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DMMA COLLEGE OF SOUTHERN PHILIPPINES

College of Nursing
Tigatto Road, Buhangin Davao City

In Partial Fulfillment of the Course Requirements


In Nursing Care Management 104
Related Learning Experience

Brain Tumor Grade III


“Anaplastic Astrocytoma”

Presented to:
4th year level clinical instructors of DMMA College of Southern
Philippines

Presented by:
Cagabhion, Joanna Mae; Apurada,Ingrid Katrina;
Padilla,Chucky Angelo; Arevalo,Hanneli Mae;
Falco, Gracelyn Joy; Cubero, Elden Joy;
Martin, Joani Joel; Bermoy, Floridel;
Caluban, Lilibeth; Lumasag, Mark;
Callar, Jonna
ACKNOWLEDGEMENT

We, the Group 4 of DMMA College of Southern Philippines, extend


our heartfelt gratitude to the following for their valuable
contribution to this case presentation…

Patient Mrs. Maruja, and her immediate family…

The family, particularly two of her daughters, have been very helpful
in providing us details and giving us a clearer picture of who Mrs.
Maruja is, speaking in behalf of their now incoherent and
incapacitated mother.

Our clinical instructress during the ICU exposure, Ms. Rizza Lei
Loreto, R.N…

She has given us insights and background of the disease, and has
spared us some time to gather and collate data relevant to this case.
Her positive outlook and caring nature has helped us look past beyond
our faults and shortcomings, pushing us to do better and learning from
our mistakes. Thank you, Ma’am.

Clinical instructors Ms. Pamela M. Veroy, R.N., Ms. Lovely B.


Lagat, R.N., and level IV coordinator Mr. Alberto S. Alejandre II,
R.N…

For laying the foundation of our knowledge and skills needed for us to
be efficient nurses and effective proponents of this noble profession;
for disciplining us to be responsible for every action we do, and for
looking out for our safety and security.

DMMA College of Southern Philippines…

For being our training ground in enhancing our capabilities as future


nurses.
The staff of MCDC (Medical Center Of Digos Cooperative)…

Namely the physicians, nurses, and nursing assistants, who were kind
enough to allow us to use the patient’s data to aid us in the
presentation of this case.

Our beloved parents and guardians…

For their patience, and undying emotional and financial support to


achieve our goals and dreams. Thank you very much.

Our groupmates…

For accomplishing each task assigned to them; for the many wonderful
memorable moments and the bond that we share.

Above all, our God Almighty, the supreme ruler of the universe,
in whom all things find their purpose.
TABLE OF CONTENTS

A. Acknowledgement--------------------------------------------- ii
B. Introduction------------------------------------------------ 1
C. Objectives-------------------------------------------------- 3
a. General objectives
b. Specific objectives
D. Personal information----------------------------------------- 5
a. Patient’s Data
b. Family Health History
c. Genogram
d. Past Health History
e. Present Health History
f. Developmental Data
E. Physical Assessment----------------------------------------- 10
F. Anatomy & Physiology---------------------------------------- 14
G. Pathophysiology--------------------------------------------- 18
a. Etiology
b. Symptomatology
c. Diagram
d. Narrative
H. Medical Management------------------------------------------ 28
a. Doctor’s Order
b. Laboratory & Diagnostic Exams
c. Drug Study
I. Nursing Management------------------------------------------ 46
a. Nursing Care Plans (3 Actual & 2 High Risk)
b. Prognosis
c. Discharge plan
J. Bibliography------------------------------------------------ 65
INTRODUCTION

Human existence is always associated with complexities. Man in


itself is a structured compound. It is with systems and subsystems
that interrelate its functions to enable to breathe, to move, to
think.
The main switch in a man’s anatomical and physiologic function is
his brain. The brain contains a vast network of neurons that control
the body’s vital functions. Yet this system is vulnerable, and its
optimal function depends on several key factors. Thus, any alteration
to this system and function greatly affects the body as a whole.
From the latter function and the activity of the brain, revolves
the basic ideology of this case study. A brain tumor is a mass of
cells that have grown and multiplied uncontrollably. Primary brain
tumors originate in the brain and rarely spread to other parts of the
body.
The incidence of brain tumors appears to have increased in the
past few decades. And an estimated 18,000 new cases of malignant
tumors occur per year: 14.2 per 100,000 men and 13.9 per 100,000 women
(ABTA, 2009). Tumors in the brain ultimately cause death by impairing
vital functions, such as respiration, or by increasing ICP.
This case study which primarily talks about brain tumor is
directed towards presenting the disease per se, the management and
interventions and the other vital facts that remain in oblivion to the
great number of population of this country.
Considering that brain tumor truly and evidently has a
devastating impact on our nation’s health, our group, Group 4 BSN IV
of DMMA College of Southern Philippines, has regarded this study
significant to the fields of nursing education, practice and research
because the completion of this study does not only comply for
dissemination information purposes, but for sensible learning as well.
In the same way it is our own means of posing a challenge to the
innovative minds of this field to come up with important advances not
only in its diagnosis but more so to the consistent improvements in
its therapies.
The existence then is full of surprises. It is in a continuous
cycle that is barely fathomable by the human mind. Brain tumor for one
is notorious. It is hard to accept and is immensely difficult to treat
effectively. Thus, this case study on brain tumor basing on Maruja’s
condition becomes an inspiration that we as a group, through our
thorough study and learning of this disease process could change its
standard of care. Hard as it may seem, but with the will, one
innovation in this field would set up the window of opportunity. We
can make a change and we can start this change now.
OBJECTIVES

General Objectives:
That within our four weeks E.R./I.C.U. exposure (Medical Mission
Group of Hospital, Davao Adventist Hospital, Medical Center of Digos
Cooperative), we may be able to choose a case study that will
contribute and expand our knowledge and improve our skills on specific
procedures concerning our recent concept which is Acute Biologic
Crisis/Emergency-Disaster Nursing.
Our group has formulated the following Specific Objectives to
guide us towards the completion of this case study. That within our
four weeks E.R./I.C.U. exposure (MMGH, DAH, and MCDC), we may be able
to:
 Select a relevant subject for our case study;

 Establish good interpersonal and professional relationship


with our patient and his accompanying family member;
 Formulate an introduction that can present a concise
overview of the case study;
 Identify its contribution in the fields of nursing
education, practice, and research;
 Formulate specific, measurable, attainable, realistic and
time bounded objectives that will serve as a guide for the
accomplishment of this study;
 Collect data regarding the past and present health history
of our patient;
 Assess our patient in a cephalocaudal direction to serve as
our baseline data in determining the changes in patient’s
body;
 Determine and discuss the anatomy and physiology of the
body systems involved,
 Identify the predisposing and precipitating factors that
contribute to the onset of the disease;
 Trace the pathophysiology of the disease process;
 List the actual and possible symptoms that our patient my
manifest;
 Study and relate the significance of the diagnostic
examinations done;
 Research on the drug study of the medication given to our
patient;
 Formulate effective nursing care plan with three actual
problems and two high risks problems;
 Share our knowledge and skills to our chosen patient;
 Work together with the health team providing continuous
care;
 Provide significant health teachings that would promote our
patient’s health and wellness; and
 List all the references used in the study.
PATIENT’S DATA

Name: Maruja
Birth date: May 25, 1948
Age: 61 years old
Sex: Female
Birthplace: Digos City
Address: B28, L32 Emily Homes Digos City
Civil Status: Widow
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: College Graduate-BSed
Siblings: 9 Siblings
Children: 9 Children
Chief Complaints: Fever and Chills
Diagnosis: Brain Tumor Grade III “Anaplastic Astrocytoma
Attending Physician: Dr. Robles
Date of Admission: September 25, 2009
Time of Admission: 9:45 PM
HEALTH HISTORY

Family Health History


The informants of this history taking are the children of
Maruja. Her children cannot recall specific information regarding
their grandparents. The information they can recall is that, the
mother of Maruja was hypertensive and died due to old age & the her
father was also hypertensive and died due to prostate cancer. The
informants can no longer remember the details regarding the siblings
of the father and mother of Maruja. Also, they can no longer remember
the grandmother and grandfather of their mother.
Regarding the health of the brothers and sisters of Maruja,
most of them are hypertensive. The eldest died because of diabetes
mellitus. The 3rd sibling died due to prostate cancer.
*Refer to GENOGRAM.

Past Health History


>GENERAL- Fair, attributing to what the client’s daughter said,
she stated that her mother works five days a week, eight hours a
day and was able to complete the 8 hours sleep regimen thus she
wasn’t able to exercise daily as part of healthy lifestyle, her
diet is composed of meat and she seldom prefers vegetable.
Since the daughter wasn’t able to describe the complete
description of her lifestyle we concluded that her health history
isn’t at all healthy and can’t also be considered as healthy.
>PAST ILLNESSES- History of untreated hypertension (Essential
Hypertension) since 1994. History of DM II since 1994. No history
of measles, mumps, diphtheria, or whooping cough. History of
chickenpox during her first pregnancy.
>INJURIES- - History of motorcycle accident last 2006 and was not
hospitalized. Sustained concussions and multiple abrasions.
Treated only at home.
>HOSPITALIZATIONS- 2009-7x Hospitalized due to sudden weight loss
and anorexia.
>SURGERY- Fistula (Details can no longer be remembered by
informant) & Craniotomy/Craniectomy Last March 2009
>ALLERGIES- Chalk
>IMMUNIZATION- Complete
>SUBSTANCE ABUSE- Tobacco 1 stick per meal
>DIET- Meat Eater, Grilled Meats (sinugbang Bangus)
>SLEEP PATTERN- well rested; 7-8 hours of sleep
>CURRENT MEDICATIONS- Norten 10mg O.D.
Food supplements-(Details cannot be
remembered by informant)
Herbal medicines-(Details cannot be
remembered by informant)
Present Health History
Last February, Maruja was diagnosed to have brain tumor”
Anaplastic Astrocytoma”. Last March, she underwent
craniotomy/craniectomy and a month after patient underwent radiation
therapy for just 12 days. The family decided to stop the radiation
therapy.
Three months prior to admission patient experience headache,
seizure, vomiting, visual disturbance. Repeat CT scan was done and
found out that there is recurrence of tumor.
One week prior to admission, the patient was admitted due
to decrease platelet concentration, platelet transfusion was done with
8 units infused. A day prior to admission she develop fever associated
with chills and watery stools these prompted admission.
DEVELOPMENTAL DATA

Human growth and development is an interdisciplinary scientific


study of the ways people change over time. It covers quantitative and
qualitative changes from conception to death and stresses the process
of life changes from physical, cognitive and social-cultural aspects.
This case study focuses on Erik Erikson’s psychosocial theory and
Robert Havighurst’s physiological development theory.

A. ERIK ERIKSON’S PSYCHOSOCIAL THEORY

Middle Adult: 40 – 65 years old


Psychosocial Crisis: Generativity vs. Stagnation
• Generativity is the concern for establishing and guiding the next
generation.
• Becomes more altruistic and concepts of service to others and
love and compassion gain prominence.
• Becomes more engaged with civic and social works.

In the process of our interview, we found out that our client


achieved the sense of generativity. Our client is mainly concerned in
guiding her children. She often teaches her children to be good and be
responsible persons along in their lives. Prior to the diagnosis of
her current condition, she has been very satisfied and fulfilled
because almost all of her children are professionals and have their
own stable jobs. The children have told us that sometimes she
socializes with her old friends.
B. ROBERT HAVIGHURST’S PHYSIOLOGICAL THEORY

Middle Age: 40 – 65 years old


• Achieving adult civic and social responsibility.
• Establishing and maintaining an economic standard of living.
• Assisting teenage children to become responsible and happy
adults.
• Developing adult leisure time activities.
• Relating oneself to one’s spouse as a person.
• Accepting and adjusting to the physiologic change of middle age.
• Adjusting to aging process.

Based on our client, she was socially responsible. When it comes to


their economic status, they are stable and have maintained a good
living environment at home. Her children said that they were always
reminded to be responsible and to be in control of their own lives
especially now that she has brain tumor and can no longer assume her
responsibility as a mother to them. Furthermore they were advised by
her to help each other out whenever one is in trouble.
PHYSICAL ASSESSMENT

Name: Maruja Dx: Brain Tumor Grade III


Age: 61 years old “Anaplastic Astrocytoma
Sex: Female Attending Physician: Dr. Robles

Date and time of Assessment: September 28, 2009, 4:00 PM

GENERAL SURVEY
Received this patient, a 61 year old woman who is lying in bed,
not in respiratory distress. She appears slightly older than her
stated age. Awake, with IVF of #4 PNSS 1L @ 80cc/hour, infusing well
at right arm. Glascow Coma Scale of 7/15.
During assessment she is conscious but cannot verbalize.

VITAL SIGNS
Patient has temperature of 36.7 degrees Celsius, axillary, with
heart rate (HR) of 121 beats per minute, pulse rate (PR) of 120 beats
per minute; regular respiratory rate (RR) of 21 breaths per minute;
BP-100/70 mmhg. GCS of 7/15

SKIN
The skin is light cool and dry. Scattered lentigens are present
all over the body. No nail abnormalities present. Skin turgor noted to
be poor.

HEAD
The head is deformed on the craniotomy/craniectomy site.
Patient’s hair assumes the color white, is observed to be fine in
consistency and soft in texture. The scalp is dry with evidence of
scars and lesions. Patient has symmetrical facial features. Upon
command, patient cannot move eyebrows, frown, close eyelids tightly
and smile.
EYES
The client’s eyelids and eyebrows are symmetrical in alignment.
The pupils are round and are reactive to light. Accommodation was not
well seen. Patient cannot see peripherally, she is using central
vision only. The visual fields by confrontation cannot be assessed.
Patient cannot follow the direction anymore. Lid margins are clear,
lacrimal duct openings are evident at the nasal side the upper and
lower lids.

EARS
Auricles have the same color as the facial skin. They are
symmetrical and are aligned with the outer canthus of the eyes.
Auricles are flexible, firm, and nontender. Upon assessment, no
redness or purulent discharges were seen on the external canal.
Patient is only able to hear when spoken to in a loud tone.

NOSE
The nares of the patient’s nose upon assessment appear to be
normal with its septum in midline. The mucosa is pinkish in color and
both nares are patent. Symmetrical olfactory organs, thus, in good
condition.

MOUTH
Lips appear to be dry and pale. The mucosa of the oral cavity is
pale and without masses, leukoplakia or other lesions. There is good
dentition and good dental hygiene. The tongue is in midline and does
not deviate to other side. The rest of the other parts of the mouth
and throat appear to be normal.

PHARYNX
The patient’s uvula is in midline. Tonsils noted to be
obstructive. Thus, patient’s appetite is not good. Patient has
difficulty swallowing.
NECK
The patient’s neck is symmetrical. Upon palpation, lymph nodes in
the neck are not swollen. Thyroid glands not tender and not enlarged.
Neck muscles are equal in size. Trachea is positioned in the midline
upon palpation.

CHEST AND LUNGS


The chest upon inspection is normal in shape. The patient’s
breathing is regular. Posterior mobility and posture of the thorax
upon respiration is symmetrical. Chest expansion is symmetrical.
Breath sounds upon auscultation is resonant.

HEART
The apical beat of the heart is heard over the apex of the heart
which is located at the fifth intercostal space (point of maximal
impulse). Heart sounds are regular at S1-S2 base. No murmurs or skip
beats noted.

BREAST AND AXILLA


Breast sizes are equal, slightly rounded and symmetrical. Nipples
are similar, small, rounded and with a fair brown color. Areolas are
round and bilaterally the same. Axilla is smooth without lesions. No
enlarged lymph nodes or masses upon palpation.

ABDOMEN
The abdomen is generally symmetrical in configuration and has
normal growling sounds of 12. Upon percussion, the abdomen is tympanic
in sound. No masses or pain noted upon palpation.

GENITO- URINARY
Children said there is no problem with the genitals. There are no
lesions as verbalized by their children. Excretion and elimination of
waste is daily. Patient is currently in diapers. Stool yellowish in
color and urine is light yellow in color.
BACK AND EXTREMITIES
The peripheral pulses are regular when assessed. Her nails and
nail beds appear to be pinkish in color. Range of motion not noted.
Her muscle tone and strength on both extremities are weak. Spine is in
midline. Stature and gait is unassessed due to her bedridden state.

Cranial Nerves

Olfactory: The client was able to identify the aroma of served foods.
Optic: The client was not able to read reading materials.
Occulomotor: The client was not able to follow moving objects
gradually.
Trochlear: The client was not able to follow any moving objects
gradually.
Trigeminal: The client can feel pain, she can’t differentiate cold and
hot temperature. And was able to move his jaw during mouth opening
gradually.
Abduscens: The client was able to move his eyes laterally in slow
motion.
Facial: The client can’t express any facial expression.
Vestibulocochlear: The client can’t maintain equilibrium with
assistance and can’t hear words clearly.
Glossopharyngeal: The client can swallow food and not able to move his
tongue in different ways.
Vagus: The client was able to swallow normally.
Spinal Accessory: The client was able to move his head and shoulders
in a moderate manner.
Hypoglossal: The client was able to move his tongue gradually.
ANATOMY AND PHYSIOLOGY

The Central Nervous System

The essential components of the central nervous system (CNS) are


the brain and spinal cord.

Brain
The brain is a soft, spongy mass of nerve cells and supportive
tissue connected to the spinal cord. The brain of an adult weighs
approximately three pounds. In the center of the brain are four
connected hollow spaces called ventricles. The ventricles contain a
liquid called cerebrospinal fluid (CSF) that circulates throughout the
CNS. The brain controls our five senses in addition to our emotions,
thoughts, speech, physical coordination, movement, and sensation.

Spinal Cord
The spinal cord is a long, cylindrical mass of nerves that
extends from the brain stem down the length of the spine. The spinal
cord controls movement and sensation.
The CNS uses billions of nerve cells, nerve fibers and supportive
cells to relay messages to the rest of our body. The CNS is different
from the peripheral nervous system (PNS). The PNS is made up of nerves
that connect the CNS to the sensory organs, muscles, blood vessels,
and glands. The brain and spinal cord are protected by the skull, the
spinal column, and the meninges.

Skull
The skull is a framework of eight cranial and 14 facial bones
that protect the brain from being damaged. The cranium, the part of
the skull that covers the brain, is made up of four major bones: the
frontal, occipital, sphenoid, and ethmoid bones. There are four other
bones in the cranium: two temporal bones, which are located on the
sides and base of the skull, and two parietal bones, which fuse at the
top of the skull. The areas where the bones in the skull meet are
called suture lines.

Spinal Column
The spinal column is composed of 33 irregular, spool shaped bones
called vertebrae that are stacked one on top of the other. The spinal
column is divided into five sections that extend from the base of the
skull to the tailbone: the cervical, thoracic, lumbar, sacral and
coccygeal. The spinal column protects the spinal cord.
Three membranes, or layers of tissue called meninges, surround the
brain and spinal cord.

Ventricles
The ventricles are four connected, fluid-filled cavities located
in the center of the brain. The ventricles contain the choroid plexus,
structures that produce cerebrospinal fluid.

The Sections of the Brain


The brain is divided into sections, each of which controls a
distinct aspect of human movement and behavior. A brain tumor can
affect function (movement and/or behavior) depending on where in the
brain the tumor is located.

Cerebrum
The cerebrum is the largest area of the brain. It has two
sections called the right and left hemispheres. The right cerebral
hemisphere typically controls the left side of the body, whereas the
left cerebral hemisphere controls the right side of the body. Each
hemisphere is further divided into four sections called lobes: the
frontal, parietal, temporal and occipital lobes. Each lobe controls
different behaviors and sections of the body. The outer layer of the
brain is called the cortex. It is made up of bodies of nerve cells
known as gray matter. Much of the brain’s activities occur in the gray
matter. The internal layers of the cerebrum are made up of nerve
fibers called axons or white matter. The white matter contains nerve
fibers that allow communication between the brain and various parts of
the body. The cerebrum also houses many internal nerve structures,
such as the thalamus, hypothalamus and pituitary gland. These
structures are responsible for processing different messages being
sent to the brain and for sending messages from the brain to other
parts of the body.

Frontal Lobes
The frontal lobes make up the front portion of the cerebral
hemisphere. The frontal lobes control many of the brain’s activities
including attention, abstract thought, problem solving, reasoning,
judgment, initiative, inhibition, memory, parts of speech, moods,
major body movements, and bowel and bladder control.

Parietal Lobes
The parietal lobes are in the upper central portion of the
cerebral hemispheres. The parietal lobes process all messages being
sent to and from the brain regarding physical sensations. The parietal
lobes are responsible for interpreting the meaning of physical
sensations to determine such factors as size, shape, weight, texture
and consistency. They interpret spatial orientation and how we are
aware of the parts of our own body. The parietal lobes also help us to
make calculations, read and write.

Temporal Lobes
The temporal lobes form the lower portion of the cerebral
hemispheres. The temporal lobes manage most auditory activities in the
brain by translating words into meaning. There is also a small,
important section of the temporal lobe that controls the brain’s
ability to form long-term memory patterns. The left temporal lobe
controls language comprehension in most people. For this reason, the
left temporal lobe is considered the dominant lobe.

Occipital Lobes
The occipital lobes are in the back portion of the cerebral
hemispheres. The occipital lobes control vision. The right occipital
lobe processes what is seen out of the left field of vision, and the
left occipital lobe processes what is seen out of the right field of
vision.

Cerebellum
The cerebellum, located behind the brain stem, has many
connections to the brain and the spinal cord. The cerebellum is
responsible for coordinating muscle groups and controlling small
movements and balance.
ETIOLOGY

Predisposing Present Justification


Age and Gender • The average age that an adult is
>61 years old diagnosed with a brain tumor is
57years. Rates for neuro epithelial
tumors (gliomas) are almost 1.4 times
greater in males than females.
Glioblastomas, lymphomas, and germ
cell tumors are more common in males
than in females. In contrast,
meningiomas affect twice as many
females as males. The findings of one
study suggest that female hormones may
have a protective effect against
certain types of brain tumors. More
investigation is necessary to account
for gender differences. Tumors in
cranial and spinal nerves and in the
sellar region of the brain (the area
just behind the eyes) occur equally in
males and females.
Geography and There is a lot of variation in the
Ethnicity trends of brain tumor patients along
geographic and ethnic lines. Access to
health care is one influential factor.
Reported rates for primary malignant
brain tumors tend to be higher in
countries with more accessible and
highly developed medical care, such as
Northern Europe and the United States.
Countries such as India and the
Philippines have the lowest reported
rates. This would seem to indicate
that the difference is due to better
diagnosis and reporting in more
developed countries. However, there is
some evidence that cultural, ethnic,
or geographic differences do play a
role in the disease.
Hereditary and • “Genetic predisposition,” as it is
Genetic Influences called, probably accounts for less
> Maternal side than five percent of brain tumors.
grandfather Other people may have what researchers
prostate cancer call a “genetic susceptibility” for
developing cancer.
Genetic susceptibility means their
bodies may not be as efficient at
processing certain substances,
removing carcinogens, or repairing
damaged DNA. When exposed to toxic
agents in the environment, they may
more easily develop cancer. It seems
likely that the majority of brain
tumors are linked to interactions
between genes and toxins in the
environment, because such a small
percentage of brain tumors are linked
to heredity. Molecular studies have
found deletions (missing parts) or
mutations (defects) of crucial genes
that control the cell cycle. These are
suspected to play a role in forming
brain tumors. Many patterns of
deletions and mutations have been
identified in some tumor types. There
is still much work to be done to
systematically identify the molecular
alterations in primary brain tumors
and to develop methods to treat them.
Precipitating Present Rationale
Ionizing Radiation 1. Treatment of disease with therapeutic
> Radiation Therapy ionizing radiation (including x-rays)
for 12 days is a strong risk factor for brain
tumors. One study showed a high rate
of prior therapeutic irradiation among
patients with glioblastoma.
Second primary brain tumors also occur
more frequently than expected
especially among patients treated with
radiation therapy.
Exposure to • Several types of viruses have been
Infections, shown to cause brain tumors in
Viruses, and experimental animal studies. Since it
Allergens is so difficult to design meaningful
>Allergy to Chalk studies on humans, the topic has
received little attention. There have
been findings which raise the
possibility that certain allergies and
common infections (including chicken
pox and shingles) may play a role in
preventing brain tumors. More study is
needed.
Head Injuries and • Serious head trauma has long been
Seizures suspected as a cause of brain tumors.
>motorcycle In fact, studies show a positive
accident last 2006 correlation between head trauma and
meningioma, but a negative link to
glioma. A history of seizures has been
consistently associated with brain
tumors, but since brain tumors are
known to cause seizures, it is unclear
if seizures and/or seizure medication
can increase tumor risk. As for drugs
and medications, there have been few
studies of any links to adult brain
tumors.
Diet • In animal studies, certain chemical
> Meat Eater, substances known as N-nitroso
Grilled Meats compounds have been clearly identified
(sinugbang Bangus) as carcinogenic (causing cancer) to
the nervous system.
N-nitroso compounds are present in
cured meats (nitrites), cigarette
smoke, cosmetics, and many other
sources. These compounds are also
produced inside the human body as the
digestive process breaks down food
(including vegetables) and drugs.
Given the great amount of exposure to
these compounds and the variety of
sources, it is extremely difficult to
determine any individual’s lifetime
exposure.
Some studies of diet and vitamin
supplementation seem to indicate that
dietary N-nitroso compounds might
influence the risk of both pediatric
and adult brain tumors. Researchers
have observed in some studies that
brain tumor patients (or their
mothers) have generally consumed more
cured foods than control groups.
Avoiding cured food and eating more
fruits and vegetables that are high in
anti oxidant vitamins may lessen the
risk of developing cancer.
Chemicals in the Some workers are exposed to
Workplace and the carcinogenic or toxic substances in
Home the workplace. Researchers have
attempted to pinpoint links to brain
tumors, but gathering evidence is
difficult. Workers are rarely exposed
to one single chemical, and certain
chemicals probably interact with
others to increase or decrease risk.
Therefore, researchers have been
unable to make any definite links
between brain tumors and specific
chemicals, even those known to be
carcinogenic.
Cellular Telephones Electromagnetic Fields With the
and Radio Frequency expansion of wireless communication
(RF) technologies, radio frequency (RF)
exposure is an important concern. It
is important not to confuse RF fields
with ionizing radiation, such as x-
rays or gamma rays. Unlike ionizing
radiation, RF fields cannot cause
ionization or radioactivity in the
body. Because of this, RF fields are
called non-ionizing.
Concern over possible health effects
of using cellular telephones has
prompted studies looking at the
relation between cell phone usage and
an increased risk of brain tumors. The
results of several studies suggest
that there is no association. However,
it may be important to continue study
in this area because cell phone usage
is becoming increasingly common.
Many studies were conducted during a
time when analog phones were the main
type of cell phone, as compared to
digital phones today. Total amount of
phone use was lower, and the number of
cell phone users was fewer then.
Moreover, long-term studies are
probably needed because some brain
tumors may take a long time to
develop.
Air Pollution • Certain toxic air pollutants are known
>Exposed to to cause cancer in humans. Ultra fine
Pollution-Commuter particles, including diesel soot and
other combustion products, are able to
lodge deep in human lungs and even
enter the bloodstream due to their
microscopic size. One study is
investigating a possible link between
brain tumors and air pollution.

SYMPTOMATOLOGY

Symptoms Presence Rationale


Anorexia • Maybe due to side effects of treatment
such as opiates, radiotherapy or
chemotherapyany of which may decrease
food intake. (Smeltzer and Bare 2008)
Weight loss • Cancer cells are voracious consumerr
of nutrients that were supposedly for
the body. (Smeltzer and Bare 2008)
Increased • According to moroe-Kellie, if one of
Intracranial Pressure the components of the skull increase
in volume ICP also increases, a
condition which is then accopanied by
headache and nausea and vomiting.
(Brunner’s and Suddarths 2008)
Headache • Common in the morning which is made
worst by coughing, straining and
sudden movement; may also be due to
Tumor invading,compressing or
distorting the pain sensitive
structures of the brain;other
contributing factors are edema and
increased ICP. (Brunner’s and
Suddarths 2008)
Vomiting • Usually due to irritation of the Vagal
centers in the Medulla. (Brunner’s and
Suddarths 2008)
Seizure-like • Due to involvement of Motor Cortex
Movements wherein there is paroxysmal discharges
which is manifested by grand-mal
seizure and somewhat alterations in
sensation. (Brunner’s and Suddarths
2008)
Visual Changes • Such as Visual hallucinations,
homonymous hemianopsia is due to
involvementof occipital lobe and or
due to presence of lessions among the
pathways of visual area. (Brunner’s
and Suddarths 2008)
Dizziness • Primarily due to involve ment of
cerebellumwhich is responsible for
skeletal muscle activity and controls
our balance and equilibrium.
(Brunner’s and Suddarths 2008)
Changes in emotional • Due to involvement of frontal lobe
state and behavior, which is responsible for Intellectual
Difficulty thinking, reasoning, speech and behavior.
speaking, or finding (Brunner’s and Suddarths 2008)
words
Tinnitus and vertigo • Due to Eight Cranial nerve
(vestibulocochlear) dysfunction the
one responsible for transmission of
impulsesfor sense of balance and sense
of hearing. (Brunner’s and Suddarths
2008)
Numbness and Due to involvement of fifth cranial
tingling of face and nerve (Trigeminal) which is involve in
tongue facial sensation, corneal reflex and
mastication. (Brunner’s and Suddarths
2008)
Weakness and • Due to involvement of seventh cranial
paralysis nerve which is involved majorily in
facial expression and muscle movement,
salivation and tearing,taste,
sensation in the ear. (Brunner’s and
Suddarths 2008)

Precipitating Factors:
• Diet- Meat Eater, Grilled
Meats (sinugbang Bangus)
PATHOPHYSIOLOGY
• Illnesses- DM II Since 1994
• Injuries-motorcycle accident
Predisposing factors: last 2006
• Genetics- Maternal side • Allergens-Chalk
grandfather prostate
• Substance abuse-Tobacco 1
cancer
stick per meal
• Age- 61 yrs. old • Ionizing radiation-Radiation
• Geography and Ethnicity Therapy for 12 days
• Sex • Environment-Exposed to
Pollution-Commuter
Multi-bit
Hypothesis:
• Ionizing
radiation Glial cells in the brain.
• Cellular Glioblastoma-most common brain tumor.
telephones Anaplastic astrocytoma is common among
• Head trauma elderly people. (Smeltzer & Bare)
• Age
• Genetics
• Illnesses
• Injuries
• Diet
• Substance
abuse

Cellular Damage

Apoptosis
Persistence of Multi-
bit Factors

 Point mutation
 Chromosomal
translocation
 Chromosomal
amplification
 Chromosomal change
 Gene silencing

Invasion Signs and Symptoms:

Cellular • Headaches, which can be


Aberration most severe in the
morning
• Seizures or convulsions
Tumor growth
• Anorexia
(obstruction)
• Weight loss
• Dizziness
• Changes in Emotional
state and behavior
• Tinnitus and vertigo
Progression Progression

Progression

Signs and Symptoms:


Increased tumor size
• Difficulty thinking,
Consumption of speaking, or finding words
nutrients by tumor • Personality changes
• Weakness or paralysis in
Tumor growth to one part or one side ofthe
different areas of body
the brain • Vomiting
• Loss of balance
Increased ICP
• Vision changes
Compression of parts • Nausea or vomiting
• Confusion and
disorientation
• Numbness and tingling of
face and tongue

If not treated:

If treated:

Medical-Surgical management
• Surgery-
Craniectomy/Craniotomy
last March 2009
• Radiotherapy-Radiation
therapy for 12 days
• Chemotherapy

POOR PROGNOSIS
(Patient up to this level only)

Cerebral Ischemia Primary malignant


neoplasm
• VEGF-Vascular
Endothelial
Cerebral Growth Factor
Hypoxia • TAF-Tumor
Angiogenesis
Factor

Inflammation

Cerebral edema Angiogenesis

No Room for Invasion to lymphatic


Expansion and blood vessels

Cardiac/respiratory
arrest Arrest in capillary
bed organs

Transport interaction
DEATH with other blood
elements

Adherence of tumor
cells

Metastasis

DEATH
NARRATIVE PATHOPHYSIOLOGY
The cause of brain tumor is unknown. The only known risk factor
is exposure to ionizing radiation, Additional possible causes (multi
hit hypothesis) have been investigated, but results of studies are
conflicting and convincing; suggested causes have included use of
cellular telephones, exposure to high tension wires, use of hair dyes,
head trauma, and dietary exposure to such factors as nitrates C found
in some processed and barbecued foods.
In this particular case study, the tumor originated within the
brain tissue (e.g. glioma) specifically in the frontal lobe. Maruja’s
brain tumor was graded III “Anaplastic Astrocytoma”.
Glial cells are cells that make up the structure and support
system of the brain and spinal cord. These cells are damage due to
different factors (Multi hit hypothesis) and their will be a
programmed cell death or apoptosis. There is persistence of this multi
hit factors. The effect would be point mutation, chromosomal
translocation, chromosomal amplification, chromosomal changes and gene
silencing. Cellular aberration will then occur. The abnormal glial
cells form a clone and begin to proliferate abnormally, ignoring
growth regulating signals in the environment surrounding the cell.
Thus, tumor growth occurs. Then there would progression of the tumor.
The tumor increases in size. There will be consumption of nutrients by
tumor and tumor will grow to different areas of the brain. Then the
effect would be increased intracranial pressure and there will be
compression of the brain.
If the brain tumor is treated with surgery, radiation and
chemotherapy, the patient will likely to have poor prognosis. If the
tumor is not treated then Death or Metastasis will occur.

DOCTOR’S ORDERS

9/25/09
10:15PM Pls. admit under the service of Dr. Robles
 V/S q2°

 NPO temporarily
 Labs : CBC, typing
U/A
RBS ↑ 27.8
FBS
Na, K
Crea
ECG
Stool exam with occult blood

 Start venoclysis PNSS 1L @ 80 cc/°


 Meds:
1. Paracetamol 500mg 1 tab q4° PRN
2. Decilone forte 5mg 1 tab TID
3. Piozone 15mg 1 tab OD
4. Nexium 40mg 1 tab OD
5. Piracetam 800mg 1 tab OD
6. Keppra 500mg ½ tab in AM; ¼ tab in PM
7. Polynerve 1 tab OD
 Give regular insulin 10 µ SQ & 10 µ IVTT now

 For rpt RBS every 2 hours


 MHBR

 O2 inhalation @ 2-3 L/m


 Will inform AP. Refer accordingly

 Ranitidine 1 amp IVTT q8hrs


 Mucosta 1 tab TID

 RBS monitoring q6°, to refer


9/26/09
 Give regular insulin 10 µ SQ now

 NPO except meds


1:15 am
6:30 am
8:40 am
5:20 pm  Pls. do plt. Hct monitoring q8°

 IVF of PNSS 1 L to follow SFSR


 Tranexamic acid 500mg 1 cap TID

 Vit. K 1 tablet OD
 Hold platelet monitoring

 Shift Ranitidine IV to Nexium 400mg 1 tab OD as


ordered
 Soft diet
 FD to 200 cc IVF to regulate 80 cc
6:10 pm
 SD dopamine 200/200mL to run @ 20 cc/hr
 Pls. give 10 µ SQ regular insulin now
6:26 pm
 Pls. give 8 units regular insulin SQ now

9/27/09
 ↓ dopamine to 15 gtts/min

12:10 am
 Nebulize with Combivent q8°
6:45 am
10:20 am

 Start Levofloxacin 500 mg (Floxel) 1 tablet OD


 ↓ Tranexamic acid to PRN for active bleeding

 IVF TF: PNSS 1L @ SR


 Give 8 µ RI SQ

 Dopamine 200/250 premix to run @ 15 gtts/min


DIAGNOSTIC AND LABORATORY TESTS

TEST Result Normal Clinical Significance


Values
HEMATOLOGY
September 26, 2009

WBC 3.9 5-10 LOW-


RBC 3.72 4.20-6:30 LOW-
HGB 105 120-160 LOW-
HCT 32.3 37-47 LOW-
MCV 86.7 80-97 NORMAL
MCH 28.2 26-32 NORMAL
MCHC 325 310-360 NORMAL
PLT 36 150-400 LOW-

BLOOD CHEMISTRY FBS RESULT NORMAL VALUES Clinical Significance

Time SI UNITS 3.87-5.83 All result are above


12NN 14.8mmol/L normal range and increase
6AM 17.2 fasting plasma glucose
6PM 18.3 levels may also stem from
12NN 19.3 brain tumor.
12:15AM 22.9
6PM 12.6
12NN 6.9
6AM 11.0
Increase fasting plasma
RBS glucose levels
8.76 3.87-5.83
CREATININE 75.31 53-150 Provide more sensitive
measure of renal damage
than blood urea nitrogen
levels, non protein end
product of creatinine
metabolism that appears
in serum in amount
proportional to the body
muscle mass
SODIUM 150 130-150 Sodium level is within
the normal range
POTASSIUM 3.4 3.5-5.3 In hypokalemia serum
potassium level is
decreased

ECG shows flattened T-


WAVE elevated U-WAVE,
positive decreased ST
segment.

Eleanor C. Ong, M.D.


8/24/09

Medical Certificate

Maruja was admitted @ DDH from 8/7/09 to 8/22/09 due to ICP for
Grade 3 Anaplastic Astrocytoma for radiotherapy.
John E. Mata, M.D.
08/06/09

S/P Craniotomy for excision of brain tumor on March 17, 2009 @


Davao Regional Hospital.
Histopath: Anaplastic Astrocytoma
Pls. see repeat CT scan
Plan: for radiation therapy and possible chemotherapy
Referral to oncologist.

DRH, Apukon, Tagum City

Date: Aug. 03. ‘09


CT Film No. 09-414
Parts examined: cranium
Type of Examination: CT scan
Referred by: Dr. Mata
Findings
CT scan of the Brain:
Multiple contiguous axial images of the brain were obtained. Non-
ionic intravenous contrast was given.
Reference made from the previous CT examination dated March 20,
2009.

Clinical history: S/P craniectomy secondary to anaplastic


astrocytoma.
Present finding of an enhancing residual, heterogenous mass with
ill-defined borders seen occupying both frontal lobes. The mass
approximately measures 6.6 x 6.7 x 6.5 cm (AP x W x CC). There is
increase in compression of both lateral and 3rd ventricles. The
temporal horn of the right lateral ventricle is dilated. There is
complete resorption of the intracranial hemorrhages and
pneumocephalus. There is no interval change in the well-defined
hypodensity seen in the thalamus. There is no midline shift.

The sella and CP angles are normal for the patient’s stated age.

There is interval decrease in the opacities of both frontal


sinuses. Sclerotic changes are seen in both mastoids, unchanged.

Craniectomy change is noted in both frontal bones.


Impression:
• Bilateral frontal lobe mass. Tumor occrence is considered.
• Interval increase in the degree of non-communicating
hydrocephalus.
• Small chronic infarct, left thalamus, unchanged.

• No evidence of intracerebral hemorrhage.


• Interval decrease in the bilateral frontal sinuses

• Chronic bilateral mastoiditis, unchanged.


• S/P craniectomy, both frontal bones.
Ginny Ann Bacaltos-Cequiña, M.D.,DPBR, FCT-MRISP
Radiologist

SURGICAL PATHOLOGY REPORT


April 10, 2009
Specimen: Osteoma Brain Tissue
Date: March 17, 2009
Anaplastic Astrocytoma, Brain, Biopsy
DRUG STUDY

GENERIC NAME: Esomeprazole

BRAND NAME: Nexium

CLASSIFICATION(S): Antiulcer Agents

INDICATIONS: GERD including erosive esophagitis. With amoxicillin and


clarithromycin to eradicate H. pylori in duodenal ulcer disease or
history of duodenal ulcer disease.

MECHANISM OF ACTION: Binds to an enzyme on gastric parietal cell in


the presence of acidic gastric pH, preventing the final transport of
hydrogen ions into the gastric lumen.

CONTRAINDICATIONS: Hypersensitivity; Lactation ( not recommend)

ROUTE and DOSAGE: 40mg 1tab. OD

SIDE EFFECTS: CNS: headache, GI: abdominal pain, constipation,


diarrhea, dry mouth, flatulence, Nausea.
NURSING RESPONSIBILITIES:

1. Instruct patient to take medication as directed to the full course


of therapy, feeling better.
2. Take missed doses as soon as remembered but not if almost time for
next dose. Do not double doses.
3. Advise patient to avoid alcohol, products containing alcohol,
products containing aspirin or NSAIDs and food that may cause an
increase in GI irritation.
4. Advise patient to report onset of black, tarry stools; diarrhea;
abdominal pain; or persistent headache to health care professional.
GENERIC NAME: Ranitidine

BRAND NAME: Zantac

CLASSIFICATION(S): Histamine2 Antagonist

INDICATIONS: Short term treatment of active duodenal ulcer and benign


gastric ulcer. Treatment and prevention of heartburn, acid
indigestion, and sour stomach.

MECHANISM OF ACTION: Inhibits the action of histamine at the H2


receptor site located primarily in gastric parietal cells, resulting
in inhibition of gastric acid secretion.

CONTRAINDICATIONS: CNS: confusion, dizziness, drowsiness,


hallucinations, and headache. CV: arryhtmias GI: altered taste, dark
stools, diarrhea, nausea. HEMAT: anemia, neutropenia,thrombocytopenia.

ROUTE and DOSAGE: 1amp IVTT q 8hrs

SIDE EFFECTS: CNS: confusion, dizziness, drowsiness, hallucination,


and headache, CV: arrthymias, GI: altered taste, black tongue,
constipation, dark stool, diarrhea, drug- induced hepatitis, nausea.

NSG. RESPONSIBILITIES:
1. Instruct patient to take medication as directed for the full course
of therapy, even if feeling better.
2. Advise patients taking OTC preparations not to take the maximum
dose continuously for more than 2 weeks. Without consulting health
care professional.
3. Inform patient that smoking interferes with the action of histamine
antagonist.
4. May cause drowsiness or dizziness. Caution patient to avoid driving
or other activities requiring alertness until response to the drug is
known.
GENERIC NAME: Phytonadione

BRAND NAME: Vitamin k

CLASSIFICATION(S): Antidotes, vitamins

INDICATIONS: Prevention and treatment of hypothrombinemia, which may


be associated of excessive doses of oral anticoagulants.

MECHANISM OF ACTION: Required for hepatic synthesis of blood


coagulation factors II (prothrombin), VII, IX and X. prevention of
bleeding due to hypothrombinemia.

CONTRAINDICATIONS: Hypersensitivity or intolerance to benzyl alcohol


(injection only)

ROUTE and DOSAGE: 1tab. OD

SIDE EFFECTS: GI: gastric upset, unusual taste, DERM: flushing, rash,
urticaria, HEMA: hemolytic anemia, LOCAL: Erythema, pain at injection
site, swelling.

NSG. RESPONSIBILITIES:
1. Instruct patient to take medication as directed for the full
course of therapy, even if feeling better.
2. Cooking does not destroy substantial amounts of Vit. K. Patient
should not drastically alter diet while taking Vit. K.
3. Emphasize the importance of frequent lab test to monitor
coagulation factors.
4. Advise patient to report any unusual bleeding (bleeding gums,
nosebleed, black tarry stool, excessive menstrual flow.)
5. Advise patient to carry identification at all times describing
disease process.
GENERIC NAME: Dopamine

BRAND NAME: Intropin

CLASSIFICATION(S): Intropics ,vasopressors

INDICATIONS: Adjunct to standard measures to improve blood pressure,


cardiac output in treatment of shock unresponsive to fluid
replacement.

MECHANISM OF ACTION: Small doses (0.5-3 mcg/kg?min) stimulate


dopaminergic receptors, producing renal vasodilation. Large doses (2-
10 mcg?kg/min)stimulate dopaminergic and beta1-adrenergic receptors,
producing cardiac stimulation and renal vasodilation. Doses greater
than 10mcg/kg/min stimulate alpha-adrenergic receptors and may cause
renal vasoconstriction.

CONTRAINDICATIONS: Tachyrrythmias, Pheochromocytoma, hypersensitivity


to bisulfites.

ROUTE and DOSAGE: 200/200ml to run @ 20cc/hr

SIDE EFFECTS: CNS: headache, EENT: mydriasis, RESP: dyspnea CV:


arrhthmyias, hypotension, angina, ECG change, palpitations,
vasoconstriction, GI: Nausea and vomiting.

NSG. RESPONSIBILITIES:
1. Explain to patient the rationale for instituting this medication
and the need for frequent monitoring.
2. Advise patient to inform nurse immediately if chest pain; dyspnea:
numbness; tingling or burning of extremities occur.
3. Instruct patient to inform nurse immediately of pain or discomfort
@ IV site.
4. Monitor urine output frequently throughout administration. Repeat
decreases in urine output promptly.
5. Palpate peripheral pulses and assess appearance of extremities
routinely throughout dopamine administration. Notify physician if
quality of pulse deteriorates of if extremities become cold or
mottled.
GENERIC NAME: Insulin

BRAND NAME: Novolog

CLASSIFICATION(S): Antidiabetic hormone

INDICATIONS: Treatment of insulin dependent diabetes mellitus type 1.


Management of non-insulin dependent diabetes mellitus type 2.
unresponsive to treatment with diet and or oral hypoglycemic agents.

MECHANISM OF ACTION: Lower blood glucose by increasing transport into


cells and prompting the conversion of glucose to glycogen. Promote the
conversion of amino acids to proteins in muscle and stimulate
triglyceride formation.

CONTRAINDICATIONS: Allergy or hypersensitivity to a particular type of


insulin, preservatives or other additives.

ROUTE and DOSAGE: 10’u’ sq to 10’u’ IVTT

SIDE EFFECTS: DERM: Urticaria, ENDO: hypoglycemia, rebound


hyperglycemia, LOCAL: lipodystrophy, itching, redness, swelling.

NSG. RESPONSIBILITIES:
1.Explain to patient that this medication controls hyperglycemia but
does not cure diabetes. Therapy is long term.
2. Emphasize the importance of compliance with nutritional guidelines
and regular exercise as directed by health care professional.
3. Instruct patient on signs and symptoms of hypoglycemia and
hyperglycemia and what to do if they occur.
4. Patient with diabetes mellitus should carry a source of
sugar( candy, sugar packets) and identification describing their
disease and treatment regimen at all times.
5.Advise patient to consult health care professional prior using
alcohol or other medications currently with insulin.
GENERIC NAME: Dexamethasone

BRAND NAME: Decilone Forte

CLASSIFICATION(S): Cortecosteroids

INDICATIONS: Inflammatory & allergic conditions responsive to


corticosteroid therapy eg skin diseases, collagen diseases, blood
dyscrasia, certain neoplastic disease & adrenocortical insufficiency.

MECHANISM OF ACTION: All agents suppress inflammation and the normal


immune response. Replace endogenous cortisol in deficiency states.

CONTRAINDICATIONS: Active untreated infections. Known alcohol,


bisulfite, or tartazine hypersensitivity or intolerance ( some product
contain these and should be avoided in susceptible patients.

ROUTE and DOSAGE: 5mg 1tab TID

SIDE EFFECTS: Excessive mental stimulation, increase appetite, muscle


twitching, wt gain, tachycardia, insomnia & psychic disturbances.

NSG. RESPONSIBILITIES:
1. Instruct patient it should be taken with food.
2. Corticosteroids cause immunosuppression and may mask symptoms of
infection.
3. Instruct patient to avoid people with known contagious illnesses
and to report possible infections immediately.
4. Advise patient to notify health care professional of medication
regimen before treatment.
5. Explain need for continued medical follow-up to assess
effectiveness and possible side-effects of medication.
GENERIC NAME: Phenytoin

BRAND NAME: Keppra

CLASSIFICATION(S): Anti-convulsant

INDICATIONS: Monotherapy in the treatment of partial onset seizures w/


or w/o secondary generalization in patients from 16 yr w/ newly
diagnosed epilepsy. As adjunctive therapy in the treatment of partial
onset seizures w/ or w/o secondary generalization in adults & childn
≥4 yr w/ epilepsy. Adjunctive therapy in the treatment of myoclonic
seizures in adults & adolescents from 12 yr w/ Juvenile Myoclonic
Epilepsy. Adjunctive therapy for patients >4 yr w/ Primary Generalized
Tonic, Clonic Seizure (PGTCS).

MECHANISM OF ACTION: Produces all levels of CNS depression. Depresses


the sensory cortex, decreases motor activity, and alter cerebellar
function. Inhibits transmission in the nervous system and raises the
seizure threshold.

CONTRAINDICATIONS: Children <4 yr. Lactation.

ROUTE and DOSAGE: 500mg ½ tab. in AM ¼ tab. in PM.

SIDE EFFECTS: Most common are somnolence, asthenia & dizziness. In


monotherapy most frequent are fatigue & somnolence. Also common are
amnesia, ataxia, convulsion, headache, hyperkinesia, tremor, balance
disorder, disturbance in attention, memory impairment, agitation,
depression, emotional lability, hostility/aggression, insomnia,
nervousness/irritability, personality disorder, thinking abnormally,
abdominal pain, diarrhea, dyspepsia, nausea, vomiting, anorexia, wt
increase, vertigo, diplopia, blurred vision, myalgia, accidental
injury, infection, nasopharyngitis, increased cough, rash, eczema,
pruritus, thrombocytopenia. Pancreatitis, hepatic failure, hepatitis,
abnormal liver function test, wt loss, alopecia, leukopenia,
neutropenia, pancytopenia, (w/ bone marrow suppression).

NSG. RESPONSIBILITIES:
1. Instruct patient may be taken with or without food.
2. Advise patient to take medication exactly as directed.
3. Tell patient that medication may cause daytime drowsiness.
4. Caution patient to avoid taking alcohol or other CNS depressant
concurrently with this medication.
5. Advise patients on prolonged therapy not to discontinue medication
without consulting health care professional.
GENERIC NAME: Tranexamic acid

BRAND NAME: Dostan

CLASSIFICATION(S): Hemostatic

INDICATIONS: Prophylaxis & treatment of hemorrhage associated w/


excessive fibrinolysis; prophylaxis of hereditary angioedema.

MECHANISM OF ACTION: Promotes hemostasis by activating the intrinsic


pathway of the coagulation cascade. Factor Xa, in other factors,
converts prothombin to trombhin leading to formation of a hemostatic
plug by converting fibrogen to fibren.

CONTRAINDICATIONS: Active intravascular clotting.

ROUTE and DOSAGE:

SIDE EFFECTS: Dose-related GI disturbances. Hypotension.

NSG. RESPONSIBILITIES:
1. Check for the platelet count before administering the
medication.
2. Report S&S of hypersensitivity ie; wheezing, chest tightness,
itching hives, decrease BP and shock.
3. Avoid activities that may cause injury such as contact sports
and falling activities
4. Report any unusual swelling/ joint pains or adverse effects.

GENERIC NAME: Polynerv


BRAND NAME: Polynerv

CLASSIFICATION(S): Vitamin B complex/vitamin C

INDICATIONS: euritis, polyneuritis, lumbago, cervical & shoulder-arm


syndrome, rheumatic pains, herpes zoster, alcoholism, cardiac
disorders, diabetic neuropathy, hyperemesis gravidarum,
encephalopathies, iatrogenic complications arising from INH,
reserpine, or phenothiazines.

MECHANISM OF ACTION: Serve as components of enzyme that catalyze


numerous varied metabolic reactions. Necessary for homeostasis. Water
–soluble vitamins (B and C) rarely cause toxicity. Fat soluble
vitamins (D and E) may accumulate and cause toxicity.

CONTRAINDICATIONS: Hypersensitivity to additives, preservatives, or


colorants.

ROUTE and DOSAGE: 1tab. OD

SIDE EFFECTS: Yellow discoloration of urine.

NSG. RESPONSIBILITIES:
1. Advise patient to take medication exactly as directed.
2. Asses patient for signs of vitamin deficiency before and
periodically throughout therapy.
3. Asses nutritional status through 24-hr diet recall.
4. Determine frequency of consumption of vitamin-rich food.

GENERIC NAME: Mucosta


BRAND NAME: Otsuka

CLASSIFICATION(S): Anti-acid, Anti-reflux, anti-ulcer

INDICATIONS: Acute gastritis & acute exacerbation of chronic


gastritis. Gastric ulcer.

MECHANISM OF ACTION: Neutralize gastric acid following this solution


in gastric content. Inactivate pepsin in Ph is raised to >4.

CONTRAINDICATIONS: In severe abdominal pain of unknown cause,


especially if accompanied by fever. Anuria, renal failure,

ROUTE and DOSAGE: 1 tab. TID

SIDE EFFECTS: Constipation, bloating, diarrhea, nausea, vomiting,


rash, pruritus.

NSG. RESPONSIBILITIES:
1. Caution patient to healthcare professional before taking antacid,
more than 2 weeks if problem is reccuring.
2. Advise patient not to take this medication not to take this
medication within 2 hr. of taking other medication.
3. Some antacids contain large amount of Na. caution patient of Na
restricted diet o check Na content when long term high dose therapy.
NURSING CARE PLANS
Nursing Impaired physical mobility related to sensory motor disturbance.
Diagnosis
Cause Analysis Tumors can directly destroy brain cells. They can also indirectly damage cells by
producing inflammation, compressing other parts of the brain as the tumor grows,
causing swelling in the brain, and increasing pressure within the skull. Headaches,
seizures, weakness in one part of the body, and changes in the person's mental
functions are most common.
Cues Needs Objectives Intervention Rationale Evaluation
1. Assist in range -Enhances
Objective Cues: A After 8 hours of of motion exercises circulation, Goal partially
-Weak C nursing on all extremities restores or met since patient
-Muscle atrophy T interventions, and joints, using maintains muscle was able to
-Irritability I the patient will slow, smooth tone and joint participate
V be able to do a movements. mobility, and through out the
I passive ROM prevent muscle assisted
T exercises to atrophy. exercises. Thus
Y avoid muscle she still has
- atrophy. 2. Elevate lower -Loss of vascular difficulty to
E extremities at tone and muscle perform exercise
X intervals when in action results in by herself alone.
E chair, or raise foot pooling of blood
R of bed when and venous stasis
C permitted in in the lower
I individual abdomen and lower
S situation. Assess extremities, with
E for edema of feet increase risk of
and ankles. hypotension and
thrombus
formation.

3. Inspect the skin -Altered


P daily. Observe for circulation and
A pressure areas, and loss of sensation
T provide meticulous potentiate
T skin care. pressure sore
E formation.
R
N 4. Monitor BP before -Orthostatic
and after the hypotension may
activity in acute occur as a result
phase on until of venous pooling.
stable. Change in Side-to-side
position slowly. movement or
elevation of head
can aggravate
hypotension.
5. Plan activities -Prevents fatigue,
to provide allowing
uninterrupted rest opportunity for
periods. Encourage maximal efforts or
involvement within participation by
individual tolerance patient.
or ability.

6. Encourage use of -Reduces muscle


relaxation tone tension/
techniques. fatigue, may help
limit pain of
muscle spasms,
spasticity.

7. Administer muscle -May be useful in


relaxants or anti- limiting or
spasticity as reducing pain
prescribed. associated with
spasticity
Nursing Situational low self-esteem related to functional impairment.
Diagnosis
Cause Analysis Since the Tumor is located at the frontal lobe area which is primarily responsible
for speech, behavior, specific movements, memory and emotions tumor would lead to
compression thus affecting the effectiveness of the areas’ specific functions.
Cues Needs Objectives Intervention Rationale Evaluation
1. Discuss with the -Aids in defining
Objective Cues: S After 4 hours of client/family how concerns to begin Goal met as
-Indecisive E nursing the diagnosis and problem solving evidenced by
-Weak L interventions, treatment are process. family member
-Nonassertive F the family affecting the were able to help
behavior - members will be client's personal the patient
-Irritability P able to help the life/home and work accept here
E patient accept activities. condition.
R her situation.
C 2. Encourage -May help reduce
E discussion of problems that
P problem-solve interfere with
T concerns about acceptance of
I effects of treatment or
O cancer/treatments on aggravate
N role as parent. progression of
disease.

3. Acknowledge -Validates reality


difficulties client of client's
may be experiencing. feelings.
Give information
that counseling is
often necessary and
S important in the
E adaptation process.
L
F 4. Provide emotional -Although some
- support for client client
C and family during adapt/adjust to
O diagnostic tests. cancer effects or
N side effects of
C therapy, many need
E additional support
P during this
T period.

5. Use touch during -Affirmation of


P interactions, if individuality and
A acceptable to acceptance is
T client, and maintain important in
T eye contact. reducing client's
E feelings of
R insecurity and
N self-doubt.

6. Refer client to -Group support is


supportive group usually very
programs. beneficial for
both client and
family, providing
contact with
other clients with
cancer at various
levels of
treatment and/or
recovery,
validating
feelings, and
assisting with
problem solving.
Nursing Imbalanced Nutrition: less than body requirements related to consequences of
Diagnosis radiation treatment.
Cause Analysis Radiation therapy is a common treatment for brain tumors where surgery or
radiosurgery can not be utilized. Side effects of radiation therapy will depend on
the type of radiation received, the amount of the surface of the brain targeted, the
site targeted, and the total dose of radiation. In general, there will be hair loss,
skin irritation, possible hearing problems, nausea, vomiting, loss of appetite, and
neurologic effects.
Cues Needs Objectives Intervention Rationale Evaluation
Subjective Cues: 1. Monitor daily -Identifies
“Wala na kaau N After 8 hours of food intake, have nutritional Goal unmet as
siya gana mukaon U nursing client keep food strengths/ patient showed no
nars” verbalized T interventions, dairy as indicated. deficiencies. improvement in
by the daughter. R patient will be her appetite.
I able to 2. Assess skin/ -Helps in
Objective Cues: T demonstrate mucous membrane for identification of
-Poor muscle I improvements in pallor. protein calorie
tone O her appetite. malnutrition.
-Loss of N
appetite A 3. Encourage open -Often a source of
-Irritability L communication emotional
-Pale - regarding anorexia. distress,
especially for
family members who
wants to feed
client frequently.
When client
refuses, the
family member feel
rejected/frustrate
d.

M 4. Adjust diet -The effectiveness


E before and of the diet
T immediately after adjustment is very
A treatment. individualized in
B relief of post-
O therapy nausea.
L
I 5. Avoid overly -Can trigger
C sweet, fatty or nausea and
spicy foods. vomiting response.
P
A 6. Advice patient to -The radiation can
T sleep alone at affect other
T night. individual.
E
R 7. Instruct the -The urine and
N patient to flush stool of the
the toilet after patient who
using. undergone
radiation therapy
has an effect
to other
individual.
Nursing Risk for impaired skin integrity related to prolonged bed rest.
Diagnosis
Cause Analysis Prolonged bedrest may result to disruption of blood supply to specific part of the
body thus resulting to sore also known as decubitus ulcer, specifically this is
exhibited by clients having DM;(Brunner’s and Suddarth’s 2008); Ulcers may arise due
to compression of blood vessels supplying the area of the body this would result to
death of that specific part (Smeltzer-Bare 2008).
Cues Needs Objectives Intervention Rationale Evaluation
1. Assess and -To provide
Objective Cues: N After 8 hours of inspect the skin for immediate Goal met as
-Weak U nursing signs of bedsores. intervention evidence by
T interventions, absence of signs
-Poor skin R the patient will indicating skin
turgor I not exhibit signs 2. Encourage watcher -To promote compression
T of bedsores. to turn patient side circulation and throughout the
-On complete bed I to side every 2 assess the area whole shift, thus
rest O hours. for signs of suggest absence
N ulceration. of skin
A ulceration.
L 3. Maintain skin -To promote skin
- hygiene. integrity
M
E
T 4. Provide adequate -To provide
A clothing/covers. comfort for the
B patient.
O
L 5. Emphasize -To maintain
I importance of general good
C adequate health and skin
nutritional/ fluid turgor.
P intake.
A
T 6. Recommend -To enhance venous
T elevation of lower return and reduce
E extremities. edema formation.
R
N 7. Encourage passive -To enhance
range of motion circulation.
exercises.
Nursing Risk for injury related to body weakness secondary to Brain tumor.
Diagnosis
Cause Analysis Brain tumor would affect many parts of the brain which is very essential to
mobility, behavior; sensory neural and sensory motor functioning in which if
therefore affected by any compression such as Tumor or due to increased intracranial
pressure would lead to alterations that may lead to injury. (Brunner’s-Suddarth’s
2008).
Cues Needs Objectives Intervention Rationale Evaluation
1. Monitor V/S. -To have a Goal met as
Objective Cues: H After 8 hours of baseline data and evidenced by
-Poor muscle E nursing to check for patient hadn’t
tone A intervention, our further experienced any
-Weak L patient will be unusualities. injury throughout
T able to be free the whole shift,
H from injury. 2. Check patient - To prevent safety
- surrounding and hazards that may environment for
P immediate harm the patient. the patient is
E environment. therefore
R achieved.
C 3. Keep bed wheels - To prevent from
E locked and side slipping and
P rails up as ordered. sliding or falling
T off from the bed
I and avoid false
O imprisonment.
N
4. Orient patient - To keep patient
A and significant and significant
N others with safety others aware and
D measures. knowledgeable.

5. Instruct the - Presence of


watchers to keep personnel ensures
close to patient’s safety of patient
H bed side, especially and it encourages
E when there is no patient to
A health care continue endeavor.
L provider.
T
H 6. Instruct watchers - It helps to
to be aware of indicate the need
M impulsive behavioral of additional
A actions suggestive intervention and
N of impaired supervision to
A judgment. promote patients
G safety.
E
M 7. Evaluate all the -Ongoing
E safety precautions evaluation
N rendered. determines whether
T or not the patient
and watchers
P understood the
A safety precautions
T rendered.
T
E
R
N
DISCHARGE PLAN

MEDICATIONS
 Discuss all take home medications to the patient and
significant others.
 Encourage to take drugs with food if not contraindicated.
 Inform them that the drugs may exhibit undesirable side
effects.
 This enables them to know what drugs to be taken and its
desired doses.
 Some drugs may cause GI irritation if taken with empty
stomach.
 Adverse reaction is with life threatening effects to the
patient. Immediate consultation is necessary to prevent
untoward injuries.
Activity
 Have adequate rest and sleep.

 This recharges the energies to function better, both


physically and mentally.
TREATMENT
 Explain the treatment and medication purpose to be
continued at home.
 It is needed for maintenance and control of disease.
HEALTH TEACHINGS
 Instructed S.O to increase fluid intake to 8 glasses of
water a day.
 Emphasized hand washing technique.

 Encouraged S.O to prepare foods that are nutritious such as


vegetables and fruits.
OUTPATIENT ORDERS
 Remind the family on their follow-up check-up with their
physician.
 Encourage them to carry out follow-up diagnostic exam.
 Maintain a good and safe environment.

 To evaluate the progress of the treatment.


 To evaluate worsening condition of the patient that needs
medical attention.
 May facilitate fast recovery and prevent the patient from
further injury.

DIET

 Encourage to have three basic food groups in the diet with


low salt low fat.
 To provide balance diet.

HYGIENE

 Have personal hygiene daily;


 Keep the patient’s skin intact and free of lesions

 These remove dirt, and maintain germ-free physical


appearance.
 To prevent skin breakage that may be a contributing factor
in the entry of microorganisms
PROGNOSIS

CRITERIA POOR FAIR GOOD JUSTIFICATION


Onset of illness • Upon the onset of illness,
the condition was
diagnosed last march of
this year. In a matter of
6 months the tumor
progressively grew. Her
Tumor was obviously
present with changes that
are sudden and dramatic.

Duration of • The disease itself is a


illness neoplastic one. The tumor
grew fast and after the
surgical intervention
(craniotomy/craniectomy)
there is re occurrence of
tumor in just about 5
months after the said
surgical intervention.

Precipitating • The precipitating factor


Factor that puts our patient at
risk for this disease is
her diet. She is a meat
lover, she loves to eat
Grilled Meats (sinugbang
Bangus). Carcinogenic
foods will put one’s
health on the danger of
neoplasms.
Willingness to Our patient is
take medication • experiencing neurological
changes due to the tumor.
Thus, making choice is a
problem.
Age of patient Being 61 years old, our
patient belongs to the
• bracket of age when this
particular disease peaks
and affects older ones.
Environment Our patient’s environment
• does not predispose our
patient to the development
of Brain Tumor nor place
our patient health at
risk.

Family support Our patient’s family is


very supportive with our
• patient’s current plight.
They are not only
supportive of her
financially but more so,
emotionally. They are most
of the time with her as
she struggles with her
disease and throughout the
course of her actual and
possible treatment
POOR- 4/7 x 100= 57%
FAIR-1/7 x 100= 14%
GOOD-2/7 x 100=28%

Overall Prognosis: POOR

When diagnosed with a brain tumor, one of the first things a


patient usually wants to know is “How long will I live?” The answer is
never certain, and we encourage patients and families not to focus on
statistics. No individual is a statistic; each person’s prognosis is
different.
Survival is strongly related to a person’s age and tumor type.
Regarding our patient. Survival rate is affected due to her age.
People with glioblastoma consistently have the poorest survival in all
age groups. Our patient have this kind of tumor so the survival rate
is also affected. Also, Brain tumors that grow slowly have a better
prognosis than fast-growing tumors. Tumor progression from benign to
malignant negatively affects survival. Regarding our client, its very
obvious that her tumor progressively growing faster.
BIBILIOGRAPHY

Smeltzer & Bare (2008). Medical Surgical Nursing. Lippincott.

Brunner’s & Suddarth’s (2008). Medical Surgical Nursing.

Black (2008). Medical Surgical Nursing.

Spratto & Woods (2008). Nurse’s Drug Handbook.

Moorhouse et al (2007). Nursing Care Plans.

WWW.NursingCrib.com

WWW.NursesPDR.com/database2008

www.mayoclinic.com

www.cancer.org

www.emedlineplus.com

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