I. Introduction A surgery is one of the most stressful procedures a patient could undergo. There are numerous types of surgeries, each one tailored to fit a certain purpose, may it be to deliver a child ( i.e. cesarean section), remove a part ( i.e. craniectomy), to visualize and gain access to a structure within ( i.e. craniotomy) or to repair a defect ( i.e. cranioplasty). This is a case of Master Labrador, Ralph, 12 years old, who was admitted last May 2, 2008 at Cebu Doctors’ University Hospital to undergo a cranioplasty. Two years ago the patient sustained an epidural hematoma from motor-vehicular accident in Argao. He was brought to Cebu Doctors’ University Hospital last February 26, 2006 and underwent craniotomy and evacuation of epidural hematoma. He was advised to undergo a cranioplasty six months after recovery but was only able to come back for compliance due to financial reasons. A cranioplasty is a surgical repair of a cranial defect. Cranial defects may result from fractures, infections, surgical procedures ( cranial bone biopsy, craniotomy) or a cranial deformity. Indications for the procedure include protection from external trauma, alleviation of pain or seizures and cosmetics. The artificial cranium may be fashioned from the autogenous bone grafts, metal ( e.g. tantalum) or acrylic material ( e.g. methylmethacrylate). Methylmethacrylate is the preferred material for cranioplasty, except in cases of wound infection, in which autogenous grafts are better accepted. In cranioplasty, the scalp is incised over the defect. The defect may be trimmed as necessary. Methylmethacrylate is mixed according to the manufacturer’s directions. The surgeon then molds the material to fit the defect. Acrylic is removed from the polyethylene bag and allowed to harden. Excess material may be trimmed with rongeurs or power saw. A craniotome may be used to smooth the rough spots. Holes are drilled in the periphery of the acrylic plate and the cranial defect. The plate is placed over the defect and secured by the stainless steel wired passed through the holes and the wound is irrigated and closed.
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This case study was chosen because of the challenge that it posed- it involves the head and skull which contains the central processing unit of the body, a single mistake could be fatal and could turn a life upside down if not end it. At the end of this case study, the student nurse expects to expand her knowledge regarding the surgical procedure known as cranioplasty, and refine her skills in caring for a patient who has undergone the said surgical procedure.
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II. Objectives General Objectives: After 3 days of student nurse-patient interaction, the student nurse will be able to learn more about cranioplasty, effectively provide holistic caring care and inculcate positive attitude while caring for a patient who has undergone the said procedure. After 3 days of student nurse-patient interaction, the patient will be able to learn more and cope with the surgical operation cranioplasty, avoid complications that may arise post-operatively and incorporate lifestyle modifications until he returns to his optimum level of functioning. Specific objectives: After 3 days of providing holistic caring care and facilitating student nurse-patient interaction, the student nurse will be able to: 1. perform a thorough assessment of a school-age child in his present condition, and discuss the physical, social and cognitive characteristics of a school-age child 2. identify the signs and symptoms presented by the patient in relation to the causative factor of the condition 3. avoid complications which may arise from the surgical procedure 4. implement a comprehensive plan of care for the patient who has undergone cranioplasty, and 5. evaluate the interventions provided in the given span of time for efficiency and effectiveness. After 3 days of receiving holistic care and participating in student nurse-patient interaction, the patient and his significant others will be able to: 1. establish trust towards the student nurse
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2. cooperate in procedures performed to the patient for the management and treatment , such as medication administration and vital signs taking 3. manifest a decrease in the signs and symptoms associated with the surgical procedure, such as pain 4. perform, with minimal assistance from the student nurse and significant others, activities of daily living 5. terminate the therapeutic student nurse-patient interaction at the end of the given span of time
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III. Nursing Assessment 1. Personal History 1.1 Patient’s profile Name: Ralph de los Reyes Labrador Age: 12 years old Sex: Male Civil Status: Single Religion: Roman Catholic Date of admission: May 2, 2008 Room no.: 422 Complaints: Diagnosis: Physician: Dr. Milo Vergara 1.2 Family and Individual Information, Social and Health History Master Labrador, Ralph, the eldest son of Mrs. Labrador, was admitted last May 2, 2008 at 11:49am. Two years prior to admission, patient sustained an epidural hematoma from a motor-vehicular accident in Argao. He was in his grandparents; care back then. He was riding his bicycle in the highway when a bus came speeding towards his direction. He was admitted for the first time at Cebu Doctors’ University Hospital last February 26, 2006 and underwent evacuation of hematoma and craniotomy. He was in comatose for three to four days but regained consciousness and was stabilized and in good condition when discharged. Patient’s mother was advised to bring back her son six months after for a cranioplasty but they were not able to comply due to financial constraints. Few days prior to admission, they had raised enough money thus subsequent admission. Ralph is completely immunized. He had chickenpox at seven years old. He has no maintenance medications and no vitamins. Family history reveals
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hypertension on the maternal and paternal sides and bronchial asthma on the paternal side. He has no food and drug allergies. He is asthmatic. Last asthma attack was two years ago and was managed with ventolin syrup. 1.3 Level of Growth and Development 1.3.1
Normal Development Physical Changes Physiologically, the school-age years or middle years begin with the
shedding of the first deciduous tooth and end at puberty with the acquisition of the final, permanent teeth ( with the exception of wisdom teeth). The period of middle childhood is a time of gradual growth and development with more even progress in both physical and emotional aspects. School-age children’s annual average weight gain is approximately 3-5 lb. (1.3-2.2 kg); the increase in height is 1-2 inches (2.5-5 cm). Children who did not lose the lordosis and knock-kneed appearance of toddlers during the preschool period lose these now. Posture becomes erect. Their body proportions take on a slimmer look, with longer legs, varying body proportion and a lower center of gravity. The most pronounced changes that indicate increasing maturity in children are a decrease in head circumference in relation to standing height, a decrease in waist circumference in relation to height and an increase in leg length related to height. Facial proportions change as the face grows faster in relation to the remainder of the cranium. The skull and brain grow very slowly during this period and increase little in size. Maturity of the gastrointestinal system is reflected in fewer stomach upsets, better maintenance of blood glucose levels , and increased stomach capacity, which permits retention of food for longer periods. Physical maturation is evident in other body tissues and organs, as well. Bladder capacity is generally greater in girls than in boys. The heart grows more slowly during the middle years and is smaller in relation to the rest of the body than at any other period of life. Heart and respiratory rates steadily decrease and blood pressure increases during
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ages 6 to 12. Heart rate ranges from 70 to 80 beats per minute, respiratory rate 15 to 25 breaths cycles per minute, and an average blood pressure of 112/60 mmHg. Psychocosial Development Freud described middle childhood as the latency period, a time of tranquility between the oedipal phase of early childhood and the eroticism of adolescence. During this time, children experience relationships with same-sex peers following the indifference of earlier years and preceding the heterosexual fascination that occurs for most boys and girls in puberty. According to Erickson, a sense of industry or a stage of accomplishment is achieved somewhere between age 6 and adolescence. School-age children are eager to develop skills and participate in meaningful and socially useful work. Interests expand in the middle years, and with a growing sense of independence , children want to engage in tasks that can be carried through to completion. Reinforcement in the form of grades, material rewards, additional privileges and recognition provides encouragement and stimulation. Peer approval is a strong motivating power. The danger inherent in this period of development is the occurrence of situations that might result in as sense of inferiority. When the reward structure is based on evidence of mastery, children who are incapable of developing those skills are at risk for feeling inadequate and inferior. No child is able to do everything well, and children must learn that they will not be able to master every skill they attempt. Children need and want real achievement. When they have access to tasks that need to be done, that they are able to do well despite individual differences in their innate capacities and emotional development, and for which they are suitably rewarded, children achieve a sense of industry. Cognitive Development When children enter the school years, they begin to acquire the ability to relate a series of events to mental representations that can be expressed both verbally and symbolically. This is the stage Piaget describes as concrete
7
operations, when children are able to use thought processes to experience events and actions. The rigid, egocentric view of the preschool years is replaced by mental processes that allow children to see things from another’s point of view. During this stage, children develop an understanding of relationships between things and ideas. They progress from making judgments based on what they see to making judgments based on what they reason. They master the concept of conversation, develop classification skills and their ability to read becomes the most significant and valuable tool for independent inquiry. Sexuality Preadolescence is the period of approximately 2 years that begins at the end of middle childhood and ends with the thirteenth birthday. Because puberty signals the beginning of the development of secondary sex characteristics, prepubescence typically occurs during preadolescence. There’s no universal age at which children assume the characteristics of prepubescence. The first physiologic signs appear at about 9 years of age and are usually clearly evident in 11-12 years old children. Boys experience little visible sexual maturation during preadolescence. Pubic hair present across pubis, penis lengthens, breast enlargement occurs and there’s dramatic linear growth spurt. 1.3.2
The Ill School-Age Child One of the biggest problems facing a school-age child with an illness or
physical challenge is time lost from school. This threatens not only academic achievement but also the child’s relationships with his or her peers. It may make him or her the “odd person out” with respect to making friends or joining gangs. Whether children are confined to home or hospitalized, helping them keep in contact with friends can help foster socialization that is important for continued development.
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In caring for a school-age child who is ill, choose short term activities that can be completed independently. Be careful not to insult a child with tasks that are obviously not age-appropriate. Master Labrador, Ralph was admitted last May 2, 2008 with the following vital signs: heart rate was 100 beats per minute, respiratory rate 25 breath cycles per minute, temperature of 36.5 degress Celsius and blood pressure of 90/60 mmHg. Upon admission he weighed 28.3 kg. Primary assessment revealed a scar at the right parieto-temporal area and on approximately 5-6 cm scar on the left periumbilical region of the abdomen. Patient was observed to be outgoing, cooperative and socially able to relate to nurses and student nurses. He had questions and wasn’t shy about them. Aside from his mother, he had his aunts to accompany him during the whole length of hospital stay.
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2. Diagnostic Results Complete Blood Count ( May 7, 2008) Hemoglobin Hematocrit WBC count Neutrophil Basophil Eosinophil Lymphocyte Monocyte Bands Atypical
Results 13.1 g/L 39.5 % 13.70 10^3/uL 45 % 0 7 47 1 0 PNDG
lymphocyte Blasts Red Cell Count MCV MCH MCHC MPV RDW Platelet
PNDG 4.9 10^6/uL 80.5 26.7 33 6.69 14.1 344
Normal Values 12-16 g/L 36-45 % 4.5-13.0 10^3/uL 25-70 % 0-3 % 0-8 % 20-65 % 0-9 % 0%
Significance normal normal normal normal normal normal normal normal normal normal
10^6/uL 78-102 fL 25-35 pg 31-36 g/L 4.50-100 cL 0-100 % 140-440 10^3/uL
normal normal normal normal normal normal normal normal
Normal Values 2.3-9.5 min. sec. 5-15 min.sec.
Significance normal normal
Normal Values sec 10-13 sec. 70-120 % < 1.2
Significance normal normal normal normal
Hematology ( May 7, 2008) Blood type: O+ Bleeding Time Clotting
Results 5’22’’ 12’13’’
Prothrombin Time (May 7, 2008) Control PRO time % activity LNR
Results 14.9 12.7 107.2 0.94
CT Scan on Head ( May 7, 2008) Impression: 1. S/P Right parietal craniotomy
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2. Focal encephalomalacic changes at the left frontal lobe. Please correlate clinically.
3. Present Profile of Functional Health Pattern ( Pre-operative) 3.1 Health Perception Ralph sees his present condition as good. He and his mother has no worries regarding his current health status. His last asthma attack was two years ago and they’re thankful it hasn’t recur since after the accident. He perceived complete immunization and is not taking any vitamins.
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3.2 Nutritional- Metabolic Pattern Patient eats three full meals of rice, fish and sometimes chicken and red meat. He eats these during breakfast, lunch and dinner. He usually eats junkfood and drinks ice juice or ice candy during snack time. He drinks up to 1.5 liters of water a day and rarely takes in fruit juices, milk or coffee. He does not take any vitamins or food supplements. Upon admission, his weight was 28.3 kg. 3.3 Elimination Pattern Ralph does not have any problem in urinary elimination ( oliguria, polyuria, dysuria, retention, etc.) as far as he could remember. He is able to urinate up to a maximum of seven times a day, with around 60 mL of urine per voiding. He defecates brown, semiformed stool often every other day. He does not use laxatives nor diuretics. 3.4 Activity-Exercise Pattern Patient plays table tennis at school. He has no difficulty performing activities of daily living. He does not experience shortness of breath during playing. Upon pre-operative assessment, his vital signs were: temperature of 36.5 degrees Celsius; pulse rate of 84 brats per minute; respiration of 20 breath cycles per minute and blood pressure of 90/60 mmHg. 3.5 Cognitive/Perceptual Pattern Ralph speaks mostly in Cebuano. He knows Tagalog and claims to be proficient in English. He is able to read and write. He has no hearing aids or eyeglasses; however he reports that he cannot hear well with his right ear. He can sense heat, cold, sharpness, and dullness. He can determine rough and smooth surfaces, as well as application of pressure on all extremities. Patient reports that since the accident, he has short-term memory lapses and there are times that he has difficulty summoning the right word/name for an event/object. 3.6 Rest/Sleep Pattern
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Prior to hospitalization, the patient sleeps at around 8pm and wakes up at 7 am the next day. He has no difficulty falling and staying asleep. Upon hospitalization, patient is able to sleep at 9-9:30 pm, and sometimes 10 pm due to vital signs taking and other routine procedures. His mother stated that the patient is unusually restless during the night and is probably anxious about the upcoming procedure.He usually takes short nap at home, usually after arriving from school. 3.7 Self-Perception Pattern Ralph is well-adjusted. He stated that he is somewhat anxious for tomorrow’s surgery but his mother has helped calm him down. He expressed his desire to go home and play with his siblings 3.8 Role-Relationship Pattern Ralph speaks well, with coherent thoughts, and facial expressions with gestures that are appropriate. He lives with this mother in Argao and has two siblings, all boys and all younger than him, His parents are separated. His mother stated that Ralph is hard-headed and often, wants to go his own way. 3.9 Sexuality and Reproductive Pattern Ralph is in the prepubescence period. He admits to having noticed growth of hair under the axilla and pubic hair across the pubis but other than that he refuses to divulge details. 3.10Coping-Stress Tolerance Pattern Ralph plays basketball after school. Whenever he feels down, he watches television or play with his brothers at home. 3.11Value-Belief System Ralph is a Roman Catholic and is taught by his mother to pray and attend mass every Sunday. He stated that he is thankful to God for not taking him two years ago. He jokingly said that the accident may be a wake-up call for him to stop being hardheaded and a burden to his mother.
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4. Present Profile of Functional Health Pattern (Post-operative) 4.1 Health Perception Ralph considers his present state of health as well but recuperating. He and his mother both know that as long as he takes care of himself and follow the doctor’s orders he will heal in time and prevent complications of the surgery. 4.2 Nutritional-Metabolic Pattern The patient was to have diet as tolerated upon full awakening as ordered by his doctor. He still eats the same meal at breakfast, lunch and dinner. He eats bread and crackers for snacks. He drinks 1200- 1680 ml of water a day. He still does not take any vitamins or food supplements. After the operation, his weight was slight decreased to 28 kg. He was prescribed Oxacillin 750 g IVTT every 6 hours, an antibiotic as prophylactic management to prevent infection and Mefenamic acid 500 g 1 cap every 8 per orem for pain management. 4.3 Elimination Pattern Ralph still does not have urinary elimination problems after the surgical operation.He voids 5-6 times per day, with around 60 ml of urine per voiding. He defecates brown, semi-formed stools every other say. He doe not use laxatives nor diuretics. 4.4 Activity-Exercise Pattern The patient does not do any strenuous physical activities, avoids leaning over and straining too much for fear of post-operative complications. Upon return to the ward, his vital signs are: temperature of 37 degrres Celsius, respiratory rate of 18 breaths per minute, pulse rate of 85 beats per minute and blood pressure of 90/60 mmhg. 4.5 Cognitive-Perceptual Pattern Patient was drowsy after the surgical operation but regained alertness after several hours of sleep. No significant sensorineural changes have been noted. His cognitive functioning is intact. 4.6 Rest-Sleep Pattern No significant changes in sleep pattern has been noted post-operatively. He tales interspersed naps in the morning and afternoon.
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4.7 Self-perception Pattern Ralph is relieved now that the operation is over. He knows that if he follows his medication regimen and stays in the hospital for a few days to recuperqate, he will eventually heal and return to his usual level of functioning. 4.8 Role-relationship Pattern Patient expressed his longing to be home and play with his brothers. His hospital stay has started to bore him already. 4.9 Coping-stress tolerance Pattern The patient has no other option left now to cope with stress except talking with his mother and aunts and watching television. 4.10 Value-Belief system Ralph prays fervently for healing. He expressed his gratitude to the Lord for keeping him safe during and after surgery. 5. Pathophysiology and Rationale 5.1 Normal Anatomy and Physiology Structure Protecting the Brain The brain is contained in the rigid skull, which protects it from injury. The major bones of the skull are the frontal, temporal, parietal and occipital bones. These bones join at the suture lines.
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Figure 1. The Human Skull The meninges, the fibrous connective tissues that cover the brain and spinal cord, provide protection, support and nourishment to the brain and spinal cord. The layers of the meninges are the dura, arachnoid and pia mater. Dura mater- the outermost layer; covers the brain and the spinal cord. It is tough, thick, inelastic, fibrous, and gray. There are four extensions of the dura: the falx cerebri, which separates the two hemispheres in a longitudinal plane; the tentorium, which is an unfolding of the dura that forms a tough, membranous shelf; the falx cerebelli, which is between the two lateral lobes of the cerebellum; and the diaphragm sellae, which provides a roof for the sella turcica. The tentorium supports the hemispheres and separates them from the lower part of the brain. When excess pressure occurs in the cranial cavity, brain tissue may be compressed against the tentorium or displaced downward, a process called herniation. Between the dura mater and the skull in the cranium, and between the periosteum and dura in the vertebral column, is the epidural space, a potential space. Arachnoid- the middle membrane; an extremely thin, delicate membrane that closely resembles a spider web. It appears white because there is no blood supply. It contains the choroids plexus which is responsible for the cebrospinal fluid production. Subdural space is between the dura and arachnoid layer and subarachnoid space is between the arachnoid and pia layers and contains the cerebrospinal fluid. Pia mater- the innermost membrane; a thin, transparent layer that hugs the brain closely and extends into every fold of the brain’s surface. Figure 2.
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5.2 Schematic Diagram Predisposing Factor
Precipitating Factor
Congenital anomalies Bone infection Tumor in the head Family history of brain cancer stroke
Motor-vehicular accidents Craniotomy Craniectomy Cranial bone biopsy
Signs and Symptoms
Defect in the cranial bone as shown in the CT scan; in the patient’s case defect was on the right pariental bone Softness of the area of defect upon palpation Scar on the area of previous 17patient’s case, surgery ; in the scar on the right parietal area of the scalp
Surgical Management Cranioplasty to repair the cranial bone defect
Medical Management
Nursing Management
Antibiotic therapy to prevent infection
Elevate head of bed 30 degrees Encourage deep breathing exercises
Analgesia for pain management
Promote cleanliness and proper handwashing Encourage increased fluid intake Teach divertional activities to help manage pain
Optimum Level of Functioning
5.3 Cranioplasty secondary to a Craniotomy to Evacuate an Epidural Hematoma A cranioplasty, as mentioned earlier, is a surgical repair of a defect of the cranium. Cranial defects result from fractures, infections, surgical procedures or a congenital deformity. Ralph Labrador is a 12 year old child who had undergone craniotomy two years ago to evacuate an epidural hematoma. He was supposed to come back 6 months after a complete recovery from the previous surgical procedure but was not able to due top financial constraints. An epidural hematoma results from arterial bleeding into the space between the dura and the inner table of the skull. It is often caused by a fracture o fthe temporal
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bone, which houses the meningeal artery. Epidural hematomas may be characterized by the presence of a “lucid interval” that lasts for minutes during which the client is talking and walking. This follows a momentary unconsciousness that occurred within minutes of injury. Following the lucid interval, the symptoms progress rapidly with potential catastrophic intracranial pressure elevation and structural changes. An epidural hematoma is a neurosurgical emergency. Ralph Labrador obtained the epidural hematoma from a motor-vehicular accident two years ago and he underwent craniotomy to evacuate the epidural hematoma and save his life. Post surgery he was in coma for 4 days. He woke up the next day confused . Two years post-surgery, he and his mother noticed a change in his academic performance level and short-term memory lapses. He also has difficulty hearing with his right ear and complains of having difficulty summoning the right word for a certain event or object. After a severe traumatic brain injury, the patient is always expected to exhibit abnormalities secondary to the injury obtained. The previously mentioned deficits exhibited by Ralph Labrador all belong to the temporal lobe’s function. The temporal lobe is responsible for the complicated memory patterns and is the auditory center for sound interpretation. It is also in this lobe that the Wernicke’s area for speech is found. This association area plays a significant role in higher-level brain function. It enables processing of words into coherent thought and recognition of the idea behind written or printed languages.
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Cranioplasty was performed to repair the cranial defect on Ralph’s right parietal bone, a defect obtained from the emergency surgical procedure performed on him two years ago. This cranioplasty will help protect his brain from the traumatic injuries in the future and reinforce the function of his skull. Figure 3. Hematoma
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5.4 Signs and Symptoms Classical Signs
Clinical Signs Pre-operative
Post-operative
Rationale
Defect in the cranial
Manifested; defect
Not manifested
bone as shown in
on right parietal
the CT scan was a
the CT scan
bone
remnant of the
The defect shown on
previous surgery the patient may have undergone. -pg. 1050; MedicalSurgical Nursing by Ignatavicius Scar on the area of
Manifested; on right
Manifested
previous surgery
parietal area of scalp
The defect shown on the CT scan was a remnant of the previous surgery the patient may have undergone. -pg. 1050; Medical-
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Surgical Nursing by Ignatavicius Softness of the area
Manifested; on right
Not observable
of defect upon
parietal area of scalp
palpation
In craniotomy, a burr hole is made to serve as an opening through which blood or fluid may be evacuated. Cranioplasty is often done after. -pg. 367 Pocket Guide to the Operating Room by Goldman
IV. Nursing Interventions 1. Care Guide for Patients who have undergone cranioplasty Nutrition and Fluids Clients should be assisted to take in at least 2,500 ml of fluids a day unless conditions contraindicate this amount. Although there is no evidence that excessive doses of vitamins or minerals enhance wound healing, adequate amounts are extremely important. The nurse should ensure that clients receive sufficient protein, vitamins C,A,B, B5 and Zinc. Because an inadequate intake of calories, protein, vitamins and iron is believed to be a risk factor for pressure ulcer development, nutritional supplements should be considered for nutritionally compromised patients. Monitor weight regularly to help assess nutritional status. Preventing Infection
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There are two main aspects of controlling wound infection: preventing microorganisms from entering the wound and preventing transmission of blood borne pathogens to or from the client to others. Standard precautions include wearing of gloves when touching blood and body fluids and when handling items soiled with blood or body fluids; and washing thoroughly of hands after removing gloves. Head dressing should be inspected each day post-operatively until it is removed on the third post-operative day. Head dressings should not be disturbed for the first 24 hours unless inordinate bleeding requires that they must. Health care professionals and significant others should touch or change the dressing only when wearing sterile gloves and using sterile instrument.
Positioning The head of the bed is elevated 30 degrees to decrease intracranial pressure. To promote healing, patient should be positioned to keep pressure off the wound. Patient should be assisted to be as mobile as possible to enhance circulation. Deep breathing exercises while sitting is also advised to prevent accumulation of respiratory secretions.
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Seen patient , Mast. Ralph Labrador,sittin g on bed watching
television without IV. He is 12 years old and is for cranioplasty.
Actual state Of patient’s condition
A. Psychologic deficit: Anxiety -restlessness -client reported increased feeling of tension or as mother stated: “overexcitement” -client does foot shuffling -”kulbaan gamay” as verbalized by the patient
Brunswick Lens Model (Pre-operative)
B. Physiologic deficit: disturbed sleep pattern - client now sleeps late than his usual bed time -mother stated tat client is unusually restless during the night probably due to anxiety -client reported increased feeling of tension or as mother stated: “overexcitement” C. Knowledge deficit I.Anxiety:restlessness related to fear of -patient frequently asks questions unknown outcomes of surgery II.Disturbed sleep pattern: sleeping later regarding the procedure than his bedtime related to fear of -patient is only 12 years old -none of the family members is unknown outcome of surgery III. Knowledge deficit : frequent asking of in the medical field and none questions regarding the surgical procedure could give a simple explanation cranioplasty related to lack of of what he is about to go through explanation from significant others cues
Nursing Diagnoses
Measures to: A. reduce Anxiety -acknowledged fear -encouraged patient to verbalize feelings -spent some time with the patient -encouraged guided imagery -provided touch, massage B improve Sleep Pattern - clustered nursing activities - minimized fluid intake during night time -restricted intake of caffeinecontaining foods and fluids -supported continuation of patient’s bedtime rituals - encouraged patient to verbalize feelings C. improve knowledge on cranioplasty -evaluated capabilities and readiness to learn -reviewed information regarding injury process and after effects -showed the patient a picture of the skull and brain and explained in simple terms the surgical procedure
98 % resolu -tion Of Psychologi c
and physiologic problems experienced by the patient
Nursing Actions Desired Outcome Objectives Goal After 8 hrs. of student nurse –patient interaction, After 3 days of student the patient will be able to : 1. demonstrate decrease in anxiety as evidenced by nurse-patient interaction, patient will be able to attain decrease in restless ness optimum level of 2.improve sleep pattern as shown by sleeping functioning during his usual bedtime 3.verbalize purpose of the procedure
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Brunswick Lens Model (Post-operative)
Seen patient , Mast. Ralph Labrador,sittin g on bed watching
television without IV. He is 12 years old and is for cranioplasty.
Actual state Of patient’s condition
A. promote comfort -positioned patient so that his affected side will not receive much pressure -perforemded massage but not on affected part -encouraged deep breathing exercises -promoted rest -administered medications per doctor’s order
A.Physiologic Overload:Alteration in comfort -intermittetn pain on right parietal area of head; pain started hours after arriving from the OR;it is described as mildly stinging, aggravated by sudden head movement, relieved by rest and treated with Mefenamic acid 1 cap q8h po -patient rated pain as 5 in a pain scale 0f 0-10 wherein 0 stands for no pain and 10 as most painful
B.Risk for ineffective breathing pattern -patient has bronchial asthma and has undergone surgery for hours under general anesthesia -respiratory rate 18 breaths per minute C.Risk for infestion -patient is post-cranioplasty with head dressing reinforced with sterile pads
cues
Measures to:
I.Alteration in comfort:pain related to disruption of tissue integrity secondary to surgical procedure II.Risk for ineffective breathing pattern related to post-operative cerebral edema III.Risk for infection related to wound obtained during surgery
Nursing Diagnoses
98 % resolu -tion Of
B maintain respiratory function -placed patient in a semi-prone position -suctioned trachea -elevated head of bedas prescribed physiologic -administered nothing per orem until active problems coughing and swallowing reflexes returned experienced by C. maintain vital signs within normal range the patient -monitored site for signs of infection -instructed patient to report presence of salty taste -instruceted patient to avoid coughing, blowing nose -used aseptic technique when handling dressings -administered prophylaxis per doctor’s order
Nursing Actions
Desired Outcome Goal 1. demonstrate decrease in pain sensation as evidenced by a painAfter 3 days of student nurse-patient interaction, scale rating as 1 in a pain scale of 0-10 2.maintain adequate respi.function as evidenced by respi.rates in patient will be able to attain normal levels optimum level of 3.exhibit absence of infection as evidenced by vital signs in functioning normal range After 8 hrs. of student nurse –patient interaction, the patient will be able to :Objectives
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Patient’s name: Ralph Labrador
Age: 12 years old
Physician: Dr.Vergara Nilo
Room no. : 422
Sex: Male
Date: May 8, 2008
Nursing Care Plan (pre-operative) Needs/Problems
Nursing
Scientific
Objectives of
Diagnosis Anxiety:
Basis Anxiety or
Care After 8 hours of
restlessness
fear of the
student nurse-
I. Anxiety
related to
unknown is
patient
-restlessness
fear of
real.
interaction, the
-client reported
unknown
Feelings
patient will be
increased feeling
outcome of
are real and
able to:
of tension or as
surgery
changes in
1.demonstrate a
mother stated:
vital signs
decrease in
“overexcitement”
may
anxiety as
-client does foot
suggest the
evidenced by a
feelings so they can be
shuffling when the
degree of a
decrease in
discussed and dealt
nurse and his
patient’s
restless ness
with.-
mother talked to
anxiety
him about the
before a
b.encourage patient to
-It is helpful to bring out
upcoming surgery
certain
verbalize feelings
feelings so they can be
Cues A. Physiologic deficit:
Nursing Actions
Rationale
Measures to:
1. reduce anxiety a. acknowledge fear
-It is helpful to bring out
pg.745,NCPs,Doenges
procedure.
discussed and dealt
It is helpful
with-
To bring
pg.745,NCPs,Marilyn 26
out these
c.spend some time
Doenges
feelings out
with the patient
-continuous support may
in the open
help patient regain
so they can
internal locus of control-
be
d.encourage guided
pg.746,NCPs,Doenges
discussed
imagery
-promote release of
and dealt
endorphins and reduce
with
anxiety-
- pg.
e. provide
pg.745,NCPs,Doenges
745,NCPs,
touch,massage
-aids in meeting basic
Marilyn
human need decreasing
Doenges
sense of isolationpg.745,NCP,Doengespg.745,NCPs,Doenges
Patient’s name: Ralph Labrador
Age: 12 years old 27
Physician: Dr.Vergara Nilo
Room no. : 422
Sex: Male
Date: May 8, 2008
Nursing Care Plan (pre-operative) Needs/Problems
Nursing
Scientific Basis
Objectives of Care
Nursing Actions
Cues B.Physiologic
Diagnosis Disturbed
The effect of the
After 8 hours of
deficit:
sleep pattern:
change in sleep
student nurse-
sleeping later
patterns in
patient interaction,
II. Disturbed sleep
than his
children prior to
the patient will be
pattern
bedtime
and after an
able to:
related to fear
elective surgery
2.improve sleep
of unknown
has not been
pattern as shown by
outcome of
evaluated
sleeping during his
2. improve sleep
surgery
objectively.
usual bedtime
pattern
Rationale
Measures to:
Sleep in hospital
a. cluster nursing
- to give client
may influence
activities
time to rest with
biological
less disturbance-
processes related
pg.744,NCPs,Do
to circadian
enges
rhythm. It is
b. minimize fluid
- to prevent
reasonable to
intake during night
frequent urination
assume that
time
during the night
hospitalized
when patient is
children have
supposed to sleep 28
disturbed sleep
pg.744,NCPs,Do
patterns prior to
enges
and following
c. restricted intake of
- Caffeine
elective surgery.
caffeine-containing
lengthens the
We hypothesize
foods and fluids
time it takes to
that melatonin
fall asleep,
will improve
reducing your
sleep patterns
total sleeping
prior to and
time-pg.5; Get
following
Z’s now;
surgery, by
Geoffrey
reducing sleep
Burchfield
latency and
d.supported
-Children need a
extending total
continuation of
familiar and
sleep time. We
patient’s bedtime
pleasant routine
also hypothesize
rituals
and these are
that this
bedtime rituals
improvement
which can help
will have
children sleep on
positive impact
time- pg.37; Get
on anesthetic
Z’s now;
stress measures
Geoffrey
and on recovery.
Burchfield 29
-pg.50,Beyond the Relaxation Response by
e. - encouraged
- The source of
patient to verbalize
uneasiness or
feelings
anxiety, which is often a cause of
Herbert Benzon
sleep disturbance, is not always known or recognized. It is helpful to bring out feelings so they can be discussed and dealt with.pg.745,NCPs,Do enges
Patient’s name: Ralph Labrador
Age: 12 years old
Physician: Dr.Vergara Nilo
Room no. : 422
Sex: Male
Date: May 8, 2008
Nursing Care Plan (pre-operative) 30
Needs/Problems
Nursing
Scientific Basis
Objectives of Care
Nursing Actions
Rationale
Cues C.Knowledge
Diagnosis Knowledge
An anxious
After 8 hours of
deficit:
deficit:
patient could use
student nurse-
frequent
some emotional
patient interaction,
asking of
support and an
the patient will be
-patient frequently
questions
explanation of
able to:
asks questions
regarding the
what he is about
3.verbalize in his
about the procedure
surgical
to go through.
own level of
-patient is only 12
procedure
They need a
understanding the
2. improve
-permits
years old
related to lack
simple
purpose and
knowledge on
presentation of
-none of the family
of simple
explanation,
prognosis of the
cranioplasty
material based on
members is in the
explanation
appropriate for
procedure he is
a. evaluate
individual needs
medical field and
from
their level in
about to undergo
capabilities and
pg.225,NCPs,Doe
none could give a
significant
order to alleviate
readiness to learn
nges
simple explaination
others
their anxiety.-
-aids in
of what he is about
pg.50,Beyond the
establishing
to go through
Relaxation
realistic
Measures to:
Response by
b. review information
expectations and
Herbert Benzon
regarding injury
promotes
process and after
understanding of
effects
current situation and nedds-
31
pg225,NCPs,Doe nges c. show the patient a
-provides a visual
picture of the skull
stimuli for
and the brain and
learning-
explain in simple
pg.225,NCPs,Doe
terms the surgical
nges
procedure
atient’s name: Ralph Labrador Room no. : 422
Age: 12 years old Sex: Male Nursing Care Plan (post-operative)
32
Physician: Dr.Vergara Nilo Date: May 8, 2008
Needs/Problems
Nursing
Scientific Basis
Objectives of Care
Nursing Actions
Rationale
Cues Physiologic
Diagnosis I.Alteration in
Naked nerve
After 8 hours of
overload:
comfort:pain
endings found in
student nurse-
I.Alteration in
related to
the tissue are
patient interaction,
comfort
disruption of
called pain
the patient will be
tissue
receptors.Once
able to:
intermittetn pain on
integrity
an injury/break
1.demonstrate
right parietal area
secondary to
in the skin
decrease in pain
of head; pain
surgical
occurs, they send
sensation as
started hours after
procedure
nerve impulses
evidenced by a pain that his affected side
arriving from the
and chemicals to
scale rating as 1 in
will not receive much nerve triggering
OR;it is described
the brain
a pain scale of 0-10
pressure
as mildly stinging,
indicating the
pg.368,NPG,Doe
aggravated by
presence of pain
nges
sudden head movement, relieved by rest and treated with Mefenamic acid 1 cap q8h po -patient rated pain
-pg.210, Essentials of
Measures to:
1. promote comfort a. position patient so
-to avoid stimulation of the pain sensation-
b. perform
-serves as a
massage but not on
distraction
affected part
technique-
human anatomy
pg.315-316,MCN
and physiology
by Adelle
by Elaine Marieb
Pelliteri
as 5 in a pain scale
c.promote adequate
-rest promotes
0f 0-10 wherein 0
rest
healing and
33
stands for no pain
growth-
and 10 as most
pg.211,NCPs,
painful
Doenges -alleviates painpg.212;NCPs;Do enges
Patient’s name: Ralph Labrador Room no. : 422
Age: 12 years old Sex: Male Nursing Care Plan (post-operative) 34
e. administer
-alleviates pain-
medications per
pg.212;NCPs;
doctor’s order
Doenges
Physician: Dr.Vergara Nilo Date: May 8, 2008
Needs/Problems
Nursing
Scientific Basis
Objectives of Care
Nursing Actions
Cues II.Risk for
Diagnosis Risk for
After surgery the
2. maintain
2.maintain
ineffective
ineffective
frequency of
adequate
respiratory function
breathing pattern
breathing
post-operative
respiratory function
Rationale
pattern related complications
as evidenced by a
a. place patient in a
-the position
-patient has
to post-
monitoring is
respiratory rate at
semi-prone/ lateral
facilitates
bronchial asthma
anesthesia
based on the
normal range
position
respiratory gas
and has undergone
complications
patient’s clinical
exchange-
surgery for hours
status. Causes of
pg.2184;
under a general
anesthesia-
med.surg;
anesthesia
related death are
-respiratory rate of
usually linked to
b. suction trachea and Brunner and
18 breath cycles per
the respiratory
pharynx
minute
system. These
-removes
include
secretions
insufficient
pg.2184;
intubation or
med.surg;
proper
Brunner &
ventilation which
Suddarth
Suddarth
results in hypoxia, which
c. elevate head of bed -provides
is a deficiency of
20-30 degrees as 35
adequate lung
oxygen reaching
prescribed and
expansion
the tissues of the
promote purse-lip
pg.2184;
body.
breathing exercises
med.surg;
Complications
Brunner &
are mostly
Suddarth
related to General
d. administer nothing
-prevents
Gaseous-state
by mouth until active
aspiration
anesthesia and
coughing and
-page 2154; Med
may include
swallowing reflexes
Surg; Brunner &
laryngospasm,
are demonstrated
Suddarth
bronchospasm, aspiration, intubation injury, pulmonary edema, respiratory arrest .-pp. 378381,Stoelting, R.K, Pharmacology & Physiology in 36
Anesthetic Practice
Patient’s name: Ralph Labrador Room no. : 422
Age: 12 years old Sex: Male Nursing Care Plan (post-operative) 37
Physician: Dr.Vergara Nilo Date: May 8, 2008
Needs/Problems
Nursing
Scientific Basis
Objectives of Care
Nursing Actions
Cues III.Risk for
Diagnosis Risk for
The patient
3. exhibit absence
3. maintain vital
infection
infection
undergoing
of infection as
signs within the
related to
neurosurgery is
evidenced by vital
normal range
-patient is post-
wound
at risk for
signs within the
cranioplasty with
obtained
infection related
normal range
head dressing
during
reinforced with
surgery
sterile pads
Rationale
a. monitor site for
-these signs
to brain
redness, tenderness,
indicate infection
exposure, bone
bulging, separation,
at the site-
exposure and
foul odor
med.surg;
presence of IV
Brunner
lines for fluid administration.
b. instruct patient to
-this can be
Risk is increased
report presence of
caused by CSF
for those who
post-nasal drip or
leaking down the
undergo lengthy
salty taste
throat
intracranial
pg.2188;
procedures.-page
med.surg;
2187; Med.Surg.
Brunner &
Ng.; Brunner and
Suddarth
Suddarth
38
c. instruct patient to
-can cause CSF
avoid coughing,
leakage by
sneezing or blowing
creating pressure
nose
on operative site pg.2188; med.surg; Brunner & Suddarth
d. use aseptic
-prevent
technique when
contamination
handling dressings
and infection -page 2188; Med Surg; Brunner & Suddarth
e. administer
-prevent
prophylaxis per
infection--page
doctor’s order
2188; Med Surg; Brunner & Suddarth
Patient’s name: Ralph Labrador Room no. : 422
Age: 12 years old Sex: Male
Physician: Dr.Vergara Nilo Date: May 8, 2008
Drug Therapeutic Record Drug / Dose
Classification /
Indications /
Principle of Care 39
Treatment
Evaluation
/ Frequency / Route Mefenamic acid 500 g 1 cap every 8 per orem
Contraindications / Side-effects Classification: Indications: 1. Advise patient 1. Keep a record and - nonsteroidal anti- mild to moderate and significant monitor frequency, inflammatory drugs pain others that drug is location, duration, ;analgesic only for short term character, onset and Mechanism:- Mefenamic Contraindications: use and may intensity of pain. acid binds the - hypersensitivity aggravate condition 2 Perform back prostaglandin synthetase to the drug if use is prolonged. massage, and not on the receptors COX-1 and 2. Tell patient to injured site. COX-2, inhibiting the Side-effects: take drug as 3. Perform deep action of prostaglandin CNS: dizziness, prescribed and not breathing exercises. synthetase. As these vertigo, headache, to increase dose or 4. Provide adequate rest. receptors have a role as a somnolence dosage interval 5. Provide distractions major mediator of Gastrointestinal: unless ordered. to take patient's mind off inflammation and/or a nausea, vomiting 3. Advise the the pain. role for prostanoid Genitourinary: patient to inform 6. Discourage signaling in activityurinary retention, the prescriber if constrictive clothing. dependent plasticity, the urinary frequency taking OTC drugs symptoms of pain are Respiratory: since interactions temporarily reduced. respiratory may occur. depression Source: pp. 405-406; Nursing Drug Handbook 2006, 26th Edition; Lippincott, Williams and Wilkins
Oxacillin 750 g IVTT every 6 hours
Mechanism
Classification: - anti-infective narrow spectrum beta-lactam antibiotic of the
Indications: - treatment and prophylaxis for infections of the respiratory tract,
1. Check for allergies to the drug. 2. If large doses are given, therapy is prolonged, or patient 40
1. Monitor vital signs. 2. Tell patient to take the entire quantity prescribed
The patient was able to verbalize a decrease in pain sensation on a pain scale of 0-10, with 0 as “no pain” and 10 as “most painful,” from 5, “moderate pain” to 3, “tolerable pain.”
No evidence of suppuration on superficial wounds. The patient has
penicillin class. Mechanism: - inhibits cell wall synthesis, promoting cell wall / osmotic instability; usually bactericidal
EENT, skin, soft tissue, GIT, biliary, abdominal bone and joints, UTI Contraindications: - hypersensitivity to penicillins, lactation, renal insufficiency
is at high risk, monitor for signs and symptoms of super infection. 3. Tell patient not to confuse drug with other penicillins that sound alike. 4. Instruct patient to report discomfort at IV insertion site. 5. Advise patient to notify prescriber about loose stools or diarrhea.
even if he feels “better.” 3. Encourage bed rest. 4. Advise patient to take a well-balanced diet. 5. Promote proper hand washing, hygiene, and environmental sanitation.
manifested a normal temperature 36.8 degrees celsius; skin is warm to touch, noted with sweating, with no flushing and no chills.
Side-effects: Central Nervous System: headache, dizziness Cardiovascular: phlebitis Gastrointestinal: pseudomembranous colitis, nausea, vomiting, diarrhea, abdominal cramps th Source: pg. 168; MIMS, 108 Edition and pp. 105-107; Nursing Drug Handbook 2005, 25th Edition; Lippincott, Williams and Wilkins
41
Patient’s name: Ralph Labrador
Age: 12 years old
Physician: Dr.Vergara Nilo
Room no. : 422
Sex: Male
Date: May 8, 2008
SOAPIE No. 1 S-
“Kulbaan gamay,” as verbalized by the patient
O-
client does foot shuffling when the nurse and his mother talkied to him about the procedure; client is restless
A- Anxiety: restlessness related to fear of unknown outcome of surgery P-
to reduce anxiety
I-
acknowledged fear; encouraged patient to verbalize feelings ; spent time with the patient; encouraged guided imagery; provided touch, massage
E-
“Mahadlok ko okay wala akong mama ana gud. Dili siya makasud kuyog nako ingon ang nurse ganina,” as verbalized by the patient
42
Patient’s name: Ralph Labrador
Age: 12 years old
Physician: Dr.Vergara Nilo
Room no. : 422
Sex: Male
Date: May 8, 2008
SOAPIE No. 2 S-
“5 ang kasakit,” as verbalized by the patient referring to the pain scale 0-10 wherein 0 stands for “no pain” and 10 for “most painful”
O-
client tries to move slowly; client barely moves/ turns head
A-
Alteration in comfort: acute pain related to disruption of skin, tissue, muscle and blood vessel integrity secondary to the surgical procedure
P-
to promote comfort
I-
positioned patient so that affected side will not receive much pressure; performed massage but not on affected side; encouraged deep breathing exercises; promoted adequate rest; administered medication per doctor’s order
E- “Din a kayo sakit. 1 na,” as verbalized by the patient referring to the pain scale 0-10 wherein 0 stands for “no pain” and 10 for “most painful”
43
Patient’s name: Ralph Labrador
Age: 12 years old
Physician: Dr.Vergara Nilo
Room no. : 422
Sex: Male
Date: May 8, 2008
Play Therapy Developmental Change School age (6-12 years)
Type of Play Competitive
Objective of play After 15-20
Implemental Play “Questions and
Evaluation Patient was able
-the period in which the
quiet games
minutes of
Ladder”
to follow the rules
child’s body proportions
and activities
student nurse-
take on a slimmer look,
-although
patient
Materials needed:
was able to
with longer legs, varying play at this
interaction, the
-a snake ladder
answer the
body proportion and a
stage is
patient will be
board
student nurse’s
lower center of gravity.
highly active,
able to:
-2 chips with
review questions.
Freud described this
school-age
different colors
He lost the game
period as a time of
children also
1. follow the rules -cards containing
but he stated that
tranquility between the
enjoy quiet
of the game
he enjoyed it just
Oedipal phase of early
solitary
2. demonstrate his questions
like the way he
childhood and eroticism
games or
reading skills and
Mechanics of the
enjoyed the
of adolescence. During
games they
sportsmanship
game:
original snake and
this time children
can play with
3. learn more
1. student nurse
ladder game.
experience relationships
their best
about cranioplasty will serve as the
with same sex peers
buds. School
through the
patient’s playmate
following the
age children
student nurse
2. each of them
indifference of earlier
become
4. express how he
will have a chip
years and preceding the
fascinated
feels towards the
that’ll represent
heterosexual fascination
with complex
upcoming surgery
them on the s & L
that occurs for most
board, card or
board
boys and girls in
computer
3. the patient gets
puberty.-pg.356-380;
games.
to choose
Fundamentals of
Adherence to
questions from
Nursing; Barbara Kozier
the rule is
cards that he can
44
of the game. He
different
fanatic.- pg.
ask the SN;
Psychosocial task:
479; Wong’s
questions vary
industry vs. inferiority
pediatric
from personal to
Nursing by
inquiries about
Hocken berry
the surgery
Industry- or stage of accomplishment; they
4. the SN gets to
are eager to develop
question patient
skills and participate in
as a review if the
meaningful and socially
patient listened to
useful work; they
the SN’s answers
acquire a sense of
5. success in
personal and
anwering
interpersonal
advances the chip
competence
to the next level ;
Inferiority-when the
failure will lead to
reward structure is based
falling from the
on evidence of mastery,
ladder
children who are incapable of developing skills are at risk for feeling inadequate; they must learn that they will not be able to master every skill they attempt.
V. Evaluation and Recommendation 45
Healthy children and adults often heal and recover more quickly than older people who are more likely to have chronic diseases that hidner healing. Emotional support from significant others has also proved to be helpful in shortening recovery time for the patient. Being a 12 year-old, without any significant medical condition that could possibly hinder healing and with a supportive mother and aunts, the patient has a better prognosis.
Up to this point, the best recommendation in this case would be to encourage the patient and his significant others to follow all the doctor’s orders and take in the prescribed medications for an appropriate menght of time. Regarding the deficits manifested by the patient after the accident, the significant other is advised to show more patience in dealing with Ralph and if possible, forewarn the teacher of his difficulty in hearing with his right ear and short memory lapses because these may have been affecting his academic performance in school.
46
VI. Evaluation and Implication of the Case Study to:
Nursing Practice This case study nurtures the student nurse’s ability to integrate knowledge, attitude and skills taught in the classroom, into the actual clinical set-up. It provides the student nurse a comprehensive view about the field of medical diseases and their surgical intervention and broadens knowledge in giving holistic care to the patient. It benefits not only the patient and significant others but the student nurse as well. Nursing Education This case study is as vital as classroom teaching as a clinical exposure in nursing education as it broadens the student nurse’s knowledge even more. It is an additional force in promoting nursing education as it better helps the nurse understand the disease condition and updates one’s knowledge about the management of the disease . Nursing Research This case study enhances the student nurse’s research ability as one strives to have a comprehensive and thorough investigation about the case. The student nurse utilizes the maximum resources available and is able to use them effectively in making good and comprehensive research. This case study can be used as a source for further researches.
VII. Bibliography 47
Brunner and Suddarth; Medical-Surgical Nursing; 10th edition; JB. Lippincott Company,2008
Doenges,Moorehouse, et al; Nurse’s Pocket Guide: Diagnosis, Intervention and Rationale; 9th edition; FA Davis Company, 2004
Doenges,Moorehouse, et al; Nursing Care Plans: Guidelines for individualizing patient care; FA Davis Company, 2004
Grolier Incorporated; Grolier Encyclopedia of Knowledge; Academic American Encyclopedia, 1998
Hockenberry, Marilyn J., et al; Wong’s Essential of Pediatric Nursing; 7th edition; Mosby Inc. 2005
Kozier, Barbara, et al; Fundamentals of Nursing; 7th edition; Pearson Education, Inc, 2004
Marieb, Elaine N.; Essentials of Human Anatomy and Physiology; 7th edition; Pearson Education, Inc, 2003
Smeltzer, Suzanne C., et al; Medical-Surgical Nursing; 10th edition; JB Lippincott Company, 2004
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