case study-or

8/7/2019 case study-or

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St. Paul University Manila

(St. Paul University System)

680 Pedro Gil St., Malate, 1004 Manila, Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE STUDY

(Application of Nursing Process)

I. Patients Information

This is the case of a patient with initials of W.B. He is a 38 year old male. He had

progression of headache. His MRI showed a 2.5x2.5 cm suprasellar mass with obstructive HCP and wa

at Philippine General Hospital.

The patient has no known allergies to any food or drugs and with medications of

Ranitidine 50mg IV q8, Cloxacillin 1g IV ANST(-) 1 hour prior to OR, Gentamycin 80mg IV 1 hour pri

q8, Mannitol 100cc IV q6. The clients final diagnosis is craniopharygioma.

II. Physical Assessment

Clients Initial: W.B.

Clients Admitting Diagnosis: Craniopharyngioma


2/23

AREAS TO BE ASSESSEDMETHODS OF

ASSESSMENT

NORMAL

FINDINGSACTUA

HEAD

Skull

Inspection

(Size, shape, symmetry

and deformities)

Rounded(normocephalic and

symmetric, withfrontal, parietal, and

occipitalprominences); smooth

skull contour; nodeformities

Rounde

skull

def

Scalp & Hair

Inspection

(Color, lesions, hairdistribution and

consistency)

White scalp, no lice,no dandruff, no

lesions, hair evenlydistributed, thick,

shiny, free from splitends

White sc

dandruhair even

thick, shsp

Face

Inspection

(Shape, texture,symmetry of movements,

facial expressions, edemaand hollowness)

Oval, square or round

in shape, symmetricalfacial movements,smooth, free from

wrinkles, noinvoluntary

movements, and facialexpression depends on

mood. Symmetricnasolobial folds. No

signs of edema andhollowness.

Roun

symmmovemewrinkle

and outereyes, n

movemeexpressi

mood aSymme

folds.edema an

Eyebrows

Inspection(hair distribution,

alignment, and skinquality and movement)

Hair evenlydistributed; skin

intact. Eyebrowssymmetrically

aligned; equal

Evenly dskin is i

lesionsymmetr

mov


3/23

movement.

Eyelashes

Inspection

(Evenness of distributionand direction of curl)

Equally distributed;

curled slightlyoutward.

Eyelash

distribcurled sli

EYES AND

VISIONEyelids

Inspection(Surface characteristics,

position in relation tothe cornea, ability,

frequency of blinking,edema, discharge and

scaling.)

Skin intact; nodischarge; no

discoloration. Lidsclose symmetrically,

bilaterally blinking.No edema and

scaling.

Eyelidskin; No

and dinoted

symmbilatera

Absences

EARS ANDHEARING

Auricles

Inspection

(Color, symmetry ofsize, and position)

Color same as facial

skin. Symmetrical.Auricle aligned with

outer canthus of eye,about 10

Ofrom

vertical.

UnifoSymme

1cm hiouter ca

NOSE AND

SINUSESNose

Inspection

(Shape, size, or color andflaring or discharge from

the nose)

Symmetric andstraight. Proportional

to face. No dischargeor flaring. Uniform in

color.

Symmetr

It is poslateral

facpropor

face an

MOUTH AND

ORO-

PHARYNX

Lips and Buccal

Mucosa

Inspection

(Symmetry of contour,color, and texture)

Uniform pink in color.Soft, moist, smooth

texture. Symmetry ofcontour. Ability to

purse lips.

Th

symmbrown in

smoot


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NECK Neck Muscles

Inspection(Abnormal swellings or

masses)

Muscles equal in size;head centered. No

swelling and masses.

Neck mu

in size. Hin the c

swellin

UPPER

EXTRE-

MITIES

Muscle

Inspection(Size and symmetry,

contractures and tremors)

Equal size on both

sides of body. Nocontractures and

tremors.

Clientboth upp

equal anon his b

contrtrem

Bones Inspection No deformities. N

Brachial and radial

arteries

Palpation

Pulse rate palpated

over the brachial and

radial pulse. Normalradial pulse count is

60-100 beats per

minute for adultpeople.

Pulse rat

the bracpulse. Cl

a no

PR

THORAXAnterior

Thorax

Inspection

(Breathing pattern)

Quiet, rhythm, and

effortless respirations.

Quiet,

effortles

ABDOMEN

Four

quadrants of

Abdomen

Inspection(skin integrity, contour,

and symmetry)

Unblemished skin,

uniform in color,silver-white striae(stretch mark) or

surgical scars. Flat,rounded (convex), or

scaphoid (concave).

Unbleuniform

presence

Abdomround


5/23

LOWER

EXTRE-

MITIES

Muscle

Inspection(Size and symmetry,

contractures and tremors)

Equal size on both

sides of body. Nocontractures and

tremors.

Equal siz

of thcontr

trem

Bones Inspection No deformities. N


6/23

C. Blood Chemistry- to measure different chemicals in the bloodD. Urinalysis- to assess the effects of CVD on renal function and the existence of

concurrent renal or systemic diseases

E. Tumor Markers- making a diagnosis of cancer or of a specific type of cancerF. ECG- graphical recording of the electrical activities of the heart

To ensure condition, progress and response to treatment, continuous monitoring ofthe patient is required:

y Monitor vital signs and record every four hours. This is done to be able to evaluatethe bodys response to treatment.

y Monitoring fluid intake and urinary output every shift and record to be able toevaluate kidney function based on the amount of his daily intake of fluids, through

oral means and intravenous fluid administration and urinary output.

To maintain adequate nutrition and hydration:

y IVF of PNSS 1L x 30 gtts/min- to replace fluid and electrolyte lossy Side drip of PNSS 1L x KVO and D5W 500 cc + 4 ampules of dopamine to replace

fluid and electrolyte lossy Diet as toleratedPharmacologic treatment:

y Dexamethasone 5mg IV q8y Ranitidine 50mg IV q8y Cloxacillin 1g IV ANST(-) 1 hour prior to ORy Gentamycin 80mg IV 1 hour prior to ORy Tramadol 50 mg IV q8y Mannitol 100cc IV q6To prevent spread of infection and further complications:

y Wash hands before and after assessing the patient and after each procedurey Wear mask and gloves in every procedure that is needed to be doney Practice aseptic technique in every procedure to prevent infectiony Encourage hygiene to prevent growth of microorganismsTo prevent recurrence of the disease:

y Compliance of medications as prescribed by the physiciany Always keep the clients back dryTo prevent further injury:y Observe safety precaution by raising side railsy Assist in activities of daily living


7/23

LABORATORY RESULTS

A. Blood ChemistryExamination Normal

Value

Unit Result

Significance October 4,2010

WBC 5-10x109

L 19.76 It serves as a usual guide to the severity of thdisease. Thus identifies a certain person wit

increase susceptibility to infection.

Monocyte 0.020-

0.090

% 0.109 Monocytes have several roles in the immune system

and this includes: replenishresident macrophages and dendritic cells under

normal states, and in response to inflammation

signals, monocytes can move quickly (approx. 8-12hours) to sites of infection in the tissues anddivide/differentiate into macrophages and dendritic

cells to elicit an immune response..


8/23

B. Metabolic profileDate

PerformedExamination

Normal

ValueUnit Result Significance

October 4,2010

BUN2.60-6.4

mmol/L 6.22 N

It is measuring the nitrogen portion of th

used as glomerular function and produc

excretion of the urea. The rate at which BUinfluenced by degree of tissue necrosis,

catabolism and the rate at which the kidne

urea nitrogen.

Createnine 53-115 umol/L 102 N

It signifies Impaired renal function. Creati

by-product in the breakdown of muscle cphosphate resulting from energy metabol

produced at a constant rate depending on mof the person and is removed from the bo

kidneys. A disorder in kidney function excretion of creatinine, resulting in increas

blood creatinine. It is a more specific andindicator of kidney disease than the B

Sodium136-

145mmol/L 140 N

Sodium maintains the osmotic pressure andbalance and to transmit nerve impulses.

concentration is under control of the kidnecentral nervous system acting through the

system.

Potassium 3.50-5.10

mmol/L 3.5 N

Potassium level evaluates changes in body

and is helpful in diagnosing disorders of acwater balance in the body. It is not an abso

and varies with the circulatory volume a

factors such as taking diuretics.In hypertension, the aldosterone level incrresulting to water and sodium retention w

potassium in our body is secreted that mahypokalemia.


9/23

C. UrinalysisDate

PerformedExamination

Normal

ValueResult Interpretation Significance

August 17,

2010

Color Pale

Yellowto

Amber

Pale

Yellow

Normal Result The color of the urine ranges from

pale yellow to amber because of thepigment chrome. It indicates the

concentration of the specific gravityof urine. The color of the urine is

primarily due to the urochrome(pigments that are present in the diet

or formed form the metabolism ofthe bile). Due to the present of the

abnormal pigments the color ofurine changes in many disease sates

Appearance Clear Clear Normal Result The normal urine should be clear.

However, normal urine may also becloudy which provides a warningabnormality such as pus, RBC, or

bacteria. However, excretion ofcloudy urine may not be abnormal

since the change in pH may causeprecipitation within the bladder of

normal urinary constituents.Alkaline urine may appear cloudy

because of phosphates, acid urinemay appear cloudy because of

urates.Ph 4 6.8 6 Normal Result This is an indication of the renal

tubules ability to maintain normalhydrogen ion concentration in the

plasma and extracellular fluid.

Specific 1.005 1.020 Normal Result Specific gravity is a measurement


10/23

Gravity 1.030 of the concentration of urine. It is a

means by which the kidneys abilityto concentrate urine is measured.

The range of urine specific gravitydepends on the state of hydration

varies with urine volume and theloads of solid excreted.

NURSING CARE PLAN

NURSING CARE PLAN

(includes independent and dependent Nursing functions)

Assessment Nursing

Diagnosis

Goal/Objectives Nursing Intervention Rationa

y With foley-cathetery With IVy Will be

undergoing an

invasiveprocedure

(craniotomy)

Risk forinfection relatedto surgical

incision

After 8 hours ofnursinginterventions the

patient will be ableto:

a. Have normalvital signs and

laboratoryvalues

b. Have theincision site

remain freefrom signs and

symptoms ofinfection

Independent:

Document and reportresults of perioperativenursing assessment

identify risk factors

A completenursingassessment

allowsdevelopmen

individualizecare plan

Make sure all surgicalteam members wear

appropriate operatingroom attire

Inspect operating roomfor cleanliness before

opening supplies andinstruments

The human bis a major so

of microbialcontaminatio

To provide senvironment


11/23

c. Avoiddehiscencefrom occurring

Perform a surgical hand

scrub. Put on drapes onpatient, furniture and

equipment.

Surgical han

scrub minimnumber of

microorganion skin. Ster

gown and glprotect again

contaminatiosterile drape

create sterilefield

Check package integrity,chemical indicator and if

appropriate expirationdate on all sterile items

before dispensing them

onto sterile field

All items uswithin field

be sterile or will become

contaminate

Use proper techniqueswhen opening items onto

sterile field

To avoidcontaminatio

Keep operating room

doors closed at all timesand minimize traffic in

and out

Air turbulen

caused bymovement a

mixing ofcorridor air w

room air can

sharply increbacterial couin operating

room


12/23

Maintain room

temperature and relativehumidity, unless

contraindicated

Cooler air an

lower humidinhibit micro

growth

Wash hands following

contact with patient orany object contaminatedwith blood or body fluids

Hand washin

the mosteffective mefor preventin

microbialtransmission

Disinfect and sterilize allinstruments and

equipments before andimmediately after

surgical procedure

All instrumeand equipme

used duringsurgery mus

free frommicroorgani

sterilizinginstruments

equipment ause prevents

growth andspread of

microorganiduring storag

Promptly clean areasoutside sterile field that

become contaminated by

blood, tissues or bodyfluids with an approveddisinfectants

To preventdistribution

microbes int

environment


13/23

Dependent

Perform preoperative

skin preparation ofsurgical site (done by the

surgeon)

Skin prepara

reduces residmicrobial co

to subpathogamounts and

inhibits rapidrebound gro

of microbes

Classify surgical wound

according to degree ofcontamination of wound

and surrounding tissue

Classificatio

helps to asserisk of woun

infection froendogenous

source and

determine nefor antibiotictherapy

Administer antibiotic asordered

Intraoperativadministratio

of antibioticdecrease

incidence ofwound infec

and lessen itseverity

Apply sterile dressing tosurgical wound before

remaining drapes

To avoid wocontaminatio

and subsequinfection


14/23

NURSING CARE PLAN


Cues Nursing

Diagnosis

Goal/Objectives Nursing Intervention Rat

y with copiousamount ofwhitishsecretions

y sedatedy ineffective

cough

y difficultyvocalizing

y nasal flaringy prolonged

expiration phase

y pursed lipbreathing

y shortness ofbreath

Ineffective airway

clearance relatedto presence of

tracheobronchialsecretion

After 4 hours of

nursing interventionsthe patient will be

able to:a. cough effectivelyb. expectorate

sputum

c. absentadventitious

breath soundsd. produce normal

sputum

e. have patentairwayf. have ABG levels

remain atbaseline

g. understand theneed for

adequate

Dependent

Assess respiratory statusat least every 4 hours

To detecsigns of

comprom

Place the patient in semi

fowlers position andsupport upper extremities

To aid b

and cheexpansi

ventilatelung fie

Help patient turn, coughand deep breathe

To helppooling

secretio

maintainpatency

Mobilize patient to full

capabilities

To facil

expansiventilati

Provide tissues and paperbags for hygienic sputum

disposal

To prevspreadin

infection


15/23

hydration,

sputum monitorand taking

medications asordered

h. demonstratecontrolledcoughingtechnique

Teach patient about:

y Maintaining adequatehydration

y Daily monitoring ofsputum

y Controlled coughingand postural drainagey The need to remain

active

These st

involve own hea

Dependent

Suction as needed andordered

To stimcough a

airways

Perform postural drainagepercussion and vibration

every 4 hours as ordered

To enhamobiliz

secretiointerfere

oxygena

NURSING CARE PLAN


Cues Nursing

Diagnosis

Goal/Objectives Nursing Intervention Rat

y with copiousamount of

whitishsecretions

y sedatedy ineffective

cough

Ineffective

breathing pattern

related todecreased energy

After 4 hours of

nursing interventions

the patient will be ableto:

a. normal RRb. normal ABG

levels

Dependent

Assess respiratory status

at least every 4 hours

To dete

signs ocompro

Assess ABG levels

according to facilitypolicy

To mon

oxygenventilat


16/23

y difficultyvocalizing

y nasal flaringy prolonged

expiration

phasey pursed lip

breathing

y shortness ofbreath

c. report feelingcomfortablewhen breathing

d. report feelingrested

e. demonstratediaphragmaticpursed-lipbreathing

f. achievemaximum lung

expansion withadequate

ventilation

Auscultate breath sounds

at least every 4 hours

To dete

decreasadventi

breath s

Assist patient to

comfortable position

To prom

comforexpansi

ventilatbasilar

Teach patient about:

y Pursed-lip breathingy Abdominal breathingy Performing relaxation

techniques

These mallow p

participmaintai

health simprov

ventilat


17/23

DATA FROM TEXTBOOK

What is it?

Craniopharyngioma is a tumour that develops in the area of the brain called the hypothalamus,which is close to the pituitary gland. It is usually found in children or young adults and accountsfor around 10% of all brain tumours in young people. It can however be diagnosed at any age.

How does it develop?

The pituitary gland starts growing early in a developing fetus from a small amount of tissuecalled Rathke's pouch, that starts off in the throat area and moves upwards to the brain.

Craniopharyngiomas develop from the remains of Rathke's pouch. This explains their name(cranio=skull, pharynx=throat, oma=tumor).

Is it dangerous?

Craniopharyngiomas are nearly always benign but can cause symptoms once they press uponother parts of the brain around them. Therefore they are often quite large when they are detected

and may range in size from one, to more than four inches in diameter.

What are the common symptoms?

The symptoms produced by a craniopharyngioma are variable depending upon where the tumouris and which area of the brain that it presses on.

1.

Compression of the pituitary stalk or the pituitary gland itself can interrupt themanufacture of part or all of the pituitary hormones. This may cause one or more of the

following symptoms

y Loss of growth in childreny Irregular periodsy Delayed pubertyy Reduction or loss of sexual drivey Fatiguey Low blood pressurey Dry skiny

Increased sensitivity to cold and heaty Constipationy Unexplained weight gainy An increase in Prolactin levels, which can cause a milky discharge from the nipples (in

both men and women).

2. Pressure on the nerves that control vision can cause loss of peripheral (side) vision, whichmay be noticed especially when driving


18/23

3. Involvement of the hypothalamus, an area at the base of the brain, may result in weightgain, drowsiness, problems with temperature regulation, mood changes and depression or

passing large quantities of urine leading to problems with water balance (a conditioncalled Diabetes Insipidus).

4. Other symptoms can develop for a variety of reasons and may include personalitychanges, headache, confusion, nausea and vomiting.

What happens if a craniopharyngioma is suspected?

Several specialists may need to be involved in planning investigations and supervising treatment.

1. An Endocrinologist usually assesses the patient first and arranges tests to help make thediagnosis.

2. Most people will need an operation. This is done by a Neurosurgeon and can beperformed at Ninewells Hospital.

3. Radiation is also sometimes used as treatment, usually in combination with surgery.Radiation treatment is supervised by a specialist called an Oncologist.

What tests will the Endocrinologist do?

1. Blood tests can detect whether the pituitary gland is manufacturing enough hormones. Ifany hormones are lacking, it is best to start treatment with hormone tablets as soon aspossible.

2. Complete Pituitary Function tests to assess all the major pituitary hormones.3. Water deprivation test may be required if you are passing much urine and are thirsty.4. An eye test (Visual field test) is used to determine whether there is any pressure on the

nerves controlling vision. This can usually be done on the same day as the Endocrine

Clinic appointment.5. MRI scans are used to obtain a picture of the tumour and can tell the extent of the tumourand whether it is invading or pressing on the surrounding brain. Mostcraniopharyngiomas contain fluid and many also contain some calcium (like bones). This

means that they have a unique appearance on a scan that helps to distinguish them fromother pituitary tumours. There is often a waiting list for an MRI scan.

What type of operation is needed?

The surgeon will attempt to remove most or all of the tumour and preserve as much of thenormal tissue in the pituitary and surrounding brain. The type of operation that is needed will

depend on the exact location of the tumour.

y If the tumour is mainly confined to the area of the pituitary gland, a trans-sphenoidaloperation (through the nose and sinuses) is often used.

y If the tumor is not in this region, the surgeon may need to make an opening in the skull(called a craniotomy) to allow access to the tumour.


19/23

Following surgery, tests are needed to determine if the pituitary gland is functioning normally. Ifit is not, then hormones that are lacking need to be replaced in tablet form.

Why is radiation treatment necessary?

Sometimes it is not possible to completely remove the tumour. If this happens, radiationtreatment may be recommended. The aim of radiation treatment is similar to surgery i.e. todestroy the tumour and preserve or improve pituitary function and vision. Radiation is also given

to prevent a tumour regrowing.

Hormone deficiencies can develop many years after radiation treatment has finished. For this

reason, all people who have undergone radiation treatment should be reassessed by anEndocrinologist. Initially this will happen every few months but later once or twice a year can

suffice.


20/23

PATHOPHYSIOLOGY

Craniopharyngiomas are dysontogenic tumors with benign histology and malignant

behavior, as they have a tendency to invade surrounding structures and recur after what was

thought to be total resection. Craniopharyngioma usually presents as a single large cyst or

multiple cysts filled with a turbid, proteinaceous material of brownish-yellow color that glitters

and sparkles because of a high content of floating cholesterol crystals. Because of its appearance,

it has been compared to machinery oil. It most frequently arises in the pituitary stalk and projects

into the hypothalamus. It extends horizontally along the path of least resistance in various

directionsanteriorly into the prechiasmatic cistern and subfrontal spaces; posteriorly into the

prepontine and interpeduncular cisterns, cerebellopontine angle, third ventricle, posterior fossa,

and foramen magnum; and laterally toward the subtemporal spaces. It can even reach the sylvian

fissure.

Vascular supply is dependent on different sources, usually all from the anterior

circulation. The anterior portion of the tumor is supplied by small perforators coming off A1 (ie,anterior cerebral artery); lateral portions receive perforators from the proximal portion of the

posterior communicating artery; and the intrasellar part is supplied by branches of the

intracavernous meningohypophyseal arteries. Craniopharyngioma rarely is supplied with blood

coming from the posterior circulation, unless the anterior blood supply for the anterior

hypothalamus and floor of the third ventricle is lacking.

Tumor adhesion to surrounding vascular structures represents the most common cause of

incomplete tumor removal. Fusiform dilatations of large surrounding vessels have been reported

after attempts at radical dissection of the tumor capsule; they injure vasa vasorum, thereby

weakening the adventitia. Tumor adhesion is the result of local inflammation. Severalinflammatory cytokines have been shown to be elevated in the craniopharyngioma cyst fluid

when compared with CSF. IL-1alpha and TNF-alpha were significantly elevated but lower than

10-fold. IL-6 was greater than 50,000 times more concentrated in the cystic fluid than CSF.1This

supports the hypothesis that biomodulation of the cytokine profile could lead to long periods of

stability and even tumor regression. IFN-alpha exerts diverse influences mainly on cytokine

antagonists and soluble adhesion molecules and has been shown to play a role in the treatment of

craniopharyngioma in some limited trials, both after systemic use and local, direct intracystic

use.


21/23

DRUGS STUDY

Drugs Dose, Route

and

Frequency

Classification Action/

Indication

Side Effe

Tramadol D:50mg

R: IVF: q8

Analgesic Tramadol is used similarly to codeine,

to treat moderate to moderately severepain and most types of neuralgia,

including trigeminal neuralgia.

y Nausea vomitin

y Diarrhea

Mannitol D: 100 ccc

R: IVF: q6

Diuretic Mannitol is used clinically to reduce

acutely raised intracranialpressure until more definitive

treatment can be applied, e.g.,after head trauma.

y Bradycay Hypoteny Cold

extremit

y Flushing

Cloxacillin D: 1 g

R: IVF: 1 hour

prior to OR

Antibacterial Cloxacillin is used

against staphylococci thatproduce beta-lactamase, due to its

large R chain, which does not allowthe beta-lactamases to bind.

y Nausea vomitin

y Abdomipain


22/23

Gentamycin D: 80 mg

R: IVF: 1 hour

prior to OR

Antibacterial Gentamycin is

an aminoglycoside antibiotic, used totreat many types

of bacterial infections, particularlythose caused by Gram-

negative bacteria.

y Nausea vomitin

y Constip

Dexamethasone D: 5mg

R: IVF: q8

Glucocorticoid Dexamethasone is a potent synthetic

member of the glucocorticoid classof steroid drugs. It acts as an anti-

inflammatory andimmunosuppressant.

y Stomachupset

y Allergicreaction

Ranitidine D: 50 mg

R: IVF: q8

Anti-histamine Ranitidine is a histamine H2-receptor

antagonist that inhibitsstomachacid production.


23/23

CRANIOPHARYNGIOMA

Submitted by:

Ma, Christina B. Talosig

BSN 4D

Group 9

Submitted to:

Mr. Nick I. Alfaro

Clinical Instructor

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