Download Details Case Study - Acute placement April 2012

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Emily Short
30083702
The University Of Ballarat
Case Study
Comprehensive Nursing Care
HCNUR 3015
Due: 2/5/2012
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Abstract
Miss Waters is a 46-year-old woman who has been brought in by ambulance post seizure at her
work place. Miss Waters explained that she has had a recurring headache for about 2 months which
have been getting progressively worse, noticeable personality change (aggressive) and her left leg
has noticeable weakness. On examination it is discovered she has a large mass in her brain that
was diagnosed as a grade II astrocytoma. Miss Waters was then booked in for surgery to de-bulk
the tumour. Miss Waters had a serious episode of raised intracranial pressure on the ward before
the surgery. Miss Waters then completed a few months of rehabilitation but was left with a
permanent left hemiplegia. Miss Waters explained that she has a stressful job as a business
analyst and thought that she was just stressed. She lives alone and her closest family is in
Queensland although she has a close network of friends near by.
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Relevant Past History:
Miss Waters had been experiencing headaches for the past 2 months which have been getting
worse, has taken Panadiene Forte and Neurofen for the pain with only little affect. Miss Waters had
also had an out of character emotional outburst at her work place and in the past 2 weeks she has
developed a limp in her left leg. Miss Waters stated that she thought these symptoms were due to
her stressful job and the limp was because she was tired.
Presenting Circumstance:
Miss Waters collapsed at work after an out of character outburst during a meeting, which she said
was due to her headaches and excessive fatigue. She was then seen to have a seizure and was
brought in by ambulance. Obvious weakness in her left leg but nil deformities noticed.
Social Circumstance:
Miss Waters is single and she lives on her own. She is a professional woman (business analyst)
and has a close network of friends. She has a sister who has 2 children but they live interstate in
Brisbane.
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Pathophysiology:
Astrocytoma:
The process of cells mutating into cancer cells is called ‘carcinogenesis’, a broad multistep process
that is at the start of all cancers (Corwin 2008). The carcinogenesis process starts with the DNA of
a single cell mutating during DNA replication, usually this deformity would be identified and attempt
to repair the deformity by enzymes and if repair is not possible the cell then undergoes apoptosis
(cell suicide). Corwin (2008) outlined a possible explanation for these cells then becoming
cancerous and not self-destructing could be attributed to an inherited DNA abnormality in
conjunction with prolonged environmental exposures over a long period of time
The Central Nervous System (CNS) is supported by several varieties of non-excitable cells called
neuroglia cells of which there are four different types; astrocytes, oligodentrites, microglia and
ependyma (Marieb & Hoehn, 2007). Tumours growths of these cells are known collectively as
‘gliomas’ and tumours that are Grade II and below are known as ‘low grade gliomas’ and are then
individually named by the type of cell involved and then have the suffix of –oma that indicates
tumour growth (i.e. cancer of the astrocytes is called astrocytoma) (Pouratian & Schiff 2010).
Increased Intracranial Pressure (ICP):
The skull is a ridged capsule and when the volume inside is increased the pressure is therefore
increased, as there is only a small space for the extra volume to be placed, the ICP is the pressure
exerted by the cerebrospinal fluid (CSF) within the ventricles, in adults the normal range is from 5 –
15 mmHg, an ICP of 15 – 20 mmHg is classed as an elevated ICP (Lee & Anderson, 2008).
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Health Assessment (in relation to clinical manifestations and pathophysiology):
Preadmission Clinical Manifestations:
Headaches – That have been worsening over time. Sharma et al (2006) explained that the
increased pressure in the cranial cavity causes headaches in patients with brain tumours as the
tumour is now taking up what limited space there is.
Seizure – Was witnessed having a seizure just before she was brought into hospital. You et al
(2012) explains that seizures are a common presentation of a primary brain tumour, but not in all
cases as the likely hood varies with each individual patient. There are three main reasons that
seizures may occur; firstly the alteration of excitatory and inhibitory synapse organisation secondly
changes in neurotransmitters, receptors and related enzymes and thirdly the development of
hippocampal sclerosis from tumours near the temporal lobe (Chang et al 2009).
Personality Change – Marieb and Hoehn (2007) state that astrocytes participate in the neurological
functioning and information processing in the brain, additionally Miss Waters tumour is located in
the right hemisphere of the brain which has been noted to control certain types of behaviour.
Weakness in her left leg – Due to the fact that her tumour is located in the right cranial hemisphere.
The right cranial hemisphere is responsible for movement on the left side of the body (Marieb &
Hoehn 2007).
While in Hospital:
General Physical Assessment:
The general physical assessment did not raise any new red flags, except for one that have been
discussed above.
Miss Waters blood pressure is quite high which as her condition rapidly worsens it is evident that
the cause of that could be due to raised intracranial pressure. Her increase in blood pressure could
also be confused with her high level of pain or stress incurred from the diagnosis she has just
received (William & Hopper 2007).
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Vomiting: As the pressure in the cranial cavity rises the only place the contents has to move is down
which puts direct pressure on the Medulla Oblongata which houses the vomit centre and therefore
activates it (Marieb & Hoehn 2007).
Raised Intracranial Pressure: As discussed above in relation to Miss Waters headaches the rise of
her intracranial pressure (ICP) is due to her tumour now taking up vital space in the cranial cavity
causing the pressure in the brain to rise significantly.
Psychosocial Impacts: Miss Waters lives alone and her only family is far away, she may be feeling
alone, isolated or anxious about being alone or need extra emotional support.
Medications:
Endone (Oxycodone) 2.5mg – 5mg PRN QID
To help relieve Miss Waters pain from her headache
Major Side Effects: Nausea, vomiting and constipation; increase intracranial pressure; drowsiness,
confusion, sedation; respiratory depression; bradycardia, hypotension; dependence and tolerance.
Contraindications: Increases effects of benzodiazepams, sedatives, antihistamines and
barbiturates; caution if given with other respiratory depressants; may increase hypotensive effects
of antihypertensive or diuretics; delays gastric emptying so may affect all concurrent oral medication
Nursing Considerations: Will be more effective to ease pain if given before the pain gets more
intense; withhold if respiratory rate is below 8; be aware that physical and psychological
dependence can occur; have naloxone available to reverse respiratory depression; contraindicated
in those with a brain tumour and raised intracranial pressure (Tiziani, 2007).
Diazepam 5mg – 10mg IV PRN, 10 – 15 minutely
Diazepam is being used as an antiepileptic in this case.
Major Side Effects: Drowsiness, fatigue, ataxia; headache, tremor, confusion; risk of dependence
and tolerance; constant IV doses increase the risk of drug toxicity.
Contraindications: Increased central nervous depression if given with opioids; patients with kidney
or liver disorders; oral contraceptive pills effect decrease the elimination of some metabolites of
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diazepam.
Nursing Considerations: Sudden withdrawal may cause a temporary increase in seizures; overdose
is treated with Flumazenil; monitor for drug toxicity due to regular IV doses being administered
(Tiziani 2007).
Keppra (Levetiracetam) 500mg oral BD
An antiepileptic to stop more seizures occurring.
Major Side Effects: Drowsiness, weakness, anorexia; hallucinations; depression; ecchymosis.
Contraindications: Probenecid inhibits renal clearance of metabolites.
Nursing Considerations: Withdrawal should be gradual; long-term therapy is associated with low
folate concentrations (Tiziani 2007).
Mannitol 20% 500ml IV Stat
An osmotic diuretic to help reduce Miss Waters raised intracranial pressure
Major Side Effects: Fluid and electrolyte imbalance; circulatory overload; hypotension, chest pain.
Contraindications: Those with anuria, pulmonary congestion; those with active intracranial bleeding;
those with progressive renal damage, progressive heart failure
Nursing Considerations: Crystals may have formed in the solution; monitor vital signs during
infusion; monitor urine output; observe for electrolyte imbalance; should not be administered with
blood or blood products (Tiziani 2007).
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Medical Management:
Surgical Intervention: Schnell et al (2008) stated that surgical resection is considered the number
one therapeutic intervention for patients with a low-grade glioma. It is further outlined that total
tumour resection can be limited due to their often close proximity to functional areas of the brain and
the risk of post-surgical complications and quality of life outweigh risks associated with not removing
the whole tumour (Schnell et al 2009). Additionally, Duffau (2012) outlines that tumour resection
increases the overall survival and delays further growth.
Diagnostic Tests:
Computerized Tomography (CT): A CT scan involves an x-ray beam being rotated around the
patient, the pictures are then recreated by a computer program to give a realistic three dimensional
picture of the brain (Corwin 2008).
Magnetic Resonance Imaging (MRI): MRI allows us to capture what is happening in the brain
physiologically, it allows for non-invasive study of the oxygen concentration in the brain that then in
turn gives a picture of the blood flow in the brain (Corwin 2008).
Electroencephalogram (EEG): EEG’s measure the electrical activity occurring in the brain through
electrodes that are placed on the scalp, the EEG can pick up abnormal brain activity such as;
seizures and signals indicative of brain damage (Corwin 2008).
Results and Implications for Miss Waters:
The results of the diagnostic tests confirmed that she has a mass in her right cranial hemisphere
and that it is a malignant tumour called astrocytoma.
After Miss Water’s surgery she was left with a left sided hemiplegia due to the surgeons removing a
part of her motor cortex.
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Nursing Management Plan:
Pain Management: Patient is in substantial pain due to increased intracranial pressure.
Pain relief would be my first priority as keeping the patient comfortable is important for her
physiological functioning and anxiety related to pain
Intervention: Assess pain score on a scale of 0 – 10 or faces scale if verbal communication is
impaired.
Rationale: The patient self-report is the best measure of pain levels but sometimes patients cannot
verbalise their pain.
Intervention: Administer analgesia as prescribed and monitor for excessive PRN’s or inadequate
relief.
Rationale: Keeping the patient as pain free as possible is important for the patients physiological
state as well as their psychological well-being.
Intervention: Try alternative comfort measures, i.e. noise reduction, positioning and light
minimisation.
Rationale: Decreasing excess stimuli can have a calming effect on the patient and help them to
relax (Williams & Hopper, 2007).
Confusion and Anxiety about her Diagnosis
Secondly aiming to calm the patients psychological state would be my next priority and be an
emotional support as she is alone
Intervention: Educate the patient on what her prognosis means, be honest about your knowledge of
her condition. Put together a list of questions for the surgeon/oncologist in case she becomes
overwhelmed.
Rationale: Understanding what is actually going on in regards to her health allows her to make
informed decisions about her treatment and extra emotional support may give her comfort and
confidence about her options.
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Prevent Intracranial Pressure (ICP) Increasing Further
My next priority is implementing interventions in relation to her raised ICP as the episode of ICP
happened after the first two were already implemented
Intervention: Closely monitor patients pupils and eye’s and their Glasgow coma score (GCS).
Rationale: A change in consciousness, change in speech, swollen and blood in the optic disc and
dilated pupils are all signs of an increase in ICP (Lee & Armstrong, 2008).
Intervention: Keep neck neutral without flexion and keep bed at 30° (unless otherwise indicated).
Rationale: May help drainage and prevent aspiration.
Intervention: Closely monitor vital signs.
Rationale: Changes in BP, HR and RR can indicate increased ICP.
Perioperative Care:
Perioperative interventions are my next priority as she will be having major intracranial surgery.
Interventions: Preoperative – Gain consent, complete preoperative checklist (i.e. History, nail polish
and jewellery, preoperative medications administered etc.).
Rationale: Consent is legally required by the patient before surgery and helps to ensure they’re
adequately informed, the checklist provides guidance to ensure all necessary tasks are completed
Postoperative – Monitor vital signs (especially respirations and any major changes in results),
monitor drainage and wound site for haemorrhage and signs of infection and monitor pain levels
and administer analgesia where appropriate.
Rationale: Possible breathing difficulties due to anaesthesia, risk of haemorrhage and infection are
extremely high (alarms: hypotension, tachycardia, dysrhythmias, respiratory depression), pain
management is essential for the patient’s comfort and recovery (Williams & Hopper, 2007).
Self-Care Deficits due to her Left Sided Weakness (and Eventual Hemiplegia after Surgery)
This deficit will effect every aspect of the patients day to day life including in and out of hospital and
early interventions may assist in maintaining adequate mobility.
Intervention: Ensure that there is Physiotherapy and Occupational Therapy (OT) assessment and
treatment
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Rationale: Physiotherapists are able to provide expert physical rehabilitation and OT’s can provide
assessment of Miss Waters abilities and limitations.
Intervention: Encourage highest level of independence possible
Rationale: To ensure that Miss Waters does not lose further physical functioning.
Evidence Base for the use of the Glasgow Coma Scale (GCS):
The Glasgow Coma Scale (GCS) was created in 1974 to standardise level of consciousness
assessment in patients with head injuries and logical disorders (Shoqirat, 2006). The GCS is widely
accepted in most Western countries, it provides a simple and reliable measure of consciousness
and studies have shown variability between observers is minimal, when educated properly, the
global understanding allows for accurate communication and easy interpretation of results (Barlow,
2011). The GCS assess two aspects of consciousness; arousal and cognition and is divided into
three sections to represent the higher functions of the brain; eye opening, verbal performance and
motor response, each one is given a score which are then totalled with 15 as the highest possible
score and any score under 8 is considered to indicate a severe brain injury (Pamaiahgari, 2011). In
contrast Green (2011) argued that the GCS is grossly unpredictable, complicated and inaccurate in
predicting any medical outcome, although additionally Green did concede that the GCS was never
intended for use in isolation.
Pamaiahgari (2011) explains that the GCS will not give you crucial neurological information but
allows for monitoring for any changes in the patients condition additionally May (2009) explains that
a deterioration in conscious state is one of the first signs of increasing ICP.
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Future Care Considerations and Interventions:
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Make next appointment with the oncologist/surgeon in the community.
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Ensure that the OT has been through her house and necessary adjustments made (i.e. hand
rails, ramps, accessible bathroom and toilet). Discuss with OT and Miss Waters about
returning to work options and a driving assessment.
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Make appointment with a physiotherapist in the community and discuss accessibility and
consider home visits at first.
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Assess for possible self-care neglect (i.e. inadequate nutrition due to being unable to
prepare food/clean up). Possibly refer to meals on wheels and home help with
cleaning/washing.
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Make appointments with Community Nurse to touch base with Miss Waters after a week or
however long deemed necessary after leaving hospital to provide some assistance, social
interaction and allow for assessment of Miss Waters coping at home.
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Make a quick call to Miss Waters after her first night and day at home to find out if there
were any issues that may have been overlooked during discharge and to ensure that she is
able to cope.
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Discuss transportation options to appointments and help organise where necessary (taxi,
public transport, lift with a friend, community bus etc.).
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Discuss risk of social isolation due to living alone and possible self-image deficit’s due to
hemiplegia, possible surgical scars etc.
Possible Prognosis:
Schomas et al (2009) and Pouration & Schiff (2010) both explain that frequent prognosis for
patients with a low grade glioma (LLG) is directly correlated to factors such as age (generally over
40), initial presentation with sensory motor deficits and the tumour size, all of them having a
negative impact on prognosis and related to increased tumour progression. Additionally the overall
survival rate for malignant astrocytomas is 6.9 years (Schomas et al 2009). Jung et al (2011) states
that patients with LLG’s will eventually die as a result of tumour progression or progression to a high
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grade glioma, although patients who undergo large surgical resection are shown to have a longer
overall survival rate.
Education/support for Carer(s):
As outlined above Miss Waters long term prognosis is not positive and her condition will only
decline over time and therefore further support, extra care, services, information and resources will
be needed to help maintain quality of life. Parvataneni et al (2011) expresses that carers for patients
with brain tumours frequently experience symptoms of depression. Halkett, Lobb, Oldham & Nowak
(2010) add that because the prognosis is often uncertain and the unpredictable nature of symptoms
(i.e. cognitive deficits, mood swings, memory loss, loss of independence etc.). Psycheducational
skills training and therapeutic counselling significantly decreased the stress experienced by the
carer and improved their coping skills (Parvataneni et al 2011).
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