rewarding, and its 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 dont lose points on a well written paper because of some formatting errors. David Plaut David Plaut is the founder of Reference Point Software (RPS). RPS offers a complete suite of easy-touse 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.com Reference 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. Its 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 ones 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 patients 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 cant 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. Patients 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= 122s, RR= 30s (+) 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 patients 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 patients breathing PHYSICIANS 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 6263mgtts/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 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 patients temperature returns to normal, medication must be continued according to the doctors 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. Its important to have the doctor monitor his progress. Encourage the guardians to wash patients hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter ones 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 ones 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 isnt possible, a person can help protect others by wearing a face mask and always coughing into a tissue. Share this:

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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 individuals 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; its 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 tumours 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, its also important not to put anything in patients mouth while teeth is clenched during a grand-mal seizure, its essential to monitor airway and ventilation during a seizure and to guide but not restrict patient movement. Following a seizure its 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). Its 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 Cushings 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 wideranging 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). Its 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, its 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 patients 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, its 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 cells 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, its 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. Phenytoins 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 patients 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 patients 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.

REFERENCE LIST

Allan, D. (2006) Disorders of the nervous system, in Alexander, M. F., Fawcett, J. N., & Runciman, P. J. (eds.) Nursing practice, hospital and home: the adult. 3rd edn. Edinburgh: Churchill Livingstone, pp. 395 442. Barker, E. (1990) Brain tumour: frightening diagnosis, nursing challenge, RN, 53 (9), pp. 46 52 Baumann, C. K. & Zumwalt, C. B. (1989) Intracranial neoplasms. An overview, AORN journal, 50 (20), pp. 240 257. Belford, K. (2000) Central nervous system cancers in Yarbro, C. H., Frogge, M. H., Goodman, M., & Groenward, S. L. (eds.) Cancer nursing: principles and practice. 5th edn. London: Jones & Bartlett, pp. 1048 1096. Bohan, E. & Glass Macenka, D. (2004) Surgical management of patients with primary brain tumours, Seminars in oncology nursing, 20 (4), pp. 240 252. Carpenito Moyet, L. J. (2008) Nursing diagnosis: application to clinical practice.12th edn. Philadelphia: Lippincott, Williams & Wilkins. Cohen, B. H. (1995) Headaches as a symptom of neurological disease, Seminars in pediatric neurology, 2 (2), pp. 144 150. Eriksson, J. H. (1994) Oncologic nursing. 2nd edn. Springhouse PA: Springhouse Publishing Co. Franges, E. Z. (2006) When a headache is really a brain tumor, The nurse practitioner, 31 (4), pp. 47 51. Gerrard, G. E. & Franks, K. N. (2004) Overview of the diagnosis and management of brain, spine, and meningeal metastases, Journal of

neurology neurosurgery and psychiatry, 75 (supplement II), pp. ii37 ii42 BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009). Graham, C. A. & Cloughesy, T. F. (2004) Brain tumor treatment: chemotherapy and other new developments, Seminars in oncology nursing, 20 (4), pp. 260 272. Grant, R. (2004) Overview: brain tumour diagnosis and management /Royal college of physicians guidelines, Journal of neurology neurosurgery and psychiatry, 75 (supplement II), pp. ii18 ii23 BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009). Hickey, J. V. (2003a) Brain tumors in Hickey, J. V. (ed.) The clinical practice of neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott, Williams & Wilkins, pp. 483 508. Hickey, J. V. (2003b) Seizures and epilepsy in Hickey, J. V. (ed.) The clinical practice of neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott, Williams & Wilkins, pp. 501 526. Hickey, J. V. (2003c) Management of patients undergoing neurosurgical procedures in Hickey, J. V. (ed.) The clinical practice of neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott, Williams & Wilkins, pp. 319 344. Hickey, J. V. (2003d) Intracranial hypertension theory and management of increased intracranial pressure in Hickey, J. V. (ed.) The clinical practice of neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott, Williams & Wilkins, pp. 285 318.

Janning, S. W. & Lassiter, T. F. (2003) Pharmacological management of neuroscience patients in Hickey, J. V. (ed.) The clinical practice of neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott, Williams & Wilkins, pp. 215 237. Kilpatrick, C., Kaye, A., Dohrmann, P., Gonzales, M., & Hopper, J. (1994) Epilepsy and primary cerebral tumours, Journal of clinical neuroscience, 1 (3), pp. 178 181. Krouwer, H. G. J., Pallagi, J. L., & Graves, N. M. (2000) Management of seizures in brain tumour patients at the end of life, Journal of palliative medicine, 3(4), pp. 465 475. Lovely, M. P. (1998) Quality of life of brain tumor patients, Seminars in oncology nursing, 14 (1), pp. 73 80. Lovely, M. P. (2004) Symptom management of brain tumor patients, Seminars in oncology nursing, 20 (4), pp. 273 283. McFarland, G. K. & McFarlane, E. A. (1997) Nursing diagnosis and intervention: planning for patient care. 3rd edn. St. Louis: Mosby. McKinney, P. A. (2004) Brain tumours: incidence, survival, and aetiology, Journal of neurology neurosurgery and psychiatry, 75 (supplement II), pp. ii12 ii17 BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009). Mogensen, K. (2008) The whole picture: addressing the diverse needs of the patient treated for a brain tumor, Clinical journal of oncology nursing, 12 (5), pp. 817 819.

Nahaczewski, A. E., Fowler, S. B., & Hariharan, F. S. (2004) Dexamethasone therapy on patients with brain tumors a focus on tapering, Journal of neuroscience nursing, 36 (6), pp. 340 343. National brain tumor foundation (2007) The essential guide to brain tumors. Available at: http://www.braintumor.org/upload/contents/330/GuideFINAL2007.pdf. (Accessed 15 April 2009). Palmieri, R. L. (2007) Responding to primary brain tumor, Nursing, 37 (1), pp. 36 41. Pelletier, G., Verhoef, M. J., Khatri, N., & Hagen, N. (2002) Quality of life in brain tumor patients: the relative contribution of depression, fatigue, emotional distress and existential issues, Journal of neuro-oncology, 57 (1), pp. 41 49. Rabbitt, J. E. & Page, M. S. (1998) Selected complications in neuro-oncology patients, Seminars in oncology nursing, 14 (1), pp. 53 60. Rampling, R., James, A., & Papanastassiou, V. (2004) The present and future management of malignant brain tumours: surgery, radiotherapy, chemotherapy, Journal of neurology neurosurgery and psychiatry, 75 (supplement II), pp. ii24 ii30 BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009). Smeltzer, S. C. & Bare, B. (2004) Brunner & Suddarths Textbook of medicalsurgical nursing. 10th edn. Philadelphia: Lippincott, Williams & Wilkins.

Straight, L. (2002) Activity intolerance in Ackley, B. J. & Ladwig, G. B. (eds.) Nursing diagnosis handbook. A guide to planning care. 5th edn. St Louis: Mosby, pp. 120 125. Tremont Lukats, I.W., Ratilal, B.O., Armstrong, T., & Gilbert, M.R. (2008) Antiepileptic drugs for preventing seizures in people with brain tumors, Cochrane database of systematic review, Issue 2 Art. No.: CD004424. DOI: 10.1002/14651858.CD004424.pub2. van Breemen, M. S. M, Wilms. E. B., & Vecht, C. J. (2007) Epilepsy in patients with brain tumours: epidemiology, mechanisms, and management, Lancet. Neurology, 6 (5), pp. 421 430. Whittle, I. R. The dilemma of low grade glioma, Journal of neurology neurosurgery and psychiatry, 75 (supplement II), pp. ii31 ii36 BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009).