A Nursing Case Study on

SELLAR SUPRASELLAR CRANIOPHARYNGIOMA

In Partial Fulfillment of the

Requirements in NCM 218 RLE

INTENSIVE CARE NURSING ROTATION

Submitted to:
MRS. CELINA ANGELI B. ASENETA, RN
Clinical Instructor

Submitted by:
Ma. Andrew Nicole M. Añana, St. N
Rhizza Mae Bridget F. Arcenal, St. N
Ziajara Grace G. Biruar, St. N
Jannieh Mitch P. Buenaflor, St.N
John Keanu A. Castro, St. N
Kristine Joy D. Dela Cruz, St. N
Robina Marielle R. Galay, St. N

BSN 4I – Group 1_Subgroup 2

September 27, 2023

INFORMED CONSENT FORM

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SAN PEDRO HOSPITAL LETTER

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SAN PEDRO HOSPITAL LETTER

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 TABLE OF CONTENTS
I. Introduction....................................................................................................6
II. Objectives......................................................................................................8
A. General Objectives……………………………………………………………8
B. Specific Objectives……………………………………………………………8-9
III. Database
A. Biographical Data.....................................................................................10
B. Clinical Data……………………………………………………………………11
C. Family History...........................................................................................11
D. Past Health History...................................................................................12
E. History of Present Illness..........................................................................13
F. Developmental
Data..........................................................................................................13
IV. Physical Assessment...................................................................................16
V. Definition of Diagnosis..................................................................................22
VI. Pathophysiology
A. Anatomy and Physiology...........................................................................25
B. Etiology………………………………………………………………………….34
C. Predisposing Factors................................................................................34
D. Precipitating Factors……………………………………………...…………...37
E. Symptomatology………………………………………………….……………41
F. Disease Process.......................................................................................48
G. Narrative Discussion …………………………………………………..……..49
VII. Management……………………………………………………………………..54
A. Diagnostic / Laboratory Confirmatory Tests………………………………..54
B. Medical Management……………………………………………….……….107
C. Pharmacological Management ……………………………………............111
D. Surgical Management………………………………………..……………...155
E. Nursing Management……………………………………………...………...164
F. Nursing Care Plans…………………………………………………………..166
G. Nursing Theories……………………………………………………………..212

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VIII. Discharge Planning..................................................................................215
IX. Prognosis .…..............................................................................................219
X. Review of Related Literature/Studies........................................................220
XI. References..................................................................................................223

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I. INTRODUCTION
Intensive care is the highest level of patient care and treatment
available for severely sick individuals suffering from possibly treatable
life-threatening diseases. Intensive care (critical care) is a multidisciplinary
and interprofessional specialty that is specifically developed to handle
patients who are at risk of developing or who already have life-threatening
organ failure. What distinguishes intensive care medicine is the ability to
temporarily support and, if necessary, replace the function of several
failing organ systems, including the lungs, cardiovascular system, and
kidneys (Mounwe, 2021). The goal of intensive care in this rotation is to
maintain essential functions in patients with a severe critical disease in
order to reduce mortality and morbidity. And one of these severe critical
diseases is the Sellar Suprasellar Craniopharyngioma.

Craniopharyngiomas are uncommon, benign central nervous

system cancers. Craniopharyngiomas are epithelial tumors that begin in
the suprasellar area of the brain and spread to include the hypothalamus,
optic chiasm, cranial nerves, third ventricle, and major blood arteries. The
sellar/suprasellar region is the most common location for
craniopharyngioma, accounting for 95% of all craniopharyngiomas. Its
pathophysiology is determined by its location. Craniopharyngiomas can
compress normal pituitary tissue, resulting in pituitary deficits, especially of
anterior pituitary hormones. The anterior circulation supplies blood to the
majority of craniopharyngiomas. The main site of craniopharyngioma
recurrence is the most prevalent, however metastatic foci may emerge as
a result of seeding after surgery (Torres, 2023).

For the International statistics, Craniopharyngioma (CP) is an

epithelial tumor that originates from the epithelial remains of the
craniopharyngeal duct. Every year, there are 0.5-2.5 new cases per million
people worldwide, with a bimodal distribution of ages 5 to 14 and 50 to 74.

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 Many specialists consider craniopharyngiomas to be a chronic
condition since they re-occur even after being surgically removed
(resected). The tumor is usually not hazardous because it is benign and
only rarely becomes malignant. They are responsible for 1.2-2.6% of all
intracranial cancers and 5-11% of juvenile brain tumors. (Li et al, 2021).

In the Philippines, Craniopharyngioma ranked 5th with patients that have

Tumor-related syndromes and has the most prevalent site in
Sellar-suprasellar with 14 number of patients and has a percentage of 7.1
%. This area's histopathologies found predominantly benign tumors (42%),
such as craniopharyngiomas, pilocytic astrocytomas (optic pathway
glioma), and pituitary adenomas. Benign tumors develop slowly and may
not cause symptoms until they are large enough to compromise vision,
movement, or create increased intracranial pressure. Meanwhile,
malignant tumors develop quickly enough to create uncomfortable
symptoms, necessitating fast medical attention (Orduña, 2022).

In terms of local statistics, our case study is considered local because the
patient's surgery occurred in San Pedro Hospital, and the patient was
diagnosed with Sellar Suprasellar Craniopharyngioma. This would allow
student nurses and professional nurses to assist them in understanding
where the sickness is coming from, who it is most likely to affect, and
providing appropriate nursing intervention.

This case study is significant for nursing education because it will provide
student nurses as well as professional nurses to gain wide knowledge
about the Craniopharyngioma's etiology, risk factors, treatment options,
and its disease process. This knowledge will assist student nurses and
clinical instructors in developing care plans, nursing diagnoses, holistic
therapies, and relevant health education for patients as well as the

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 watchers so that it can prevent the progression of the said condition. In
terms of nursing practice, this will help student nurses hone their skills in
caring for patients and applying precise management and proper way of
handling the patient. Finally, in terms of nursing research, this case study
would serve as supporting evidence for future researchers to construct
studies to implement better evidence-based interventions that would
reduce medical errors, improve patient outcomes and can innovate
medicines or equipment that would help patients restore their health.

II. OBJECTIVES
A. General Objectives
At the end of 3rd week of Intensive Care Nursing Rotation, the
student nurses of San Pedro College from BSN - 4I Group 1 subgroup 2
will be able to assimilate new information and acquaint oneself with
important concepts, hone one’s abilities and adopt caring attitude which
can be applied in the case of Sellar Suprasellar Craniopharyngioma
through a detailed case study.

B. Specific Objectives
In order to achieve the general objective, the student nurses
specifically aims to:
A. Provide an overview of the rotation, definition of the disease, relevant
statistics specifically in international and national aspects, and implications
of the case analysis to nursing education, practice, and research;
B. formulate objectives that are specific, measurable, attainable, realistic,
and time-bounded (SMART);
C. discuss the patient’s physical assessment;
D. identify the etiology of Sellar Suprasellar Craniopharyngioma with its
precipitating and predisposing factors that promote the emergence of the
condition;

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E. determine the symptomatology that indicate the presence of a medical
condition;
F. illustrate the disease process of Sellar Suprasellar Craniopharyngioma
through a schematic diagram;
G. explain the disease process thoroughly in narrative form;
H. present appropriate medical, surgical, and nursing management
applicable to Sellar Suprasellar Craniopharyngioma, including laboratory
tests, diagnostic examinations, medications, and interventions;
I. determine seven (7) nursing diagnosis appropriate to the condition;
J. identify the possible prognosis of the condition;
K. devise a discharge plan for the patient;
L. relate nursing theories to patient’s care;
M. gather specific reviews of related literature that are published not earlier
than five years from the conduct of this case study; and
N. cite internet websites and other references used as sources of information
using the APA format.

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III. DATA BASE

A. Biographical Data
Name: K. A. M.
Sex: Male
Birthplace: Davao City
Birthdate: April 20, 2004
Address: Bago Gallera, Davao City
Age: 19 years old
Weight: 50 kg
Height: 5’4 ft. (152.4 cm)
BMI: 21.5 kg/m2
Nationality: Filipino
Postal Address: 8000
Religion: Baptist
Civil Status: Single
Occupation: Student
Father: A. M.
Mother: V. M.

B. Clinical Data
Date of Admission: September 12, 2023
Manner of Admission: Ambulatory
Chief Complaint: Blurring of vision
Case Type: Private
Attending Physician: Dr. E. P. G. Lagapa
Admitting Diagnosis: Craniopharyngioma ®
Ward/Unit: ICU Department
Cubicle: 18
Final Diagnosis: Sellar Suprasellar Craniopharyngioma
Surgery: Frontotemporal Craniotomy, Excision of

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 Craniopharyngioma
Date of Surgery: September 14, 2023

C. Family Health History

c.1. Genogram

c.2. Narrative
On his Paternal side, his grandfather died at the age of 70 because of
cardiac arrest and cancer, however could not recall what type of cancer it was.
On the other hand, his grandmother died at the age of somewhere between 70
and 80, because of respiratory disorder. His grandparents have 4 children and all
are boys, starting with their eldest son, A. M., the patient’s father is still living but
has hypertension. Their second son is alive but is suffering from hyperuricemia.
The other two (2) sons are also alive.

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 On the Maternal side, his grandfather died at the age of 70 because of
kidney problems, while his grandmother died at the age of 72 because of liver
cancer. Their eldest son is still living. Their second child, which is their first
daughter, is alive but is suffering from lung cancer and diabetes mellitus,
however, could not recall what type of DM it is. The other two (2) brothers are
also alive. Their youngest daughter, V. .M., who is the patient’s mother, is alive
but has the same condition as his grandfather, kidney problem. Overall, his
grandparents on the maternal side had five (5) children.

The patient’s parents have two (2) children who are all living on the same
roof. Their oldest son, K. A. M, the patient is currently suffering from Sellar
Suprasellar Craniopharyngioma. On the other hand, his sister is also alive and
currently studying at SPC Davao City.

D. Past Health History

During the assessment, patient K. A. M. had a record of an eye grade of
100+, thus diagnosed with Astigmatism two (2) years ago, he’s wearing an
eyeglass as his management. Patient does not have arthritis, heart disease,
diabetes mellitus, asthma or lung problem, kidney problem, thyroid problem,
hypertension, stroke, epilepsy or seizure, nor did he undergo any depressive
state. There is also no record of any surgical procedures or previous
hospitalization and illnesses during the patient's childhood. There is no record of
any allergies to food or drugs. The patient received all necessary immunizations
during childhood and has already taken 3 doses of Pfizer (vaccine) to protect
himself against Covid-19. The patient has no history of drug use or smoking and
does not consume alcohol.

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 E. History of Present Illness
Last January 12, 2023, 8 months prior to admission, patient K. A. M had
an onset of bilateral blurring of vision. There are no other associated symptoms
reported, such as headache, eye pain, vomiting, and body weakness. There was
no consultation done on that day, as well as no medications taken, and his
condition can be tolerated as per mentioned. On July 12, 2023, 2 months prior to
admission, his bilateral blurring of vision became worse and still not associated
with any other signs and symptoms. This time, he consulted an optometrist and
was advised for ophthalmology. During the perimeter test, the result showed
bilateral hemianopsia.

F. Developmental Task

ERIK ERIKSON’S PSYCHOSOCIAL THEORY OF DEVELOPMENT

Age Developmental Criteria Justification

Tasks

Stage 6: Early Young adults MET The patient has been much
Adulthood must cultivate closer to his father since his
deep and childhood years. Being close to
Intimacy vs
affectionate the father suggests that the child
Isolation
interactions with had the opportunity to establish
(19-25 years individuals. The a secure attachment, which is
old) attainment of crucial for the development of
success is often trust and a sense of security.
associated with This early trust forms the
developing robust

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interpersonal foundation for later stages of
connections,wher psychosocial development.
eas the
Basically, the patient is close to
experience of
failure tends to his family Being very close to

engender feelings one's family indicates strong

of social isolation attachment and emotional

and solitude. This bonds, which can provide a

developmental sense of security and support
stage pertains to during the intimacy vs. isolation
the phase of early stage. These strong family ties
adulthood can serve as a foundation for
wherein forming healthy intimate
individuals relationships outside the family
explore intimate unit.
relationships. The
user's text needs The quality time with his family

to be longer to be and friends are both balanced.

rewritten Balancing time with family and

academically. friends reflects a successful
negotiation of social
Erikson posited
relationships. Erikson's theory
that establishing
suggests that during the stage of
intimate and
"Intimacy vs. Isolation,"
enduring
individuals seek to establish
relationships with
meaningful and lasting
others is
connections with others while
paramount for
still maintaining a sense of self
individuals'
development. and identity. Balancing these

Individuals who relationships indicates a healthy

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 achieve approach to intimacy.
achievement in (Thompson, 2018)
this stage will
establish
long-lasting and
stable
relationships.
(Cherry, 2022)

ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY

Age Developmental Criteria Justification

Tasks

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Stage 4: Early Beginning a career MET The patient spends his time
Adulthood studying, reading, and watching
(19-30 years series and is not fond of playing
old) games. Which indicates that the
patient is setting his path towards
a career that he wants, it is also
stated by a family member during
the interview that he always
focuses on studying and aims to
have a consistent honor standing
till college level.

According to Havighurst Humans

learn how to be productive
members of society. Adults
manage to select a mate, raise a
family, manage a home, and
further their career (Hannah L.) A
perfect example is how he
manages his time and focuses on
things that are important in the
future, by shifting his time to
establishing his path to become a
productive member in the society.

IV. PHYSICAL/NEUROLOGICAL ASSESSMENT

A. General Survey
Upon observation the client was lying on bed in a semi-fowler’s position,
and minimal movement was done as to prevent his head to be moved .

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 The client was alert and oriented as he clearly answered all the questions
during assessment. The client’s mood was appropropriate and it is evident
on the way he answered the questions. The body built of the client is
Endomorph. As indicated in the chart, his body weight is 50kg while his
height is 5’4 ft. (152.4 cm). The posture of the client was not assessed
since the patient is unable to stand.

Vital Signs Nornal Values Client’s vital Indication

signs upon
assessment

Temperature 36.6°C Normal

35.6 - 36.7 °C

Cardiac Rate 60 - 100 bpm 74 Normal

Pulse Rate 60-100 bpm 72 Normal

Respiration Rate 16-20 cpm 25 Slightly high

respiratory rate

Blood Pressure 110/70- 130/90 110/80 Normal

mmHg

Oxygen 95-100% 99% Normal

Saturation

B. Skin
Upon inspection, it was noted that the skin appeared uniform in color with
a rough texture and good skin turgor, upon palpation the skin is warm in
temperature, dry moisture levels, and there were no lesions, edema, or
ulcerations present; furthermore, the nails were observed to be well-trimmed.

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 C. Head
Upon inspection of the head, the configuration is normocephalic. When
the head was palpated, both the anterior and posterior fontanelles were closed,
and deformities were noted in the skull. The scalp was inspected and it showed
clean and lesions were noted and dandruff was also visible. The hair was equally
distributed, it was coarse and dry. The face has asymmetrical movements and it
is evident when the client smiles. Muscle strength of the jaw is normal as
observed when the patient ask to open the mouth and when yawns.

D. Eyes
Upon inspection, the structure of the eyebrows was aligned. The lids were
symmetrical and no edema and ptosis was noted. The lashes are curled outward.
The lacrimal duct was normal as no swelling or excessive tearing is noted. The
cornea and lens are smooth with no lesions observed. The conjuctiva was pale in
both eyes. The periorbital region was not sunken, and no edema and
discoloration was noted. The sclera was anicteric or white upon assessment. The
pupil was anicteric and both OD and OS was brisk. The extraocular movements
of the client showed to be normal and has uniform in convergence. When the
client was asked about corrective lenses, he indicated that he uses corrective
lenses with an eye grade of 100+.

E. Ears
Upon observation of the ears, it was observed that the both pinna was
normoset and no tenderness was notes. Other tests for hearing acuity such as
Weber and Rinne tests were not assessed because of the bandages on his
head.
F. Nose
During the assessment of the nose, it was noted that the nasolabial fold
appeared symmetrical, and the septum was observed to be in midline alignment.
Mucosa appeared to be pinkish and no blood crusts or ulceration was noted. The

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patency of both nares are patent. There were no visible lesions or abnormalities
noted in the external nasal area, and the sinuses were non-tender to palpation.

G. Mouth
When the mouth was observed, the lips were symmetrical and it was
pinkish and moist. The client’s tongue was positioned in the midline. The teeth
were complete. The mucosa, gums, and palate were pinkish.

H. Pharynx
During observation the patient’s uvula was in the midline, the mucosa
appeared pinkish in color, with no visible swelling, redness or ulceration. The
tonsils were not inflamed, and there was no enlargement noted. Gag reflex of the
client is positive.

I. Neck
Upon assessment the trachea was positioned in the midline. Upon
palpation, the lymph nodes are nonpalpable, indicating that they do not feel
enlarged or abnormal. The thyroid is nonpalpable. There was no jugular vein
distention, indicating that the jugular veins in the neck do not appear enlarged or
swollen

J. Thorax
Upon inspection, the patient's thorax shape appears symmetrical. The
spinal alignment appeared to be normal. Upon auscultation the patient's
breathing pattern is effortless, with no signs of rapid breathing (tachypnea),
difficulty breathing (dyspnea), or slow breathing (bradypnea). The chest skin
turgor is good, indicating normal skin elasticity. Respiratory excursion is
symmetrical, and there are no abnormal breath sounds

K. Heart

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 Upon inspection and palpation, the precordium is normodynamic. When
the heart sounds were auscultated, the aortic point had distinct heart sounds
including the pulmonic, tricuspid and apical point. No extra sounds were heard.
When the temporal and carotid pulses were palpated in the left and right side,
both were strong. The apical pulse was strong. The brachial and radial pulses on
the left and right were strong. The pulses in the popliteal, dorsalis pedis and
posterior tibia areas were strong in both extremities.

L. Breast
The patient’s breast was inspected, it was equal and the contour was
normal. No discoloration was observed. When the breast was palpated no
tenderness was noted. The nipple and areola was normal, no deformities and
discharges were noted, and the color is dark.

M. Abdomen
During the physical assessment of the abdomen, skin was intact. Upon
inspection, there were no masses or visible lesions observed. Upon auscultation
the bowel sounds were found to be normoactive, with a rate of 10 bowel sounds
per minute, indicating normal bowel movement and activity. Furthermore, no
friction rub was detected. Additionally, upon palpation, the bladder was
non-palpable and negative sign for Ascites.

N. Genito-urinary System
While performing a bed bath on the patient, the student nurse conducted a
genitourinary assessment and observed the patient's genital area. The pubic hair
appeared normal, indicating normal growth and distribution. Nevertheless, the
penis itself appeared well-developed, showing no signs of lesions or discharges.

O. Musculoskeletal System

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 The student nurses from BSN 4I Group 1 Subgroup 2 were not able to
assess the patient in his musculoskeletal system for he was in a complete
bed rest as per medical order.

P. Neurological Assessment
During the initial assessment, patient K. A. M. spontaneously speak and
comprehend the questions the student nurses asked him. He is also aware of his
surroundings and is oriented to time, place, person, and situation accurately.
However, the student nurses did not assess for any lapses in memory which
includes immediate or short term memory, recent, and remote memory. In
conclusion, K. A. M.’s level of consciousness was oriented throughout the
assessment.

a. Cranial Nerves
The initial assessment was done during an 11-7 shift, and patient was
advised to have sufficient rest, so student nurses wasn’t able to conduct a
complete cranial nerve examination. However, for the optic nerve, patient’s visual
acuity was tested by the doctor prior to admission and result showed 20/70 in
Oculus Dexter and 20/200 in Oculus Dexter. Also, during the assessment done
every hour, his pupil reacts to light briskly. For the oculomotor nerve, he was able
to move his eyes downward and upward. For the 8th cranial nerve, both his ears
can hear the normal tone of the nurses’ voice. Lastly, for the accessory nerve,
when student nurse asked the patient to turn his body and head to the side for
morning care, he complained of pain when doing it.

b. Glascow Coma Scale (GCS)

Component Response Score

Eye Opening Spontaneous 4

Verbal Response Oriented 5

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 Motor Response Obeying 6

Result: 15 Prognosis: Good

c. Reactive Level Scale (RLS)

Clinical Descriptor Response Score

Alert No delay in response 1

V. Definition of Diagnosis
WEBSITE
Craniopharyngiomas are tumors that form close to the pituitary gland at
the base of the brain and are histologically benign but locally aggressive. Despite
reports of craniopharyngioma malignancy, this is an extremely uncommon
phenomenon. These tumors, which are typically very sticky and adhesive tumors,
typically affect the pituitary stalk, the tissue that connects the pituitary gland to
the hypothalamus. They differ in their solid and cystic content, with the majority
containing at least some cystic material.

They make up between two and three percent of all brain tumors, however
they are extremely uncommon, with an incidence of just two per million persons.
They are often present during infancy (ages 5–14) or late adulthood (ages
50–74), and they show no gender or racial prejudice (American Association of
Neurological Surgeons, 2022).

Reference:
Germanwala, A. (2022, August 22). Craniopharyngiomas – Symptoms, Causes,
Prevention and Treatments. Www.aans.org.
https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatment
s/Craniopharyngiomas

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JOURNAL
Craniopharyngiomas are uncommon, non-cancerous growths found in the
central nervous system. They are epithelial tumors that usually develop in the
region above the sella turcica within the brain. These tumors often extend to
affect critical structures like the hypothalamus, optic chiasm, cranial nerves, the
third ventricle, and major blood vessels. They can lead to various symptoms,
including but not limited to headaches, queasiness, vomiting, as well as visual
and hormonal imbalances.

The occurrence of craniopharyngioma is relatively rare, with a yearly

incidence ranging from 0.5 to 2 cases per one million individuals. While these
tumors can manifest at any age, they are commonly associated with pediatric
cases, comprising about 1.2 to 4% of all intracranial tumors. Nevertheless, it's
worth noting that approximately half of all craniopharyngioma diagnoses occur in
adults (Torres et al, 2023).

Reference:

Torres, M. O., Shafiq, I., & Mesfin, F. B. (2023, April 24). Craniopharyngioma.

Craniopharyngioma, 2(000569), 45.

https://www.ncbi.nlm.nih.gov/books/NBK459371/

BOOK

Hascek and Rousseaux’s Fundamentals of Toxicologic Pathology (2018)

defines Craniopharyngioma as benign tumors that grow near the pituitary gland.
It is an uncommon naturally-occurring neoplasm arising from the

23
craniopharyngeal duct epithelium of Rathke’s pouch composed of nests and
cords of squamous cells with areas of cyst formation. They can develop as solid
tumors or cysts (fluid-filled sacs). Approximately 10 percent to 15 percent of
pituitary tumors are craniopharyngiomas. In addition, this type of tumor accounts
for about 6 percent of all brain tumors in children.
There is a well-recognized bimodal age distribution, with the first peak
occurring at school age (5–14) and the second occurring in middle to late
adulthood (45–65). There is no gender predilection. The histologic diagnosis also
varies with age, with the papillary form of craniopharyngioma being seen almost
exclusively in the adult group, whereas adamantinomatous tumors can be found
in both groups. No environmental or genetic risk factors have been identified, and
craniopharyngioma is best considered a sporadic condition.

Reference:
Hascek, W. M., & Rousseaux, C. G. (2018). Fundamentals of Toxicologic

Pathology. Elsevier Inc. All rights reserved.

https://www.sciencedirect.com/book/9780123704696/fundamentals-of-toxi

cologic-pathology#book-info

VI. Pathophysiology

Anatomy and Physiology

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 The brain is composed of billions of nerve cells called neurons, which are
organized into several areas that are specialized for particular purposes. This
case analysis discusses craniopharyngioma, this is a condition that affects
primarily the brain. The brain is one of the components of the Nervous System
that is responsible for a variety of our body processes, including movement,
sensation, thought and emotion, are under its direction and coordination.
(Hopkins, 2020).

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 Meninges are three membrane layers that cover and protect your brain
and spinal cord (central nervous system). We got the Dura mater: This is the
outer layer, closest to the skull. The Arachnoid mater: the middle layer. And the
Pia mater: the inner layer, closest to the brain tissue.

The subarachnoid space is the space between the arachnoid mater and
the pia mater, the innermost layer of the meninges. It is filled with CSF, which
helps to cushion and protect the brain and spinal cord from injury.

26
 The brain is composed of three main parts: cerebrum, the cerebellum and
the brainstem.

The cerebrum is the largest part of the brain, and it controls the motor
and sensory information, conscious and unconscious behavior, feelings,
intelligence and memory. It is further divided into two by the great longitudinal
fissure hence the right and left hemispheres. The left hemisphere controls
speech, and abstract thinking while the right hemisphere controls spatial thinking.
From the brain, there is crossing of the motor and sensory neurons down to the
opposite side of the brainstem hence the right side of the brain regulates the
sensory and motor activities of the left side of the body, while the left side of the
brain governs the right side of the body.

Each brain hemisphere (parts of the cerebrum) has four sections, called
lobes: frontal, parietal, temporal and occipital. Each lobe controls specific
functions.

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Frontal lobe
The largest lobe of the brain, located in the front of the head, the frontal
lobe is involved in personality characteristics, decision-making and movement.
Recognition of smell usually involves parts of the frontal lobe. The frontal lobe
contains Broca’s area, which is associated with speech ability.

Parietal lobe
The middle part of the brain, the parietal lobe helps a person identify
objects and understand spatial relationships (where one’s body is compared with
objects around the person). The parietal lobe is also involved in interpreting pain
and touch in the body. The parietal lobe houses Wernicke’s area, which helps the
brain understand spoken language.

Occipital lobe
The occipital lobe is the back part of the brain that is involved with vision.
Temporal lobe. The sides of the brain, temporal lobes are involved in short-term
memory, speech, musical rhythm and some degree of smell recognition.

Temporal lobe
The sides of the brain, temporal lobes are involved in short-term memory,
speech, musical rhythm and some degree of smell recognition.

28
 The cerebellum (“little brain”) is a fist-sized portion of the brain located
at the back of the head, below the temporal and occipital lobes and above the
brainstem. Like the cerebral cortex, it has two hemispheres. The outer portion
contains neurons, and the inner area communicates with the cerebral cortex. Its
function is to coordinate voluntary muscle movements and to maintain posture,
balance and equilibrium. New studies are exploring the cerebellum’s roles in
thought, emotions and social behavior, as well as its possible involvement in
addiction, autism and schizophrenia.

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The brainstem (middle of brain) connects the cerebrum with the spinal cord. The
brainstem includes the midbrain, the pons and the medulla.

Midbrain. The midbrain (or mesencephalon) is a very complex structure

with a range of different neuron clusters (nuclei and colliculi), neural pathways
and other structures. These features facilitate various functions, from hearing and
movement to calculating responses and environmental changes. The midbrain
also contains the substantia nigra, an area affected by Parkinson’s disease that
is rich in dopamine neurons and part of the basal ganglia, which enables
movement and coordination.

Pons. The pons is the origin for four of the 12 cranial nerves, which
enable a range of activities such as tear production, chewing, blinking, focusing
vision, balance, hearing and facial expression. Named for the Latin word for
“bridge,” the pons is the connection between the midbrain and the medulla.

Medulla. At the bottom of the brainstem, the medulla is where the brain
meets the spinal cord. The medulla is essential to survival. Functions of the
medulla regulate many bodily activities, including heart rhythm, breathing, blood

30
flow, and oxygen and carbon dioxide levels. The medulla produces reflexive
activities such as sneezing, vomiting, coughing and swallowing.

The thalamus is the body's information relay station. All information from
the body's senses (except smell) must be processed through your thalamus
before being sent to your brain's cerebral cortex for interpretation. It also plays a
role in sleep, wakefulness, consciousness, learning and memory.

31
 The ventricles in the brain are located deep within the brain and a
system of four interconnected fluid-filled spaces within the brain.

The ventricles manufacture cerebrospinal fluid, or CSF, a watery fluid

that circulates in and around the ventricles and the spinal cord, and between the
meninges. CSF surrounds and cushions the spinal cord and brain, washes out
waste and impurities, and delivers nutrients.

32
 The cranial nerves are a collection of twelve pairs of nerves located at
the back of the brain. Cranial nerves carry electrical impulses from the brain to
the face, neck, and trunk. Your cranial nerves contribute to your ability to taste,
smell, hear, and sense sensations. In addition, they help you make facial
expressions, twitch your eyes, and move your tongue.

33
Etiology

Predisposing Factors Present or Absent Rationale

Genetics/ Hereditary PRESENT The actual etiology of

craniopharyngioma formation
is unknown, but mutations in
the CTNNB1 or APC genes
are found in more than 70%
of tumors. Mutations in these
genes may thereby contribute
to the development of
craniopharyngiomas.
CTNNB1 mutations are
inherited in an autosomal
dominant pattern, which
means that only one copy of
a gene variant is required to
exhibit an observable
phenotype. Further, the
offspring of an affected
person have a 50% chance of
acquiring the pathogenic
variant in APC (National
Organization for Rare
Disorders, 2023).

Based on the patient’s family

health history, both the
maternal and paternal sides
have cancer, making this risk
factor present.

34
Age PRESENT Craniopharyngiomas can
develop at any age. Although
it is commonly thought of as a
childhood condition,
accounting for 1.2 to 4% of all
brain tumors, roughly half of
all craniopharyngiomas are
discovered in adults. It
exhibits a characteristic
bimodal age distribution, with
an increased incidence rate
in children aged 5 to 14 years
and in adults aged 50 to 74
years (Torres,2023).

Sex PRESENT Craniopharyngiomas are

distinct types of brain tumors
that defy the general pattern
of gender susceptibility
observed in other types of
brain tumors. Men are more
likely to develop a brain
tumor than women (Rhun &
Weller, 2020). Recent
research has revealed a
significant difference between
men and women regarding
the prevalence of a particular
protein in their brain cells.
This protein is known as the
retinoblastoma (RB) protein.

35
The retinoblastoma protein
possesses properties that
can reduce the risk of
developing cancer.
Compared to women, males
have significantly lower
activity levels of this
protective protein in their
brain cells. Due to the
decreased activity of the RB
protein in males, it appears
that men are more likely to be
diagnosed with a brain tumor
than women.

These risk factors are present

in our patient since he is
male. Given that brain tumors
are more common in males
than females, this study
supports the idea that gender
plays a role in the
development of brain tumors.
Additionally, hormonal
differences between males
and females may contribute
to the higher incidence of
brain tumors in males.

36
Race ABSENT According to the study of
brain and other central
nervous system tumor
statistics (2021), cancers of
the brain and other regions of
the nervous system are more
prevalent among whites than
among blacks or Asians.
Although our patient has
craniopharyngioma, he is
Asian, hence this risk factor is
absent.

Precipitating Factors
Craniopharyngiomas are sporadic tumors, meaning the cause of their
development is unknown and there are no known risk factors. But here are some
precipitating factors that could potentially contribute to the development of
craniopharyngiomas:

Precipitating Factors Present/ Absent Rationale

Exposure to infections, Absent This factor is not present

viruses, and allergens to our patient, There are
no records and reported
history of infection.

Epstein-Barr virus (EBV)

and cytomegalovirus
(CMV) are both
members of the
herpesvirus family,

37
known for their potential
to increase the risk of
various malignancies.
EBV, the causative
agent of mononucleosis,
has been implicated in
the development of
central nervous system
(CNS) lymphomas,
where it can affect the
lymphocytes within the
brain and spinal cord,
potentially leading to
malignancy (Dunmire,
Verghese, & Balfour,
2018). On the other
hand, CMV has been
found in high
concentrations in brain
tumor tissues,
suggesting a possible
role in tumor
pathogenesis, although
the exact mechanism
remains under
investigation (Soroceanu
& Cobbs, 2019).
Both viruses are latent,
meaning that once
you're infected, the virus

38
 remains in your body for
life but usually remains
dormant or inactive.
However, under certain
conditions or when the
immune system is
compromised, the
viruses can reactivate
and cause disease. The
potential association of
these viruses with
certain cancers,
including CNS
lymphoma and other
brain tumors, suggests
that viral infections might
play a role in cancer
development or
progression. However,
the exact mechanisms
and implications of these
associations are areas of
ongoing research.

Ionizing radiation Absent Aside from family history,

the most consistently
established risk factor
related with the
development of brain
tumors is therapeutic or

39
high-dose ionizing
radiation. Small
increases in brain tumor
risks have been
documented in relation
to medical diagnostic
radiation exposure.
Although ionizing
radiation is used in
certain brain scans and
radiation therapy to treat
brain cancers, the
chance of acquiring a
new brain tumor from
these causes is very low.
Occupational exposure
to medical radiation has
been linked to roughly
twice the chance of brain
cancer death (Brain
Tumor - Risk Factors,
2023).

Concerning the influence

of nonionizing radiation
from cell phones, the link
between this exposure
and brain cancer has
been extensively
researched. Following

40
 the discovery of an
increased glioma risk
among heavy cell phone
users, the World Health
Organization's
International Agency for
Research on Cancer
designated
radiofrequency fields as
a potential carcinogen
(Rock, 2022).

Based on the gathered

data there are no history
or reports that the
patient was exposed to
radiation for the purpose
of medical therapy.

Symptomatology

Signs and Present or Absent Rationale

Symptoms

Diplopia Present Craniopharyngiomas are

rare non-cancerous growths
that develop in close
proximity to the pituitary
gland and optic nerves. As

41
 they grow, they can exert
pressure on the pituitary
gland, causing disruptions in
hormonal balance.
Additionally, these tumors
can also compress the optic
chiasm, a point where the
two optic nerves partially
intersect, which can result in
impairments in vision.
(NORD, 2019)

Astigmatism Present Elevated intracranial

pressure, often caused by
the tumor's pressure on the
brain, can influence the
pressure inside the eye,
known as intraocular
pressure. These alterations
in intraocular pressure can
have an effect on the eye's
shape and lead to the
development of astigmatism.
(Nujits et. al., 2020)

Bilateral Hemianopia Present Craniopharyngiomas

primarily induce visual
problems by either infiltrating
or compressing the visual
pathway. These issues often
present as reduced visual

42
 clarity (visual acuity), visual
field abnormalities (typically
bitemporal hemianopia), and
irregular pupil responses.
(Nujits et. al., 2020)

Headache Present Headaches can be a result

of elevated pressure within
the brain caused by the
presence of a large
craniopharyngioma. The
most frequent reasons
behind these headaches are
the stretching of
pain-sensitive structures
within the skull due to the
tumor's growth and the
development of
hydrocephalus. As the tumor
expands, particularly in the
parasellar area near these
sensitive structures, it can
often directly impact or
include these structures,
contributing to the headache.
(Khan et. al., 2021)

Nausea and Vomiting Present Nausea and vomiting in

craniopharyngioma typically
result from the tumor's
expansion, which raises

43
 pressure within the skull.
This increased intracranial
pressure can activate
specific brain areas
responsible for inducing
nausea and triggering the
vomiting reflex, resulting in
the sensation of nausea and
subsequent vomiting as a
response to this unusual
pressure. (Khan et. al.,
2021)

Poor balance Absent In individuals with

craniopharyngioma, balance
problems can stem from
hormonal imbalances that
affect muscle coordination,
pressure applied by the
tumor on brain areas
responsible for balance,
visual issues due to the
tumor compressing the optic
chiasm, potential disruptions
in brain function from
hydrocephalus, muscle
weakness and fatigue, and
treatment-related side effects
that impact neurological
function. (Nujits et. al., 2020)

44
Excessive urination Present In people with
craniopharyngioma,
increased thirst and urination
can result from abnormalities
in the pituitary gland's
function, situated in close
proximity to the tumor. The
pituitary gland has a vital
role in managing hormones,
including antidiuretic
hormone (ADH) or
vasopressin, which regulates
the body's water equilibrium.
(Khan et. al., 2021)

Excessive thirst Absent Craniopharyngioma has the

potential to disturb the
production and control of
several hormones, including
antidiuretic hormone (ADH),
which is critical for managing
fluid balance. Disruptions in
ADH due to the tumor can
result in increased urination
and an elevated sensation of
thirst. Additionally, both the
surgical removal of the tumor
and radiation therapy can
affect the hypothalamus and
nearby pituitary gland,
potentially leading to

45
 hormonal imbalances that
contribute to excessive thirst.
(NORD, 2019)

Hearing problems Absent Hearing issues in

craniopharyngioma patients
are infrequent but might
arise from increased
pressure within the skull
affecting the inner ear,
treatment-related
complications that impact the
auditory system, or
secondary problems
resulting from the tumor's
presence, although these
occurrences are exceedingly
rare. (Nujits et. al., 2020)

Hypothalamic Absent In craniopharyngioma,

Dysfunction hypothalamic dysfunction
may arise from the tumor's
direct impact on or
compression of the
hypothalamus, which is a
vital brain area responsible
for overseeing important
bodily functions such as
hormone regulation,
temperature control, and
appetite management,

46
resulting in disturbances in
these fundamental
processes. (Guo et. al.,
2023)

47
Disease Process

For a clearer version, please click on the link provided below:

https://drive.google.com/file/d/1rneDDu7fMuCa_IjmFutVln-tHJvPFCQD/view?usp
=sharing

48
Narrative Discussion
Craniopharyngioma is a rare benign tumor that develops from the
remnants of Rathke's pouch, an embryonic structure critical in the early
development of the pituitary gland. The disease process involves several stages,
including predisposing and precipitating factors, embryogenesis, genetic
mutations, growth patterns, differentiation, diagnostic examinations and
laboratory tests, some potential pressure effects on surrounding structures, and
management. The disease process starts with predisposing factors such as
genetics/hereditary factors, age, sex, and race. Furthermore, ionizing radiation,
infections, viruses, and allergens can also contribute to the development of this
idiopathic tumor.

Rathke's pouch, a basic embryonic structure, is important during

embryogenesis. During this process, Rathke's pouch emerges from the oral
ectoderm, the developing embryo's outermost layer of cells as an essential
embryonic structure. Rathke's pouch is important in the development of the
anterior pituitary gland, which is a critical component of the endocrine system,
regulating various hormonal functions in the body. Its remnants cause abnormal
cell growth, resulting in two types of craniopharyngiomas: adamantinomatous
which is driven by mutations in the CTNNB1 gene and papillary which results
from BRAF gene mutations. As mentioned, both types of craniopharyngioma
typically grow from the remnants of Rathke's pouch, which is located near the
pituitary gland and the primitive oral cavity. The tumor has a distinct expansion
pattern, growing in two primary directions: cranially (towards the head) and
posteriorly (towards the back of the brain). This growth orientation is due to the
tumor's origin from embryonic structures close to these regions. As the tumor
grows and expands, it infiltrates and penetrates the developing diencephalon, a
critical part of the brain. Further differentiation occurs during this process, leading
to the formation of a structure known as the adenohypophysis. The
adenohypophysis, which derives from the same embryonic origins as Rathke's

49
pouch, essentially influences the pituitary gland, influencing hormonal regulation
within the body.

Following those process above, it resulted to Craniopharyngioma. Several

diagnostic methods are used to diagnose craniopharyngioma - MRI and CT
scans provide detailed images of the tumor's location and characteristics, chest
x-rays are used to look for potential lung metastasis, whereas biopsies provide a
definitive diagnosis through tissue analysis. The craniopharyngioma may put
pressure on surrounding structures as it grows in the sellar and suprasellar
regions. Notably, pressure effects within the skull are uncommon, but they can
have an impact on the inner ear, potentially causing hearing problems, however
this is only a rare case. This symptom can be manage with whisper test, tuning
fork test, audiometer fork test, and some specific nursing interventions, such as
utilizing visual aid to communicate with the patient, speak clearly and at a
moderate pace, and refer to an audiologist for further assessment. Additionally,
the tumor can also press on the pituitary gland, affecting hormonal regulation.
Adrenocorticotropic Hormone (ACTH) and Follicle-Stimulating Hormone (FSH)
levels in individuals with suspected or diagnosed craniopharyngioma can provide
valuable insight into pituitary gland function and associated endocrine
abnormalities. These hormone tests aid in determining the tumor's impact on
hormonal regulation, which is frequently disrupted due to the tumor's proximity to
the pituitary gland.

As the craniopharyngioma grows and expands, the pressure it exerts on

the pituitary gland causes a variety of progressions and manifestations affecting
various brain structures. Impingement on critical areas causes a variety of
symptoms and complications in these progressions. First, the pituitary stalk,
which connects the pituitary gland to the hypothalamus, is impacted by the
growing craniopharyngioma. This impingement interferes with the regulation of
critical hormones. Dopamine blockade affects movement control and emotional
responses, potentially leading to mood and behavior changes. Furthermore, ADH

50
obstruction to excessive thirst (polydipsia) and frequent, large-volume urination
(polyuria). This can be manage by monitoring using laboratory test, such as
urinalysis, immunology, CBC, and blood chemistry, and specific management like
promoting adequate hydration, monitor intake and output, and report any
significant changes in urinary pattern. Second, the tumor's superior growth puts
pressure on vital brain structures. Ventricular occlusion disrupts normal
circulation and absorption of cerebrospinal fluid (CSF), resulting in elevated
intracranial pressure. This increased pressure can cause severe headaches,
astigmatism, nausea, and vomiting, affecting the individual's overall well-being
and daily activities, such as poor balance. For its management, starting from
astigmatism, we can do keratometry, visual acuity test, refraction test, and slit
lamp test, and some nursing interventions like providing adequate lighting,
educate patient on proper lens care, and encourage regular eye exams or
check-ups. For poor balance, we can check it through CT scan, MRI, CBC, and
vlood chemistry, following also some nursing interventions like provide adequate
lighting, side rails up, and render health teachings about fall prevention
strategies. Next is nausea and vomiting, which had the same laboratory test with
poor balance, with nursing management of elevating the head part of the bed,
side rails up, and administering of anti-emetic drug. Lastly, headache where we
can use MRI, CT scan, and CBC for laboratory tests, and nursing management
like conducting pain assessment, providing a quiet and dimly lit environmentm,
and administer pain relief medication. Going back to the superior tumor growth,
there also occurs impingement of the optic chiasma which is crucial junction
where optic nerve fibers cross. Impingement of this structure by the tumor can
cause visual disturbances, including reduced peripheral vision, blurring, and
difficulty seeing clearly. In severe cases, it can lead to complete loss of vision.
For bilateral hemianopsia, its management includes MRI, CT scan, perimetry test
and interventions like providing adequate lighting, side rails up, and encourage
patient to participate in vision rehabilitation program. For blurring of vision, we
can do ophthalmoscopy, tonometry, refraction test, slit lamp exam, and
encourage regular eye exams or check-ups with an optometrist. Next to that is

51
extension of tumor to hypothalamus which damages the hypothalamic cells and
disrupts its normal function. Hypothalamic dysfunctions can manifest as changes
in appetite (hyperphagia or anorexia), sleep disturbances, and disruptions in the
body's hormonal balance. To prevent this, we can do MRI and CT scan, and
some interventions like monitoring patient’s vital signs and changes in mental
status, and to promote restful sleeps.

Aside from the superior tumor growth, we also have lateral tumor growth
which affects the cranial nerves located on the sides of the brain, particularly 3,
4, 5, and 6. Pressure on these nerves can cause double vision (diplopia),
difficulty moving the eyes in certain directions, and altered sensation in the
forehead and upper face. Management for diplopia includes MRI, CT scan, CBC
and interventions like ensuring adequate lighting, encourage patient to perform
eye movement exercises, and determine if eye patching is appropriate to
patient’s condition. Lastly, is the inferior tumor growth where it grows at the
bottom of the brain. The tumor has the potential to erode into the sphenoid sinus,
creating a connection between the sinus and the brain. This connection allows
bacteria from the sinus to migrate into the brain, potentially causing infections in
the central nervous system. These infections can cause serious complications,
such as meningitis or brain abscesses.

Although, craniopharyngioma is a rare benign tumor, surgery like

Frontotemporal Craniotomy, excision of craniopharygioma is the primary
treatment for this condition.The prognosis of this condition is good, however, the
quality of life is low due to hypothalamic dysfunction and the impingement of the
optic chiasma which are all present to the patient, thus his prognosis is fair.
Medical management includes desmopressin, omeprazole, tranexamic acid,
cefoxitin, ceftriaxone sodium, levetiracetam, mannitol, dexamethasone,
paracetamol, sodium chloride, dexketoprofen trometamol, and metoclopramide
hydrochloride. Dexamethasone helps suppress inflammation to the patient’s
condition and sodium chloride helps balance his electrolytes. Nursing

52
management includes elevating the pain that the patient is experiencing,
promoting optimal fluid volume, lowers risk of surgical site infection, reduced
fatigue, enhanced physical mobility, ensure activity tolerance, and reduced risk
for injury.

If Craniopharyngioma is left unmanaged, the size of the tumor will expand

more, causing deterioration to some system, namely Endocrine complications,
like growth hormone deficiency, adronocortical insufficiency, central
hypothyroidism, hypogonadism, precocious puberty, hyperprolactenemia, central
diabetes insipidus, and hypothalamic obesity. Another is Neurological
complications, such as visual disturbances, vasculopathy, stroke, necrosis,
seizures, and changes in memory. Other complications also includes
hydrocephalus, cardiovascular issues, psychological distress, and emotional
disturbances. These all lead to bad prognosis, and worse, death.

53
 VII. Management

DIAGNOSTIC EXAM (ACTUAL)

Date Test Rationale Result Interpretation Nursing

and Significance Responsibilities

9/12/2023 C-Xray If a tumor is Negative chest This report

Before Chest
PA, discovered in findings describes the
X-ray:
Lateral the brain, a results of a chest
chest x-ray may X-ray , providing 1.Explain test
be performed to a comprehensive procedure.
screen for evaluation of Explain that
cancers in the various slight discomfort
lungs. This is structures within may be felt when
because most the chest cavity. the skin is
brain tumors in The observations punctured.
adults begin in made indicate a
another organ normal and R: To let the

(usually the healthy state of patient be aware

lung) and then the examined of the test that
spread to the areas. will be done and

brain. to avoid anxiety.

Both lung fields

2.Remove all
Chest x-ray being clear
metallic objects.
uses a very suggests that
small dose of there is no R: Items such as
ionizing evidence of jewelry, pins,
radiation to infection, fluid buttons etc can
produce accumulation, or hinder the

54
pictures of the masses in the visualization of
inside of the lungs, which are the chest.
chest. It is used signs of good
3. No preparation
to evaluate the pulmonary
is required.
lungs, heart and health. The
chest wall and description of the R: Fasting or
may be used to heart and great medication
help diagnose vessels as restriction is not
shortness of normal in size needed unless
breath, and configuration directed by the
persistent indicates that health care
cough, fever, these structures provider.
chest pain or appear as
injury. It also expected, 4.Ensure the

may be used to without signs of patient is not

help diagnose enlargement, pregnant or

and monitor malformation, or suspected to be

treatment for a other pregnant.

variety of lung abnormalities,

R: X-rays are
conditions such suggesting
usually not
as pneumonia, cardiovascular
recommended
emphysema health. The intact
for pregnant
and diaphragm and
women unless
cancer.Because costophrenic
the benefit
chest x-ray is sulci imply that
outweighs the
fast and easy, it these structures,
risk of damage to
is particularly essential for
the mother and
useful in respiratory
fetus.
emergency mechanics, are
diagnosis and in good 5.Assess the

55
treatment condition, with no patient’s ability to
(Krans, 2019). signs of hold his or her
abnormalities or breath.
damage.
R: Holding one’s
breath after
Furthermore, the
inhaling enables
osseous
the lungs and
structures, which
heart to be seen
include the ribs
more clearly in
and the spine
the x-ray.
within the chest
cavity, showing 6.Provide
no gross appropriate
abnormalities, clothing.
indicate that the
bones appear R: Patients are
healthy and instructed to

normal. The remove clothing

concluding from the waist up

statements, "No and put on an

remarkable X-ray gown to

finding" and wear during the

"Negative chest procedure.
findings",
7.Instruct patient
summarize that
to cooperate
the overall
during the
examination did
procedure.
not reveal any
significant R: The patient is
abnormalities or asked to remain

56
 concerns within still because any
the chest cavity, movement will
denoting a affect the clarity
generally healthy of the image.
state in this
region.
. After Chest
X-ray:

1.No special
care.

R: Note that no
special care is
required
following the
procedure

2.Provide
comfort.

R: If the test is
facilitated at the
bedside,
reposition the
patient properly.

9/14/2023 Biopsy Even if other Gross: The examination Before the

tests indicate A. Specimen reveals features procedure:
the presence of Labeled consistent with a
a tumor, a “Craniopharyngi craniopharyngio 1.Educate the
biopsy is the oma” is ma. patient about the

57
only way to composed of This suggests purpose,
make a 4cm aggregate that the cells process,
definitive of creamy white examined did not benefits, risks,
diagnosis. to dark have any and potential
During a biopsy, -red-brown unusual or outcomes of the
a portion or the fragments. abnormal biopsy. Also
entire tumor is Some of the appearance. ensure that the
removed for fragments are Atypical cells can patient or their
microscopic calcified. sometimes be an representative
examination. indication of provides
During an B. Specimen disease, informed consent
operation for labeled including cancer, for the
craniopharyngio “Cranipharyngio so not finding procedure.
ma, a ma” is any in the
neurosurgeon composed of sample is Rationale:
may extract a approximately generally a good Ensuring that the
portion or the 3mL of bright sign.The report patient
entire tumor. A yellow cloudy indicates that understands the
pathologist then fluid. only procedure helps
diagnoses the macrophages alleviate anxiety
surgically Microscopic: were identified in and ensures that
removed tissue the smear, which the patient can
by examining it A.There are means no other make an
under a nests and cell types were informed
microscope. A sheets of detected in the decision about
pathologist is a stellate cells that sample.Macroph undergoing the
physician surrounded by ages are a type biopsy.
specializing in palisade of of white blood
the columnar cells. cell that play a 2. Conduct a
interpretation of critical role in our thorough

58
laboratory tests B.The specimen immune system. assessment,
and the contains few They help to including medical
evaluation of foamy defend against history, allergies,
cells, tissues, macrophages infections by medications, and
and organs to only. There is no ingesting foreign vital signs. They
diagnose atypical cell. substances and should also
disease. pathogens, and assess the
Pathologist who Diagnosis: they also help patient’s
specializes in A.Consistent with tissue repair. emotional state
CNS tissues with and provide
and diseases. crani[haryngiom support as
Typically, the a needed.
neurosurgeon
will attempt to B. Negative for Rationale:
remove as atypical cell, This assessment
much of the presence of helps identify any
tumor as macrophages potential risks or
feasible while only, smear. contraindications
minimizing brain for the procedure
damage and ensures that
(Craniopharyngi the patient is
oma - Childhood physically and
- Diagnosis, emotionally
2023). prepared.

3.Prepare the
patient by
positioning them
correctly and
ensuring that the

59
biopsy site is
clean and
accessible. They
also prepare and
check the
equipment and
supplies needed
for the
procedure.

Rationale:
Proper
preparation is
essential for the
success of the
biopsy and for
minimizing the
risk of infection
or complications.

4. Assist the
physician or
healthcare
provider
performing the
biopsy by
handing over
instruments,
monitoring the
patient’s vital

60
signs, and
providing comfort
and support to
the patient.

Rationale:
Assistance
ensures that the
procedure goes
smoothly, and
the patient
remains stable
and comfortable.

After the
procedure:
5. Monitor the
patient for any
signs of
complications
such as bleeding,
infection, or
adverse
reactions. They
also provide
wound care if
necessary and
educate the
patient on
at-home care for

61
the biopsy site.

Rationale:
Monitoring and
care are crucial
to prevent and
promptly address
any
complications
arising from the
biopsy.

6. Assess the
patient’s pain
level and
administer
prescribed pain
medications as
needed.

Rationale:
Managing pain
effectively is
essential for the
patient’s comfort
and well-being,
especially after
invasive
procedures.

62
7. Provide the
patient with
discharge
instructions,
including signs
and symptoms of
complications to
watch for and
when to seek
medical
attention. They
also coordinate
any necessary
follow-up
appointments.

Rationale:
Proper discharge
planning and
follow-up are
essential to
monitor the
patient’s
recovery and to
discuss the
results of the
biopsy and any
subsequent
steps in their
care.

63
 8. Document the
patient’s
assessment, the
procedure, any
interventions,
and the patient’s
response.

Rationale:
Accurate
documentation is
essential for legal
and medical
records,
continuity of
care, and for
informing
healthcare
providers of the
patient’s
condition and
treatment.

n.d. MRI An MRI is MRI of brain According to the Assess the

typically pituitary gland interpretation of patient’s medical
conducted with showed this MRI report, history, allergies,
the enhancing there is an and
administration of complex sellar - enhancement of understanding of
intravenous dye supracellar a complex mass the procedure.
to identify mass with located both Educate the

64
structures within compression of within the sella patient about the
the brain and optic chiasm turcica (sellar) procedure, what
evaluate for a considerations and above it to expect, and
tumor such as a are (suprasellar) in address any
craniopharyngio craniopharyngio the pituitary questions or
ma. This aids in ma and pituitary gland region of concerns.
the identification macroadenoma, the brain. This Rationale:
of key brain cavum septum mass is exerting Understanding
structures pellucidum pressure on the the patient's
located close to (normal variant), optic chiasm, the medical history
the tumor, such maxillary portion of the can identify
as the sinusitis (L). brain where the potential
hypothalamus, optic nerves contraindications,
pituitary stalk cross partially. such as
and gland, For the type of implanted
internal carotid mass, metallic devices.
arteries, optic craniopharyngio Education helps
nerve, and optic ma and pituitary alleviate anxiety
chiasm. Several macroadenoma and ensures
classification are the primary cooperation
systems for considerations. during the MRI.
craniopharyngio Craniopharyngio
mas, based on mas are Screen patients
imaging uncommon, for any
findings, may typically benign contraindications,
aid in tumors that can including
determining the develop near the pacemakers,
optimal pituitary gland, cochlear
treatment whereas pituitary implants, certain
(Craniopharyngi macroadenomas metal implants,

65
oma - Childhood are benign, or clips. Inquire
- Diagnosis, typically about any
2023). slow-growing possibility of
tumors that pregnancy in
originate from female patients.
the pituitary Rationale:
gland (Lithgow MRI uses strong
K,et.al 2022). magnets; the
presence of
In addition to metallic objects
this, the report or certain
also mentions conditions can
the presence of a pose risks, hence
cavum septum screening is
pellucidum, essential for
which is patient safety.
described as a
normal variant. Ensure the
This indicates patient removes
that there is an all metal objects,
excess space or including jewelry,
cavity between hearing aids, and
the layers of the dentures.
septum Provide
pellucidum, appropriate
which is usually clothing or a
not a cause for gown. Insert an
concern as it is a IV line if contrast
normal is to be used.
anatomical Rationale:

66
variation. Metal objects can
interfere with the
In addition, the magnetic field,
report indicates affecting image
the presence of quality and
maxillary posing a safety
sinusitis on the risk. An IV line is
left side (L), needed for
which indicates contrast
that the maxillary administration,
sinus is inflamed, which enhances
typically due to imaging results.
an infection or
allergy. Monitor vital
signs as
necessary and
provide
emotional
support,
especially for
patients with
claustrophobia.
Offer earplugs or
headphones, as
MRI can be loud.
Rationale:
Monitoring
ensures patient
stability.
Providing support

67
and protective
equipment
enhances patient
comfort and
safety.

Assist in correctly
positioning the
patient on the
MRI table and
ensure they are
comfortable and
secure.
Rationale:
Proper
positioning is
crucial for
obtaining
high-quality
images and
reducing the
need for repeat
scans.

Ensure that the

patient has a call
bell or another
way to
communicate
during the scan.

68
Inform the patient
about the
approximate
duration of the
procedure.
Rationale:
Maintaining
communication
ensures the
patient can signal
discomfort or
distress, and
knowing the
duration helps
set patient
expectations.

Monitor the
patient for any
adverse
reactions,
especially if
contrast was
used. Provide
post-procedure
instructions and
assess the IV
site for any
complications.
Rationale:

69
Monitoring helps
identify and
address any
immediate
post-procedure
issues, ensuring
patient
well-being.

Document the
procedure,
including patient
preparation, any
interventions
made, patient
responses, and
post-procedure
observations.
Rationale:
Accurate and
thorough
documentation is
essential for
maintaining
continuity of care
and serves as a
legal record of
the nursing care
provided.

70
 Diagnostic / Laboratory Confirmatory Tests

DIAGNOSTIC EXAM (POSSIBLE)

Test Rationale Nursing

Responsibilities

CT-Scan A Computed Tomography (CT) 1. Educate the patient on the

scan, also known as a CAT procedure, its purpose, the
scan, is a diagnostic imaging steps involved, and address
procedure that employs X-rays any concerns. Obtain
and computer technology to informed consent if
create cross-sectional (slice) required.
images of the body. A CT scan
can visualize nearly all body Rationale:
regions and is used to Ensuring the patient is informed
diagnose disease, trauma, or helps alleviate anxiety and
abnormalities in symptomatic promotes cooperation during the
patients. It is also used to procedure.
guide biopsies and other 2. Ensure the patient is
procedures, as well as to plan appropriately dressed and
and evaluate the outcomes of has removed all metal
surgery and other treatments objects. If contrast is to be
(Mayo Clinic, 2021). used, ensure IV access is
established.

Rationale:
Metal objects can interfere with

71
imaging, and preparation is
needed for the administration of
contrast media.

3. Monitor the patient’s vital

signs and provide support,
especially if they
experience anxiety or
claustrophobia.

Rationale:
Monitoring is essential to ensure
patient safety and to provide
immediate care if adverse
reactions occur.

4. Monitor the patient for any

adverse reactions to the
contrast media, assess the
IV site, and provide
post-procedure instructions.

Rationale: Identifying and

managing adverse reactions
promptly is crucial for patient
safety.

5. Document the procedure,

including preparation, any
interventions, and the

72
 patient’s response.

Rationale:
Accurate documentation is
essential for legal and medical
records and for continuity of care.

73
 LABORATORY EXAM (ACTUAL)

TEST NORMAL DEFINITION/ RESULT SIGNIFICANCE NURSING

VALUES/FINDINGS RATIONALE RESPONSIBILITIES

Complete Hemoglobin: A complete blood 149 g/L Normal Before the procedure:
Blood Count 140 - 160 g/L count (CBC) is a
(CBC) crucial and 1. Inform and explain the
Red blood cell (RBC) comprehensive 4.88 Normal test procedure to the
Released count: 4.0-5.0 x blood test that patient
date and time: 10^12/L enables your R: It is essential to inform
09/12/23 @ physician to the patient to reduce the
1:20 pm Mean corpuscular assess every 30.5 pg Normal anxiety during the
hemoglobin (MCH): category of cells procedure.
28-33 picograms (pg) within your blood. It
quantifies the 2. Explain that skin
Mean corpuscular quantity of red 91.0 fl Normal puncture might cause
volume (MCV): 82-98 blood cells (RBCs), minor discomfort.
femtoliters (fl) white blood cells R: Gaining an
(WBCs), and understanding of pain
Mean corpuscular platelets (PLTs). 33.6 g/L Normal helps reduce the fear and

74
 hemoglobin These various anxiety surrounding it and
concentration (MCHC): blood cell types this can help reduce the
33-36 g/L play vital roles, so impact of pain or
measuring their discomfort to the patient.
White blood cell levels offers 8.0 Normal
(WBC) count: valuable health 3. Encourage the patient
4.8- 10.8 x 10 ^9/L insights. This to avoid stress to the
examination can greatest extent.
Differential Neutrophil: 40-70% aid in diagnosing 66% Normal R: It affects and alters
count various medical normal hematologic
Lymphocyte: conditions and also 22% Normal values.
19-48 % in monitoring the
body's response to 4. Explain that fasting is
Monocyte : 3-9 % different diseases 9% Normal not necessary. However,
or medical fatty meals may alter the
Eosinophil: 2-8 % interventions. 2% Normal result of various tests.
R: Without a doctor's
Basophil: 0-0.5 % The complete 1 Normal instruction, fasting or
blood count (CBC) medication restriction is
Hematocrit: 0.40-0.48 test was 0.40% Normal not necessary.
% administered to the
patient following After the procedure:

75
 Platelet Count: surgery for 299.00 Normal 5. Monitor for bleeding or
150-400 x 10^9 /L craniopharyngioma hematoma formation at
in order to monitor the puncture site.
for potential R: To prevent further risks
complications such and complications.
Released Hemoglobin: as infections or 137 g/L Low
date and time: 140 - 160 g/L bleeding. This test
09/15/23 allows healthcare
Red blood cell (RBC) professionals to 4.44 Low
count: 4.0-5.0 x detect any
10^12/L indications of
infection (such as
Mean corpuscular an elevated white 30.9 pg Normal
hemoglobin (MCH): blood cell count) or
28-33 picograms (pg) bleeding disorders
(abnormal platelet
Mean corpuscular count) that may 91.0 fl Normal
volume (MCV): 82-98 arise as
femtoliters (fl) postoperative
issues.
Mean corpuscular 34.0 g/L Normal
hemoglobin

76
concentration (MCHC):
33-36 g/L

White blood cell 15.8 High

(WBC) count:
4.8- 10.8 x 10 ^9/L

Neutrophil: 40-70% 88% High

Lymphocyte: 6% Low
19-48 %

Monocyte : 3-9 % 5% Normal

Eosinophil: 2-8 % 1% Low

Basophil: 0-0.5 % 0% Normal

Hematocrit: 0.40-0.48 0.40% Normal

%

Platelet Count: 270.00 Normal

77
150-400 x 10^9 /L Based on the
most recent CBC
result from
September 15,
2023, at 2:36 am,
it was observed
that the patient
had low levels of
hemoglobin and
RBCs. These low
levels could
potentially indicate
blood loss either
during or after
surgery.
Additionally, when
hemoglobin and
RBC counts are
deficient, it could
signal the
presence of
anemia in the

78
patient. Anemia,
in the context of
postoperative
recovery from
craniopharyngiom
a surgery, refers
to a condition
where there is an
insufficient
number of healthy
red blood cells
(RBCs). In such
cases, low RBC
and hemoglobin
levels can lead to
a delayed
recuperation
following surgery.
This delay occurs
because oxygen
is vital for tissue
healing, and when

79
there's anemia,
the insufficient
oxygen supply
can protract the
healing process,
consequently
extending the
overall recovery
period for the
patient.
Furthermore, the
patient's
lymphocyte and
eosinophil counts
are diminished.
This decrease can
be attributed to
certain
medications
administered after
surgery, such as
corticosteroids or

80
immunosuppressa
nts. These drugs
are frequently
prescribed to
control
inflammation or to
moderate an
exaggerated
immune response.
However, when
lymphocyte levels
are low, indicating
a reduction in a
specific type of
white blood cell
responsible for
immune defenses,
it may imply that
the patient's
immune system is
compromised or
restrained. This

81
heightened
vulnerability to
infections can be
a noteworthy
concern following
surgery.

On the other
hands, the patient
exhibits elevated
levels of
neutrophils and
white blood cells
(WBCs),
suggesting that
this increase may
also be linked to
the body's
process of
recuperation.
These cells
contribute to the

82
 removal of injured
tissue and the
facilitation of the
mending of
surgical wounds.

Blood Creatinine: 63.6 -104.3 Blood chemistry, 61.20 Low Before the procedure:
Chemistry umol/L alternatively umol/L 1.) Inform the patient
termed a blood about the
Released Sodium: 135-145 chemistry panel or 140.80 Normal procedure; how is it
Date and mmol/L blood chemistry mmol/L done and its
Time: test, encompasses purpose.
9/12/23 @ Potassium: 3.5 -5.1 a set of laboratory 4.21 Normal R: Providing information
1:20 pm mmol/L examinations mmol/L prepares the patient
aimed at mentally and emotionally
scrutinizing the for the procedure,
chemical reducing anxiety and
Released Sodium: 135-145 constituents and 196.0 High uncertainty.
Date and mmol/L concentrations of mmol/L
Time: diverse substances 2.) Inform the patient
09/15/23 @ Potassium: 3.5-5.1 within the 4.23 Normal that he will feel a bit
2:36 am mmol/L bloodstream. mmol/L of pain when the

83
 These needle is inserted.
Total Calcium: assessments offer 2.24 Normal R: Medical procedures
2.15-2.50 mmol.L important insights mmol/L can be intimidating,
Released RBS: 4.1-5.9 mmol/L into an individual's especially for patients who
Date and general well-being, are unfamiliar with them.
Time: organ Informing patients helps
09/15/23 @ Blood Urea Nitrogen: performance, and 7.28 High demystify the process and
2:36 am 2.50- 7.10 mmol/L the existence of mmol/L reduces fear.
specific medical
Magnesium: 0.70-1.00 ailments or 3.20 Normal 3.) Advise patients that
mmol/L disorders. mmol/L they should feel as
(Whitlock, 2023) relaxed as possible
0.80 Normal while blood is being
Released Sodium: 135-145 The test is crucial mmol/L drawn out.
Date and mmol/L because it plays a R: Informed patients are
Time: vital role in more likely to cooperate
09/15/23 @ identifying any 153.1 High during the procedure,
8:47 am possible issues mmol/L making it smoother and
that might emerge more successful.
due to the surgery
Released Sodium: 135-145 or during the 151.10 4.) Advice the
Date and Tim mmol/L patient's recovery. mmol/L patient not to pull

84
e: 09/15/23 @ These issues his hands during
4:38 pm encompass the risk High the procedure.
of infections, R: For a smooth and
Released Sodium: 135-145 bleeding problems, 142.70 Normal successful procedure.
Date and Tim mmol/L or challenges mmol/L
e: 09/16/23 @ related to the During:
1:58 am Potassium: 3.5-5.1 functioning of 3.79 Normal 5.) Assist the
mmol/L organs. mmol/L patient during the
procedure.
R: Assisting them by
Released Sodium: 135-145 145.00 Normal providing clear
Date and Tim mmol/L mmol/L instructions, guidance,
e: 09/16/23 @ and reassurance can help
10:21 am ensure the procedure is
carried out effectively.
Released Sodium: 135-145 137.00 Normal
Date and Tim mmol/L mmol/L After procedure:
e: 09/16/23 @ According to the 6.) Monitor the
4:57 pm patient’s blood patient’s condition.
chemistry results, R: Regular monitoring
the level of allows healthcare
sodium is usually providers to detect any

85
high. Patients who changes in the patient's
have had surgery condition promptly. This
may encounter early detection can lead to
shifts in their fluid timely intervention and
equilibrium, which improved outcomes.
can influence the
levels of sodium in 7.) Provide comfort
their blood. For measures to divert
instance, his attention from
insufficient fluid pain or discomfort
intake or fluid R: Comfort measures,
losses due to such as relaxation
conditions like techniques, distraction, or
vomiting or soothing interventions,
diarrhea can can help alleviate pain or
result in elevated discomfort, providing
sodium immediate relief to the
concentrations. patient.
Additionally,
specific
post-surgery
medications, such

86
 as diuretics, which
enhance urine
production, have
the potential to
disrupt sodium
balance, while
corticosteroids
may cause
sodium retention
and fluid
accumulation and
therefore should
be continuously
monitored.

Urinalysis Color: Yellow Urinalysis is a Clear Normal Before Procedure:

(light/pale to dark/deep medical
Released amber) examination where 1.) Assess for any
Date and Tim a person's urine is specific instructions
e: 09/12/23 @ Transparency: Clear or analyzed to Clear Normal related to the test
8:43 pm cloudy evaluate its or the need to
physical properties, collect a specific

87
Reaction: 4.5-8 chemical 6.0 Normal type of urine
composition, and sample (e.g.,
Specific gravity: microscopic 1.015 Normal first-morning void).
1.005-1.025 components, R: Adhering to instructions
aiding healthcare ensures that the collected
WBCs - ≤2-5 providers in 1 Normal urine sample is
WBCs/hpf identifying and appropriate for the
diagnosing a range intended purpose. This is

RBCs - ≤2 RBCs/hpf of medical 2 Normal crucial for the test's

conditions and diagnostic value and the
keeping track of subsequent treatment
the individual's 1 Normal plan.
Squamous epithelial
general well-being.
cells - ≤15-20
(Smith, 2022) 2.) Explain the purpose
squamous epithelial
of the urinalysis,
cells/hpf
Craniopharyngiom 0 Normal the collection
a, a brain tumor, process, and any
Casts – 0-5 hyaline
can impact multiple None Normal necessary
casts/lpf
bodily functions, preparations, such
including hormone as collecting a
Bacteria – None control and fluid Negativ Normal clean catch or
equilibrium. e midstream sample,

88
 Urinalysis assists or refraining from
healthcare certain foods or
Glucose - Negative providers in Negativ Normal medications before
evaluating the e the test.
patient's general R: Explaining the purpose
Protein - Negative well-being by Normal of urinalysis, the collection
analyzing urine for process, and any
indications of necessary preparations,
possible problems. including the importance
Released Color: Yellow Additionally, Straw Normal of collecting a clean catch
Date and Tim (light/pale to dark/deep individuals with or midstream sample and
e: 09/15/23 @ amber) craniopharyngioma refraining from specific
2:04 am may receive foods or medications, is
Transparency: Clear or medications like Clear Normal crucial to ensure patient
cloudy desmopressin, understanding, sample
which can integrity, and accurate test
Reaction: 4.5-8 influence urine 6.5 Normal results.
composition.
Specific gravity: Urinalysis is 1.005 Normal 3.) Ensure that the
1.005-1.025 utilized by patient provides
healthcare informed consent
WBCs - ≤2-5 providers to 1 Normal for the urinalysis,

89
WBCs/hpf confirm the including an
medication's understanding of

RBCs - ≤2 RBCs/hpf efficacy and 5 High the procedure, its

monitor for any purpose, and
negative effects. potential discomfort
1 Normal or risks.
Squamous epithelial
R: Ensuring that the
cells - ≤15-20
patient provides informed
squamous epithelial
consent for the urinalysis,
cells/hpf
which includes a clear
understanding of the
Casts – 0-5 hyaline
0 Normal procedure, its purpose,
casts/lpf
and potential discomfort or
risks, is essential to
Bacteria – None 10 Normal uphold patient autonomy,
legal and ethical
standards, and their
Glucose - Negative Negativ Normal overall well-being.
e
During Procedure:
Protein - Negative Negativ Normal
e 4.) Instruct the patient

90
Released Specific gravity: 1.005 Normal on proper urine
Date and Tim 1.005-1.025 collection
e: 09/15/23 @ techniques, such as
6:04 am clean catch or
midstream
collection, and
Released Specific gravity: 1.015 Normal provide the
Date and Tim 1.005-1.025 necessary supplies.
e: 09/16/23 @ Assist the patient if
2:30 am needed.
1.010 Normal R: To ensure the accuracy
Released Specific gravity: and integrity of the urine
Date and Tim 1.005-1.025 sample. It helps prevent
e: 09/16/23 @ From the contamination, maintains
6:00 pm Urinalysis results sample quality, and
between contributes to reliable test
September 12 and results, ultimately
September 16, supporting effective
2023, all findings healthcare
fell within the decision-making.
normal range. It's
noteworthy that 5.) Maintain the

91
urine specific patient's privacy
gravity was and dignity during
consistently sample collection.
monitored R: To preserve their sense
throughout this of respect and self-worth,
period. This and foster trust in the
continuous healthcare provider.
monitoring is
essential as it 6.) Accurately label the
plays a pivotal urine specimen with
role in assessing the patient's
the patient's identification
general health, information, date,
fluid balance, and and time of
treatment collection.
response. R: Proper labeling
Variations in urine ensures that the urine
specific gravity sample is correctly
can provide matched to the patient,
valuable clues reducing the risk of
about imbalances sample mix-ups or errors
in vital electrolytes that could lead to

92
and fluid levels, misdiagnosis or incorrect
such as sodium treatment.
and potassium.
Early detection of After Procedure:
such imbalances
is critically 7.) Dispose of any
important to leftover urine
promptly address samples and
them and prevent materials used for
potential collection safely
complications. and in accordance
with hospital or
clinic guidelines.
R: To maintain proper
infection control practices
throughout the collection
process, including hand
hygiene and the use of
personal protective
equipment as necessary.

93
Immunology Free T4: 0.70-1.48 Immunology tests 0.83 Overactive Before Procedure:
Released nanograms per are medical ng/dL thyroid 1.) Ensure that the
Date and Tim deciliter (ng/dL). evaluations patient consents to
e: 09/12/23 @ performed to the immunology
3:42 pm TSH: 0.35-4.94 mIU/L assess how well 3.10 Normal test, ensuring they
the immune mIU/L comprehend the
Instrument: system is working procedure, its
Architect i100 to protect the body objectives, and any
from illnesses and possible adverse
infections. They effects or
Released Cortisol: are employed to 0.80 Low discomfort it may
Date and Tim AM = 3.7-19.4 ug/dL identify and ug/dL entail.
e: 09/13/23 @ PM = 2.9-17.3 ug/dL diagnose various R: Obtaining informed
9:34 pm health conditions, consent respects the
including patient's right to make

Prolactin: 3.46-19.40 infections, 19.06 Normal decisions about their own

ng/mL autoimmune healthcare. It

diseases, allergies, Based on the acknowledges their
and immune findings, all results autonomy and choice in
system were within the undergoing the test.
deficiencies, normal range
offering important except for Free 2.) Inform the patient

94
information that T4, which showed about what they will
aids healthcare elevated levels, encounter during
providers in indicating an the procedure,
developing suitable overactive thyroid specify any
treatment in the patient. In required
strategies and individuals with preparations like
interventions. craniopharyngiom fasting, and outline
(Institute for a, the tumor's the possible
Quality and position can discomfort or side
Efficiency in Health disrupt the effects that may
Care, 2021) pituitary gland's arise.
regulation of R: Providing information
Immunology tests hormone prepares the patient
for free T4, TSH, production, mentally and emotionally
cortisol, and including thyroid for the procedure,
prolactin are hormones. reducing anxiety and
performed on Moreover, uncertainty.
patients to treatments like
evaluate hormone surgery or After Procedure:
production and radiation therapy
regulation, helping for 3.) Ensure that the
diagnose and craniopharyngiom patient is

95
monitor conditions a can also comfortable during
associated with the influence the and after the
thyroid, adrenal pituitary gland's procedure,
glands, and function, providing emotional
pituitary gland. potentially causing support if
These conditions hormonal necessary.
encompass thyroid imbalances, R: Comfortable patients
disorders, adrenal including an are more likely to
issues, and overactive thyroid. cooperate during the
hormonal procedure, leading to a
imbalances smoother and more
affecting successful procedure.
reproductive and
stress-related 4.) Observe the patient
functions. for any immediate
adverse reactions
or discomfort after
the test.
R: To address these
effects and prevent further
complications.

96
 5.) Ensure that the
area where the
collection took
place is thoroughly
cleaned and
sanitized following
the procedure.
R: Comprehensive
cleaning and sanitizing of
the collection area are
vital to uphold patient
well-being, preserve the
quality of the sample, and
comply with infection
control standards.

97
 LABORATORY EXAM (POSSIBLE)

Test Rationale Normal Range Nursing

Responsibilities

Adrenocorticotropic Craniopharyngioma is an Before:

Adults: 10-60 pg/ml
hormone (ACTH) infrequent benign 1. Explain the procedure to the
(1.3-16.7 pmol/L)
neoplasm that has the patient and answer any
for an early morning
The anterior pituitary potential to impact the questions they may have.
sample (8 a.m.);
gland synthesizes and pituitary gland and induce R: This is important to ensure
less than 20 pg/ml
releases the disruptions in hormonal that the patient is
(4.5 pmol/L) for a
adrenocorticotropic equilibrium. Hormone well-informed about the
late afternoon
hormone (ACTH). As levels, such as ACTH, are procedure and can prepare for
sample (4 p.m.)
mentioned earlier, the frequently assessed the test accordingly
substance is a through blood testing to
polypeptide tropic determine problems with 2. Inform the patient that they
hormone that serves a the pituitary or adrenal may need to fast for a certain

98
pivotal function within glands. Individuals period before the test,
the diagnosed with depending on the healthcare
hypothalamic-pituitary- craniopharyngioma often provider's instructions.
adrenal (HPA) axis. manifest malfunction of the R: This is important to ensure
The hypothalamic-pituitary axis, accurate test results
hypothalamic-pituitary- which encompasses
adrenal (HPA) axis is deficiencies in 3. Check the patient's medical
accountable for the adrenocorticotropic history and medications to
regulation of the hormone (ACTH) ensure that they do not
physiological and production. This hormonal interfere with the test.
behavioral responses insufficiency can lead to R: This is important to ensure
of the human body to the development of that the test results are
stress. When the symptomatic accurate and reliable
concentration of hyponatremia. The
cortisol in the rehabilitation of patients 4.Weigh the patient and report
bloodstream is can be significantly their weight to the pharmacy
diminished, a cluster of affected by adrenocortical for accurate dosing of the
cells located in the dysfunction, making ACTH challenge drug to be
hypothalamus hormone replacement used for the study.
produces therapy an essential R: This is important to ensure
corticotrophin-releasing component of that the patient receives the
hormone (CRH), craniopharyngioma correct dosage of the ACTH

99
100
101
thereby triggering the treatment. When the challenge drug .
pituitary gland to presence of a
discharge craniopharyngioma is 5. Instruct the patient to
adrenocorticotropic identified, it is necessary to minimize stress to avoid
hormone (ACTH) into do blood tests to ascertain raising cortisol levels, if
the circulatory system. if any alterations have challenge testing is requested.
ACTH subsequently occurred in the pituitary R: This is important to ensure
triggers the adrenal hormones. Consequently, that the test results are
cortex to synthesize the utilization of accurate and reliable.
and release adrenocorticotropic
glucocorticoid steroid hormone (ACTH) as a During:
hormones, such as diagnostic tool for 1. Obtain a baseline cortisol
cortisol. craniopharyngioma level before the injection of
involves the assessment of cosyntropin.
ACTH is utilized both hormone levels to identify R: This is important to
as a therapeutic and diagnose endocrine establish a baseline cortisol
intervention and as a disruptions induced by the level for comparison with
diagnostic tool. ACTH presence of the tumor. cortisol levels after the
levels can be injection of cosyntropin
quantified using a
blood sample from a After:
peripheral arm vein. 1. Instruct the patient to report

102
The presence of a lack any post-administration
of adrenocorticotropic reaction to the ACTH
hormone (ACTH) challenge drug used for the
serves as an indication study.
of secondary or tertiary R: This is important to monitor
adrenal insufficiency. the patient for any adverse
On the other hand, reactions or side effects.
consistently high levels
of adrenocorticotropic
hormone (ACTH) in
cases of primary
adrenal insufficiency,
specifically in
individuals with
Addison's disease.

Follicle-stimulating The utilization of Male: Before:

hormone (FSH) follicle-stimulating hormone 1. Explain the procedure to the
(FSH) as a diagnostic tool - Before patient and answer any
Follicle-stimulating in identifying puberty: 0 to questions they may have.
hormone (FSH) is craniopharyngioma stems 5.0 mIU/mL R: This is important to ensure

103
synthesized by the from the potential of (0 to 5.0 that the patient is
pituitary gland located craniopharyngioma to IU/L) well-informed about the
in the cranial region. induce endocrine - During procedure and can prepare for
The hormone in dysfunctions, such as puberty: 0.3 the test accordingly.
question plays a crucial imbalances in hormone to 10.0
role in maintaining the levels. It is recommended mIU/mL (0.3 2. Check the patient's medical
proper functioning of to conduct a thorough to 10.0 IU/L) history and medications
the reproductive preoperative evaluation of R: To ensure that they do not
- Adult: 1.5 to
system in both males pituitary hormones, interfere with the test.
12.4 mIU/mL
and females. typically through the
(1.5 to 12.4
Follicle-stimulating essential measurement of During:
IU/L)
hormone (FSH) is growth 1. Instruct the patient to
involved in sexual hormone/insulin-like remain still during the blood
development and growth factor-1 Female: draw.
reproductive processes (GH/IGF-1), luteinizing R: For easy withdrawal of
- Before
by promoting the hormone (LH), blood.
puberty: 0 to
growth of ovarian follicle-stimulating
4.0 mIU/mL
follicles within the hormone/estradiol After:
(0 to 4.0
ovary. This expansion (FSH/E2-TEST). The 1. Apply pressure to the
IU/L)
ultimately leads to the deficit of follicle-stimulating puncture site.
release of an egg from hormone (FSH) has been - During R: To stop bleeding.
a single follicle during identified as a potential puberty: 0.3

104
ovulation in women. cause of sexual to 10.0 2. Report the test results to the
Additionally, it results in dysfunction and mIU/mL (0.3 healthcare provider.
an augmentation in amenorrhea, which refers to 10.0 IU/L) R: For further evaluation and
oestradiol synthesis to the absence of - Women who treatment.
originating from the menstrual periods in are still
ovaries. In males, women. The decrease in menstruating
follicle-stimulating levels of sex hormones, : 4.7 to 21.5
hormone (FSH) plays a including luteinizing mIU/mL (4.5
crucial role in hormone (LH) and
to 21.5 IU/L)
promoting the follicle-stimulating hormone
- After
proliferation of Sertoli (FSH), may result in a
menopause:
cells, which is diminished testosterone
25.8 to 134.8
considered the primary level in males.
mIU/mL
determinant of Consequently, the
(25.8 to
testicular volume measurement of
134.8 IU/L)
during childhood. The follicle-stimulating hormone
Sertoli cells are (FSH) levels can aid in
responsible for the diagnosing or assessing
synthesis and hormonal abnormalities
secretion of an resulting from
anti-Mullerian hormone craniopharyngioma.
(AMH), which induces

105
the regression of the
Mullerian ducts,
inhibiting the
development of female
internal reproductive
organs.
Follicle-stimulating
hormone (FSH) also
plays a role in
regulating
spermatogenesis in
males.

The follicle-stimulating
hormone (FSH) levels
in the bloodstream are
measured using an
FSH levels test. The
interpretation of the
test findings will be
contingent upon the

106
 Medical Management

Therapeutics

Date Order Rationale

9/13/23 Urine output q hourly Urine output monitoring is a vital sign for
monitoring critically ill patients, but standards for
monitoring and reporting vary widely
between ICUs. Careful monitoring of UO
could lead to earlier recognition of acute
kidney injury (AKI), response to
treatment, and better fluid management
( Jin et al, 2019).

9/13/23 PNSS 1L @ 120 cc/hr Normal saline solution is a crystalloid

solution used as sources of hydration
and electrolyte disturbances. It is
indicated in extracellular fluid
replacement such as in hemorrhage,
sepsis and dehydration. It is also used to
prime solutions for procedures such as
blood transfusions, and aid as diluents
for the infusion of compatible drug
additives (Tonog & Lakhkar, 2022)

9/13/23 NPO post midnight Ordering NPO after midnight has been a
common practice to lower the risk of
aspiration of gastric contents during
general anesthesia, which is due in part
to suppression of laryngeal reflexes from

107
 anesthesia (Chapman, 2022).
Current nil per os (npo) standards
promote pre-operative fasting as an
approach to reduce the volume and
acidity of a patient’s stomach contents to
reduce the risks of regurgitation and
subsequent pulmonary aspiration
(Goertzen, 2020).

9/14/23 Oxygen supplement 2L Most postoperative surgical patients

per minute via NC routinely receive supplemental oxygen
therapy to prevent the potential
development of hypoxemia due to
incomplete lung re-expansion, reduced
chest wall, and diaphragmatic activity
caused by surgical site pain,
consequences of hemodynamic
impairment, and residual effects of
anesthetic drugs (most notably residual
neuromuscular blockade), which may
result in atelectasis, ventilation–perfusion
mismatch, alveolar hypoventilation, and
impaired upper airway patency (Suzuki,
2020).

9/14/23 Elevate head 30 Patients undergoing Pituitary Tumor

degrees Surgery recovery are advised to sleep
with the head on the pillows because it
can help decrease headaches.
Moreover, elevating the head at least 30
degrees for 10 days after brain surgery

108
 especially if the client had CSF leak is
advised (BNI, 22 March 2022).

9/15/16 Fast drip 100cc of D5W Craniopharyngiomas can disrupt the

then start D5WL 1L at normal functioning of the pituitary gland,
125cc/hr leading to problems with water and
electrolyte balance. When managing
patients with craniopharyngioma,
healthcare providers closely monitor
electrolyte levels, especially sodium.
D5W has a lower concentration of
electrolytes (e.g., sodium) which enables
more accurate regulation of fluid and
electrolyte equilibrium by permitting
adjustments in the administration rate
tailored to the individual patient's
requirements. (Miranda et. al., 2019)

9/15/23 Repeat urine specific Urine specific gravity assesses the

gravity concentration of substances, including
electrolytes and urea, in urine in relation
to pure water. Excessive urination can
potentially disrupt electrolyte levels,
particularly sodium. Monitoring urine
specific gravity can help in early
detection of such imbalances, allowing
for timely interventions to prevent
complications like hyponatremia (low
sodium levels) or hypernatremia (high
sodium levels).

9/15/23 Free water intake Providing unrestricted access to fluids

109
 allows for the maintenance of regular
levels of plasma electrolytes and
osmolality. However, if patients cannot
adequately offset urinary fluid losses,
they will experience elevated plasma
osmolality, along with reduced urine
osmolality and a lower urine/plasma
osmolality ratio. (Edate and Albanese,
2018)

9/16/23 High back rest Brain surgery, which includes tumor

removal, can result in temporary rises in
intracranial pressure within the skull due
to reasons such as brain swelling or the
surgical process itself. Elevating the
head of the bed is employed to mitigate
this pressure increase. Lowering
intracranial pressure is crucial as
elevated pressure can pose a potential
risk to the brain and impede proper blood
circulation. (Gadol, 2023)

9/20/23 Open dressing with Brain surgery is a complex procedure

Mupirocin where the skull is opened (known as a
craniotomy) to access and remove a
tumor. As with any surgery, there is a
potential risk of infection, which includes
the risk of the surgical wound becoming
infected. The use of Mupirocin in an
open dressing can be beneficial in
lowering this risk by preventing bacteria,

110
 including the antibiotic-resistant strain
Staphylococcus aureus (MRSA), from
entering the surgical area and causing
an infection. (Cima et. al., 2018)

Pharmacological Management
A. Actual Pharmacological Management

Generic Name desmopressin

Brand Name Nocdurna, Noctiva

Classification Therapeutic class:

Hemostatics
Pharmacological class:
Posterior pituitary
hormones

Mode of Action Synthetic analogue of ADH that increases the

permeability of renal tubular epithelium to adenosine
monophosphate and water, enabling the epithelium to
promote reabsorption of water and produce a
concentrated urine. Also increases factor VIII activity by
releasing endogenous factor VIII from plasma storage
sites.

Ordered Dose and 100 mg/tab ½ tab

Route

111
Indications To treat central cranial diabetes insipidus. This is a
condition that causes the body to lose too much fluid and
become dehydrated. It is also used to control bedwetting
(nocturnal enuresis), and the frequent urination and
increased thirst caused by certain types of brain injury or
brain surgery.

Contraindications Contraindicated in patients with moderate to severe

renal impairment (defined as a creatinine clearance
below 50ml/min). DDAVP (desmopressin acetate tablets)
is contraindicated in patients with hyponatremia or a
history of hyponatremia.

Side Effects Desmopressin may cause side effects such as

headache, nausea, abdominal pain, and in rare cases,
fluid retention or hyponatremia (low sodium levels).

Adverse Effects CNS: headache, seizures; dizziness (Noctiva).

CV: flushing, slight rise in BP; fluid retention, HTN
(Noctiva).
EENT: rhinitis, epistaxis, sore throat, conjunctivitis,
edema around eyes; nasal discomfort or congestion,
nasopharyngitis, sneezing (Noctiva).
GI: nausea, abdominal cramps.
GU: vulvar pain. Metabolic: hyponatremia.
Musculoskeletal: back pain (Noctiva).
Respiratory: cough; bronchitis (Noctiva).
Skin: local erythema, swelling, or burning after injection.

Drug Interactions Drug-drug:

112
 ● Carbamazepine, chlorpropamide: May increase
ADH; may increase desmopressin effect. Avoid
using together.
● Chlorpromazine, demeclocycline, epinephrine,
heparin, lamotrigine, lithium, NSAIDs, opioid
analgesics, SSRIs, TCAs: May increase risk of
adverse effects. Monitor patient closely.
● Clofibrate: May enhance and prolong effects of
desmopressin. Monitor patient closely.

Nursing 1. Advise patient to moderate fluid intake in the evening

Responsibilities and night time hours
R: To decrease the risk of hyponatremia

2. Be alert for an imbalance in body water and

electrolytes that results in low sodium levels
(hyponatremia). Signs include headache, confusion,
listlessness, fatigue, irritability,
R: To prevent the potentially serious side effects of
hyponatremia, such as seizures or neurological issues,
and to ensure the patient's overall well-being.

3. Assess blood pressure and compare to normal values

R: Desmopressin has the potential to result in fluid
retention and a drop in blood sodium levels, which may
lead to the development of hypertension, or elevated
blood pressure.

4. Assess any breathing problems, and report difficult or

labored breathing (dyspnea).

113
 R: Desmopressin has the potential to cause water
retention, and in severe cases, it may impact the lungs,
resulting in breathing problems.

5. Instruct patient to report other bothersome side effects

such as severe or prolonged nasal congestion (when
administered intranasally), skin reactions (flushing), or
GI problems (nausea, abdominal cramps).
R: To address the effects and prevent further
complications.

Generic Name omeprazole

Brand Name Zefxon

Classification Therapeutic class: Antiulcer

Pharmacologic class:
Proton pump inhibitor

Mode of Action Omeprazole interferes with gastric acid secretion by

inhibiting the hydrogen potassium adenosine
triphosphatase (H+ K+ -ATPase) enzyme system, or
proton pump, in gastric parietal cells. Normally, the
proton pump uses energy from hydrolysis of adenosine
triphosphate to drive hydrogen (H+) and chloride (Cl−)
out of parietal cells and into the stomach lumen in
exchange for potassium (K+), which leaves the stomach

114
 lumen and enters parietal cells. After this exchange, H+
and Cl− combine in the stomach to form hydrochloric
acid (HCl). Omeprazole irreversibly blocks the exchange
of intracellular H+ and extracellular K+. By preventing
H+ from entering the stomach lumen, omeprazole keeps
additional HCl from forming.

Ordered Dose and 40 mg 1 cap OD

Route

Indications Omeprazole is indicated for the treatment of conditions

such as gastroesophageal reflux disease (GERD), peptic
ulcers, Zollinger-Ellison syndrome, and erosive
esophagitis, where it helps by reducing stomach acid
production and promoting healing.

Contraindications Concurrent therapy with rilpivirine-containing products;

hypersensitivity to omeprazole, substituted
benzimidazoles, or their components.

Side Effects Stomach cramps, bloated feeling, watery and severe

diarrhea which may also be bloody sometimes, fever,
nausea or vomiting, or unusual tiredness or weakness.

Adverse Effects CNS: Agitation, asthenia, dizziness, drowsiness, fatigue,

fever, headache, malaise, psychic disturbance,
somnolence
CV: Chest pain, hypertension, peripheral edema
EENT: Anterior ischemic optic neuropathy, optic atrophy
or neuritis, otitis media, stomatitis
ENDO: Hypoglycemia

115
 GI: Abdominal pain, acid regurgitation, constipation,
diarrhea, Clostridium difficile-associated diarrhea,
dyspepsia, elevated liver enzymes, flatulence, fundic
gland polyps (long-term use), hepatic dysfunction or
failure, indigestion, nausea, pancreatitis, vomiting
GU: Interstitial nephritis
HEME: Agranulocytosis, anemia, hemolytic anemia,
leukopenia, leukocytosis, neutropenia, pancytopenia,
thrombocytopenia
MS: Back pain, bone fracture, joint pain
RESP: Bronchospasms, cough, upper respiratory
infection
SKIN: Cutaneous lupus erythematosis, erythema
multiforme, photosensitivity, pruritus, rash,
Stevens–Johnson syndrome, toxic epidermal necrolysis,
urticaria
Other: Anaphylaxis, angioedema, hypomagnesemia,
hyponatremia, systemic lupus erythematosus, vitamin
B12 deficiency (long-term use)

Drug Interactions Drug-drug:

● Ampicillin esters, azole antifungals (such as
ketoconazole), erlotinib, iron derivatives, nilotinib:
May cause poor bioavailability of these drugs
because they need a low gastric pH for optimal
absorption. Avoid using together.
● Atazanavir, nelfinavir: May decrease plasma
concentrations of these drugs, possibly resulting
in loss of therapeutic effect. Avoid use together.
● Benzodiazepines (metabolized by hepatic
oxidation), fosphenytoin, phenytoin, warfarin: May

116
 decrease hepatic clearance, possibly leading to
increased levels of these drugs. Monitor drug
levels.
● Bisphosphonates: May decrease therapeutic
effect of bisphosphonates. Monitor therapy.
● Calcium salts: May decrease GI absorption of
calcium salts. Closely monitor clinical response
and increase calcium dosage if needed.
● Cilostazol: May increase cilostazol level. Reduce
cilostazol dosage.
● Clopidogrel: May decrease antiplatelet activity.
Avoid use together.
● Cyclosporine: May increase cyclosporine serum
concentration. Monitor cyclosporine level closely.
● Digoxin: May increase digoxin level, causing
toxicity. Monitor digoxin level.
● Fluvoxamine: May increase omeprazole level.
Monitor patient for increased adverse reactions.

Nursing 1. Give omeprazole before meals, preferably in the

Responsibilities morning for once-daily dosing.
R: For optimal control of daytime gastric acidity. Parietal
cell is maximally stimulated as it is after a meal.

2. Know that omeprazole therapy may produce false

elevations of serum chromogranin levels, used to help
diagnose the presence of neuroendocrine tumors.
R: If test results are high, physician may withhold
omeprazole therapy temporarily and repeat the test, as
ordered.

117
 3. Monitor patient’s urine output
R: Omeprazole may cause acute interstitial nephritis.
Notify prescriber if urine output decreases or there is
blood in patient’s urine.

4. Advise patient to notify for any experience of

abdominal pain and diarrhea.
R: To prevent further complications

5. Advise patient to notify if they are experiencing a

decrease in the amount of urine voided or if there is
blood in the urine.
R: To check if there is a liver problem and avoid further
complications.

Generic Name tranexamic acid

Brand Name Hemostan

Classification Antifibrinolytics

Mode of Action Tranexamic acid competitively and reversibly inhibits the

activation of plasminogen via binding at several distinct
sites, including four or five low-affinity sites and one
high-affinity site, the latter of which is involved in its
binding to fibrin. The binding of plasminogen to fibrin
induces fibrinolysis - by occupying the necessary binding

118
 sites tranexamic acid prevents this dissolution of fibrin,
thereby stabilizing the clot and preventing hemorrhage.

Ordered Dose and 500 mg IV q8

Route

Indications Tranexamic acid (TXA) is one of the most commonly

used and widely researched antifibrinolytic agents; its
role in postpartum hemorrhage,
menorrhagia,trauma-associated hemorrhage, and
surgical bleeding has been well defined.

Contraindications Tranexamic acid is contraindicated in individuals with a

history of hypersensitivity or allergic reactions to the
medication, as well as in those with active
thromboembolic disease, such as deep vein thrombosis
or pulmonary embolism.

Side Effects Side effects of tranexamic acid may include nausea,

vomiting, diarrhea, headache, and in rare cases, allergic
reactions or blood clotting disorders.

Adverse Effects Adverse effects of tranexamic acid can include serious

complications like thromboembolic events (blood clots),
seizures, and severe allergic reactions, although they
are relatively rare.

Drug Interactions Some products that may interact with this drug include:
"blood thinners" (anticoagulants such as warfarin,
heparin), drugs that prevent bleeding (including factor IX
complex, anti-inhibitor coagulant concentrates),

119
 estrogens, hormonal birth control (such as pills, patch,
ring), tibolone, tretinoin.

Nursing 1. Monitor blood pressure, pulse, and respiratory status

Responsibilities as indicated by severity of bleeding.
R: Tranexemic acid Tranexamic acid helps prevent
excessive bleeding by inhibiting the breakdown of blood
clots which can potentially affect blood pressure.

3. Assess for thromboembolic complications.

R: This medication, employed to control excessive
bleeding, has the potential to elevate the likelihood of
thromboembolic events, which encompass the
development of blood clots (thrombosis) capable of
obstructing blood vessels, leading to severe
consequences.

4. Instruct the patient to notify the nurse immediately if

bleeding recurs or if thromboembolic symptoms develop.
R: To address the effects and prevent further
complications.

5. Caution patient to make position changes slowly to

avoid orthostatic hypotension.
R: After taking tranexamic acid, it's important to refrain
from making sudden shifts in body position because this
medication can elevate the chances of experiencing
thromboembolic events.

120
Generic Name Cefoxitin - Castro

Brand Name Zengram

Classification Pharmacologic class:

Secondgeneration
cephalosporin
Therapeutic class:
Anti-infective
Pregnancy risk category:B

Mode of Action Interferes with bacterial cell-wall synthesis and division

by binding to the cell wall, causing the cell to die. Active
against gram-negative and gram positive bacteria, with
expanded activity against gram-negative bacteria.
Exhibits minimal immunosuppressant activity.

Ordered Dose and 1g IV RTOR

Route

Indications Treating bacterial infections or preventing bacterial

infections before, during, or after certain surgeries. To
reduce the development of drug-resistant bacteria and
maintain the effectiveness of Cefoxitin for Injection.

Contraindications Hypersensitivity to cephalosporins or penicillins

Side Effects Common side effects include:

● pain , bruising, swelling
● Diarrhea
● Fever
● Rash and itching
Serious side effects include:

121
 ● Hives
● Difficult breathing
● Fever
● Sore throat
● Burning in the eyes
● Skin pain
● Red or purple skin rash that
spreads and causes blistering and
peeling
● Severe stomach pain
● Jaundice

Adverse Effects CNS: headache, lethargy, paresthesia, syncope,

seizures
CV: hypotension, palpitations, chest pain, vasodilation,
thrombophlebitis
EENT: hearing loss
GI: nausea, vomiting, diarrhea,
abdominal cramps, oral candidiasis
GU: vaginal candidiasis, nephrotoxicity
Hematologic: lymphocytosis, eosinophilia, bleeding
tendency, hemolytic anemia, hypoprothrombinemia,
neutropenia, thrombocytopenia, agranulocytosis, bone
marrow depression
Hepatic: hepatic failure, hepatomegaly
Musculoskeletal: arthralgia
Respiratory: dyspnea
Skin: urticaria, maculopapular or
erythematous rash
Other: chills, fever

122
Drug Interactions Drug interaction:
Aminoglycosides, loop
diuretics: increased risk of nephrotoxicity
Probenecid: decreased excretion and
increased blood level of cefoxitin
Drug-diagnostic tests:
Alanine aminotransferase, alkaline phosphatase,
aspartate aminotransferase, bilirubin, blood urea
nitrogen, creatinine, Hemoglobin, platelets, white blood
cells: decreased values

Nursing 1. Look for patient’s history on the chart

Responsibilities R:To assess the patient for hypersensitivity

2.Double-check the medication order with the

physician's prescription
R: To ensure that the dosage, route and frequency are
correct

3. Educate clients on drug therapy

R: To promote understanding and compliance.

4. Monitor fluid intake and output

R: To note for any significant decrease in output

5. Provide safety measures

R: To protect the patient in CNS effect

6. Monitor injection site for pain, swelling, and irritation

R: Report Prolonged or excessive injection-site reactions
to the physician.

123
 7. Monitor vital signs for changes in temperature or heart
rate
R: Fever and increased heart rate can both indicate
infection or inflammation.

8. Watchout for signs of seizures

R: Notify the physician immediately if a patient develops
or increases seizure activity.

9.Instruct the patient to report reduced urinary output,

persistent diarrhea, bruising, and bleeding.
R: to note for signs of any complication

10. Document the findings

R: to evaluate the rendered medication

Generic Name ceftriaxone sodium

Brand Name Keptrix

Classification Therapeutic Class:

Antibiotics/ anti-infectives
Pharmacologic Class:
Third-generation
cephalosporins

Mode of Action Binds to bacterial cell membranes, inhibits cell wall

synthesis. Therapeutic Effect: Bactericidal.

124
Ordered Dose and 1g Sterile Powder for IV injection q12
Route

Indications Uncomplicated gonococcal vulvovaginitis; UTI; lower

respiratory tract, gynecologic, bone or joint,
intra-abdominal, skin, or skinstructure infection;
septicem; meningitis; Perioperative prophylaxis; Acute
bacterial otitis media, Acute otitis media

Contraindications Hypersensitivity to cephalosporins; Serious

hypersensitivity to penicillins; Pedi: Premature neonates
up to a postmenstrual age of 41 wk (ceftriaxone only);
Pedi: Hyperbilirubinemic neonates (may lead to bilirubin
encephalopathy); Pedi: Neonates 28 days requiring
calcium-containing IV solutions (q risk of precipitation
formation); Carnitine deficiency or inborn errors of
metabolism (cefditoren only); Hypersensitivity to milk
protein (ceftidoren only; contains sodium caseinate).

Side Effects Frequent: Discomfort with IM administration, oral

candidiasis (thrush), mild diarrhea, mild abdominal
cramping, vaginal candidiasis.

Occasional: Nausea, serum sickness–like reaction

(fever, joint pain; usually occurs after second course of
therapy and resolves after drug is discontinued).

Rare: Allergic reaction (rash, pruritus, urticaria),

thrombophlebitis (pain, redness, swelling at injection
site).

125
Adverse Effects GI: pseudomembranous colitis, diarrhea. Hematologic:
eosinophilia, thrombocytosis, leukopenia.
Skin: pain, induration, tenderness at injection site, rash.
Other: hypersensitivity reactions, serum sickness,
anaphylaxis.

Drug Interactions DRUG:

Probenecid may increase concentration. Antacids,
H2-receptor antagonists (e.g., cimetidine, famotidine),
proton pump inhibitors (e.g., pantoprazole) may
decrease absorption. May decrease therapeutic effect of
BCG (intravesical).

LAB VALUES:
May increase serum BUN, creatinine, alkaline
phosphatase, bilirubin, LDH, ALT, AST. May cause
positive direct/ indirect Coombs’ test.

Nursing Assessment:
Responsibilities 1. Assess for any cautions and contraindications,
such as drug allergies, CNS depression, and CV
disorders, to prevent any complications.
R: This is important to ensure that the patient is
not at risk of developing any adverse reactions to
the drug.

2. Conduct orientation and reflex assessment, as

well as auditory testing to evaluate any CNS
effects of the drug.

126
 R: This is important to monitor the patient's
neurological status and detect any CNS effects of
the drug.

Interventions:
3. Monitor the injection site for pain, swelling, and
irritation. Report prolonged or excessive injection
site reactions to the physician.
R: This is important to detect any adverse
reactions to the drug and prevent any
complications.

4. Check culture and sensitivity test results before

initiating therapy
R: This is important to ensure that the drug is
effective against the specific bacteria causing the
infection.

5. Administer the drug as prescribed

R: This is important to ensure that the patient
receives the correct dose of the drug.

6. Ensure that the patient receives the full course of

treatment
R: This is important to ensure that the infection is
completely treated and prevent the development
of antibiotic resistance.

Patient / Family Health Teaching:

7. Instruct the patient and family/caregivers to report

127
 other troublesome side effects such as severe or
prolonged fever, skin rash, or diarrhea
R: This is important to detect any adverse
reactions to the drug and prevent any
complications.

8. Educate the patient and family/caregivers on the

importance of completing the full course of
treatment.
R: This is important to ensure that the infection is
completely treated and prevent the development
of antibiotic resistance.

9. Inform the patient and family/caregivers about the

possible side effects of the drug.
R: This is important to prepare the patient for any
potential side effects and prevent any
complications.

(Post op)

Generic Name Levetiracetam

Brand Name Apo-Levetiracetam, Co

Levetiracetam, Dom-
Levetiracetam, Keppra,

Classification Pharmacologic class:

Pyrrolidine derivative

128
 Therapeutic class:
Anticonvulsant

Mode of Action Modulation of synaptic neurotransmitter release through

binding to the synaptic vesicle protein sv2a in the brain.

Ordered Dose and 500g IV q12

Route

Indications This drug is an Adjunctive therapy of partial onset,

myoclonic, and/or primary generalized tonic clonic
seizures.

Contraindications Contraindicated to patient with anemia, decreased blood

platelet, low levels of WBC,hypersensitivity, suicidal
thoughts, depression and hallucination.

Side Effects Weakness, headache, elevated blood pressure,

drowsiness, fatigue, loss of appetite, anxiety, amnesia,
numbness, tiredness, double vision, cough,
conjunctivitis, depression.

Adverse Effects CNS: aggression, anger, irritability, mental or mood

changes, asthenia, ataxia, dizziness, drowsiness,

129
 somnolence, fatigue, nervousness, depression, anxiety,
amnesia, hostility, coordination difficulties, headache,
paresthesia, vertigo
EENT: diplopia, pharyngitis, rhinitis, sinusitis
GI: nausea, vomiting, anorexia
Hematologic: neutropenia, leukopenia
Respiratory: Cough
Others: Infection and Pain

Drug Interactions Drug-herbs: Evening primrose oil: lowered seizure

threshold
Drug Food: taken with or without food
Drug drug interaction: Enzyme-Inducing Antiepileptic
Drugs (AEDs): can potentially reduce the effectiveness
of the drug. Cimetidine: may increase levetiracetam
levels by inhibiting its renal elimination. Alcohol: increase
side effects.

Nursing 1. Do an assessment of the patient’s history and

Responsibilities previous illness.
R: to determine if the patient has any known allergy to
the medication.

2. Measure vital signs closely especially the temperature

R: To watch for signs and symptoms of infection

3. If the drug has been administered, don't discontinue it

suddenly without the doctor's order.
R: To avoid an increase risk of sudden seizure

130
4. If the patient experiences a seizure document and
keep the patient's safety as priority.
R: this is to report the effects of this drug to the physician
and provide an early evaluation as soon as possible

5. Monitor the patient for a rash and other adverse skin

reactions.
R: might cause some serious dermatologic reaction

6. Instruct the patient to avoid activities that require

mental alertness until CNS reactions are known.
R: to avoid experiencing the side effects of the drug such
as fatigue and blurring of vision.

7. Inform the patient that he’ll undergo periodic blood

testing during therapy.
R: to identify any unknown abnormalities such as toxicity
in the blood from the dosage prescribed.

8. Teach the patient and the patient’s family not to stop

taking the drug abruptly.
R: to inform them of the danger of the side effects of this
drug and provide an education towards its mechanism.

9. Explain to the patient and family that levetiracetam

may cause mental and behavioral changes, such as
aggression, depression, irritability, and rarely psychotic
symptoms.
R: since the drug affects the electrical disturbances in
the brain.

131
 10. Ensure the patient understands the importance of
taking levetiracetam as prescribed.
R: to ensure compliance to the medication since non
compliance may increase risk of seizure.

Generic Name mannitol

Brand Name Osmitrol, Polyfusor,

Resectisol

Classification
Therapeutic class: Diuretic

Pharmacologic class:
Osmotic diuretic

Mode of Action Increases osmotic pressure of plasma in glomerular

filtrate, inhibiting tubular reabsorption of water and
electrolytes (Including sodium and potassium). These
actions enhance water flow from Various tissues and
ultimately decrease intracranial and intraocular
pressures; serum sodium level rises while potassium
and blood urea levels fall.

Ordered Dose and 100 cc IV q6

Route

Indications This drug is Indicated for the reduction of: intracranial

pressure and treatment of cerebral edema. Elevated

132
 intraocular pressure. Also protects kidneys by preventing
toxins from forming and blocking tubules.

Contraindications Active intracranial bleeding, Anuria secondary to severe

renal Disease, Progressive heart failure, pulmonary
congestion, renal damage, or renal dysfunction, Severe
pulmonary congestion or pulmonary edema and Severe
dehydration, Hypersensitivity.

Side Effects Headache, nausea, diarrhea, vomiting, thirst,

dehydration, blurred vision, arm pain, chills, fever, hives,
irregular heartbeat, electrolyte imbalance, irritation, pain
or swelling at the site.

Adverse Effects
CNS: dizziness, headache, seizures

CV: chest pain, hypotension, hypertension, tachycardia,

thrombophlebitis, heart failure, vascular overload

EENT: blurred vision, rhinitis

GI: nausea, vomiting, diarrhea, dry mouth

GU: polyuria, urinary retention, osmotic nephrosis

Skin: rash, urticaria

Metabolic: dehydration, water intoxication,

hypernatremia, hyponatremia, hypovolemia,
hypokalemia

Drug Interactions Drug-drug interaction:

Digoxin: increased risk of digoxin toxicity

133
 Diuretics: increased therapeutic effects of mannitol
Lithium: increased urinary excretion of lithium
Arsenic trioxide, levacetylmethadol: increased
hypokalemia
Drug-diagnostic tests:
Electrolytes: increased or decreased levels
Drug Food interaction:
Potassium foods: increased hyperkalemia

Nursing 1. Conduct a thorough assessment of the patient’s

Responsibilities record such as history, allergy and its current condition.
R: to determine if the patient is allowed to receive such
therapy.

2. Avoid extravasation
R: to avoid the cause of local edema and tissue
necrosis.

3. Monitor renal function tests, urinary output, fluid

balance, central venous pressure, and electrolyte levels
R: since the mannitol acts as an osmotic diuretic, which
increases urinary loss of both sodium and
electrolyte-free water.

4. Monitor the site of injection or the IV site area

R. to note and avoid extravasation and tissue necrosis

5. Do a double checking of the medication and the

concentration before administration
R: to prevent medication error and promote patient
safety during therapy

134
 6. Teach the patient about the importance of monitoring
exact urinary output.
R: since this drug is a diuretic and may cause possible
dehydration

7. Ensure that the patient's bed is secure and side rails

is up
R: to promote safety and prevent fall since one of the
side effect is dizziness

8.Teach the patient and the family of the patient about

the drug and its side effects
R: to ensure that the possible side effects are expected
and reduce worrying.

9. When mannitol is discontinued continue a close

monitoring of the patient’s status
R: to report any significant response from the drug.

10. Schedule a follow up on labs and test after during

and after the therapy
R: to evaluate the patient's response to mannitol therapy
and adjust the treatment plan as necessary

Generic Name dexamethasone

135
Brand Name Decilone, Dexamethasone
Intensol, Decadron, Solurex,
Baycadron, Sandoz

Classification Therapeutic Class: Steroidal

anti-inflammatories

Pharmacologic Class:
Corticosteroids

Mode of Action Suppresses inflammation and the normal immune

response

Ordered Dose and 5mg IV q8hrs * 4 doses

Route Shift to: 4mg/tab 1 tab BID

Indications
Prevention of neonatal respiratory distress in high-risk
pregnancies; Cerebral edema; Acute spinal cord injury
;Adrenocortical insufficiency; True preterm labor;
Antepartum hemorrhage; Preterm rupture of the
membrane; Severe pre-eclampsia

Contraindications
Hypersensitivity to the drug, benzyl alcohol, bisulfites,
EDTA, creatinine, polysorbate 80, or methylparaben;

136
 Systemic fungal infections; Active or suspected ocular or
peri-ocular infections, advanced glaucoma (intravitreal
implant); Chorioamnionitis; History of fever and lower
abdominal pain; Presence of foul-smelling vaginal
discharge and uterine tenderness; Fetal tachycardia

Side Effects Vomiting, Stomach irritation, Insomnia, Acne, Headache,

Increased hair growth, Easy bruising, Restlessness,
increased appetite, weight gain, Myalgia, increased
infection susceptibility

Adverse Effects CNS: headache, malaise, vertigo, psychiatric

disturbances, increased intracranial pressure, seizures
CV: hypotension, thrombophlebitis, myocardial rupture
after recent myocardial infarction, thromboembolism
EENT: cataracts, elevated intra-ocular pressure (IOP),
conjunctival hemorrhage (with intravitreal implant)
GI: nausea, vomiting, abdominal distention, dry mouth,
anorexia, peptic ulcer, bowel perforation, pancreatitis,
ulcerative esophagitis
Metabolic: decreased carbohydrate tolerance,
hyperglycemia, cushingoid appearance (moon face,
buffalo hump), latent diabetes mellitus, sodium and fluid
retention, negative nitrogen balance, adrenal
suppression, hypokalemic alkalosis
Musculoskeletal: muscle wasting, muscle pain,
osteoporosis, aseptic joint necrosis, tendon rupture, long
bone fractures
Skin: diaphoresis, angioedema, erythema, rash,
urticaria, contact dermatitis, decreased wound healing,
bruising, skin fragility

137
 Other: facial edema, weight gain or loss, increased
susceptibility to infection, hypersensitivity reactions

Drug Interactions Drugs:

● aminoglutethimide: Possibly diminished adrenal

suppression by dexamethasone amphotericin B
(parenteral), potassium depleting drugs: Risk of
hypokalemia
● anticholinesterases: Decreased anticholinesterase
effectiveness in myasthenia gravis producing severe
weakness
● aspirin, NSAIDs: Increased risk of adverse GI effects
● cholestyramine: Increased dexamethasone clearance
● cyclosporine: Increased activity of both drugs,
possibly resulting in seizures
● CYP3A4 inducers such as barbiturates,
carbamazepine, phenytoin, rifampin: Possibly
enhanced metabolism of dexamethasone requiring
dosage increase
● CYP3A4 inhibitors such as clarithromycin,
cobicist-containing drugs, itraconazole, ritonavir:
Possibly increased plasma concentrations of
dexamethasone with increased adverse reactions
● CYP3A4 substrates such as erythromycin, indinavir:
Possibly decreased plasma concentration of these
drugs
● digoxin: Increased risk of digitalis toxicity related to
hypokalemia
● ephedrine: Decreased half-life and increased

138
 clearance of dexamethasone
● isoniazid: Decreased blood isoniazid level
● macrolide antibiotics: Decreased dexamethasone
clearance and increased. dexamethasone effects
● oral anticoagulants such as warfarin: Inhibition of
response to oral anticoagulant
● oral contraceptives including estrogens: Increased
effect of oral contraceptives
● phenytoin: Increased risk of seizures
● thalidomide: Increased risk of toxic epidermal
necrolysis
● toxoids, vaccines: Decreased antibody response

Activities
● alcohol use: Increased risk of GI bleeding

Nursing 1. Monitor the vital signs especially the blood

Responsibilities pressure.
R: Dexamethasone can cause fluid retention and
increase blood pressure.

2. Monitor the urinary intake and output data.

R: To prevent risk for kidney problems and to note
for any fluid retention in the body.

3. Instruct the client to consult the physician before

taking any other drugs

R: Other medicines can interact with

dexamethasone which could lead to adverse

139
 effects.

4. Give oral drug with food

R: To decrease GI distress

5. Evaluate growth of the patient

R: Dexamethasone long term use may show
growth problems due to steroids affecting the
hormones

6. For patients with cerebral edema, assess them for

level of consciousness changes and headache
during the therapy.
R: To note any adverse effect that may turn into
complications.

7. Follow up a stool exam or stool lab test

R: Dexamethasone can increase the risk of
stomach or intestinal bleeding and ulcers.

8. Instruct the client to not take a double dose to

make up for a missed one.
R: To prevent damage in the optic nerves

9. Instruct the patient to avoid people with known

infection and contagious illnesses especially in
the public places.
R: Corticosteroids causes immunosuppression
and may mask symptoms of infection

140
 10. Advise the family and the patient not to stop drug
abruptly without the doctors order
R: stopping the drug abruptly may cause side and
adverse effects to arise.

Generic Name paracetamol

Brand Name Panadol, Calpol, Tylenol,

Alvedon, Ifimol IV

Classification Analgesic, Antipyretic

Mode of Action Paracetamol blocks pain by inhibiting the synthesis of

prostaglandin, a natural substance in the body that
initiates inflammation. It also reduces fever by acting on
the hypothalamus region of the brain which regulates
temperature.

Ordered Dose and 300mg IV q4 PRN

Route

Indications
Fervor; Mild and moderate pain

141
Contraindications
Known allergic reaction paracetamol or any ingredients of
the medication; Liver Failure; Pulmonary Disease;
Cardiac disease; Renal disease

Side Effects
Nausea, Swelling, Disorientation, Dizziness, Dark
Colored Urine

Adverse Effects
Difficulty breathing, Hives, Severe skin rash, Blistering,
Swelling face or throat, Stomach cramps or pain,
Swelling or tenderness in the upper abdomen or stomach
area, Yellow skin or eyes, Thrombocytopenia,
Leukopenia, Agranulocytosis

Drug Interactions Drug to drug

● Warfarin: Prolonged, regular use may prolong
prothrombin time.
● Metoclopramide and domperidone: Enhance
absorption of paracetamol
● Cholestyramine: reduces absorption of
paracetamol

Nursing 1. Exercise the right way in administering the

Responsibilities medication
R: It is essential to follow proper aseptic
technique during administration to prevent
infection. Thus, should be administered slowly to
avoid sudden drops in blood pressure.

2. Prepare the medicine carefully and accurately.

142
 R: Preparation is crucial to prevent medication
errors. Physician’s order should be rechecked to
ensure the correct concentration of paracetamol
and follow the prescribed dosage regimen.

3. In preparing the medication, shaking the bottle

well is needed.
R: this is to ensure that the medication is evenly
distributed.

4. Raise the side rails always.

R: Safety precaution is needed after taking
paracetamol to prevent fall.

5. Frequently recheck the IV line if administered

intravenously.
R: Proper care and maintenance of the Iv line,
including checking for signs of infection or
infiltration, are essential throughout the course of
paracetamol IV administration.

6. Let the patient take a bed rest.

R: One common side :effects of the drug is
dizziness. To prevent accidents or injury, it is
recommended to take a rest.

7. Do proper documentation
R: Proper documentation is essential for accurate
record-keeping and legal accountability.

143
8. Educate the patient and watcher about the
importance of adhering to prescribed dosage and
schedule and inform them about potential
withdrawal symptoms if the medication is abruptly
discontinued.
R: Education empowers the patient and promotes
adherance, improving treatment outcomes and
reducing the risk of adverse effects.

9. Do not expose medication to direct sunlight and

store it properly; as instructed in the box.
R: this will help in preserving the potency of the
drug.

10. Educate the watcher the possible side effects and

adverse effects of the drug.
R: This will provide knowledge to the watcher and
it will help him/her notify the NOD if cases of
adverse effects might occur.

11. Educate the watcher to report to the NOD if

adverse reaction occurs such as; difficulty of
breathing, hives, severe skin rash, blistering, or
swelling of the extremeties.
R: This might be an indication that the patient is
experiencing anaphylactic reactio. If this happens,
prompt medical intervetions is needed because
this condition can lead to death if not treated
promptly.

144
Generic Name sodium chloride (NaCl)

Brand Name Rhea Sodium Chloride,

Kruschen Salts, Ocu-Disal

Classification ● Electrolytes
supplement
● Sodium Supplement
● Miscellaneous
respiratpry agents
● Isotonic volume
expander

Mode of Action Controls water distribution, the balance of fluids and

electrolytes, and the osmotic pressure of the body;
maintains the acid-base balance.

Ordered Dose and 1 tab TID

Route

Indications Sodium loss due to dehydration, excessive sweating, etc;

Prevention of heat cramps; Extracellular depletion, sodium
depletion, and dehydration due to excessive diuresis;
Gastroenteritis or salt restriction

Contraindications Sodium Chloride is contraindicated for patient with

hypersensitivity to sodium chloride, and high sodium levels
in the blood. It should be administered with caution to
patients with congestive heart failure, peripheral or

145
 pulmonary edema, impaired renal function, or
pre-eclampsia. Care should also be taken when
administering sodium chloride intravenously to very young
or elderly patients. Excessive administration should be
avoided as this may result in hypokalaemia.
Restriction of sodium intake, by limiting the amount of
culinary salt consumed, may be a useful aid in the
management of some patients with hypertension

Side Effects Facial flushing, Fluid retention, Hypernatremia, GI disorders

Adverse Effects Hives, Hypernatremia, Hypokalemia, Difficulty of breathing,

Peripheral edema, Nausea and Vomiting, Stomach pain,
Headache, Confusion, Slurred speech, Body weakness,
Profuse sweating, Tremors, Tunnel vision, Eye pain

Drug Interactions + Lithium = decreases the effect of lithium

+ Tolvaptan= increase adverse/toxic effects
+ Herbal= no significant interaction
+ Food = no known interaction
+ Laboratory values = not significant

Nursing Assessment:
Responsibilities 1. Obtain vital signs of the patient and check the
patient’s BP.
R: this helps to identify any contrindication or risks.

2. Obtain baseline serum electrolyte tests

R: to obtain baseline data; contraindicated if there is
hypernatremia.

146
3. Assess fluid balance of the patient such as intake
and output, daily weight, lung sounds, and edema.
R: to obtain data; contraindicated if there is fluid
retention.

4. Do not crush/break enteric-coated or

extended-release tablets.
R: affects the absorption of the drug

5. Administer with a full glass of water.

R: facilitates swallowing of medication

6. Assess if the patient is allergic to sodium chloride.

R: contraindicated to patients with hypersensitivity to
sodium chloride

7. Monitor intake and output, daily weight, lung sounds

and edema.
R: to assess fluid balance of the patient, and assess
progress of treatment.

8. Monitor serum electrolytes, acid-base balance, and

blood pressure.
R: to assess hypernatremia and hypokalemia.
Increase sodium chloride elevates blood pressure

9. Reinforce patient and family teaching to follow

medication for discharge planning
R: taking medications religiously will prevent further
complications and promote optimal recovery

147
 10. Instruct watcher or patient to report if nausea,
vomiting, stomach cramps, and diarrhea occurs.
R: may indicate toxicity/overdose

11. Elevate the head of bed before drug administration.

R: to prevent aspiration

Generic Name dexketoprofen trometamol

Brand Name Ketesse

Classification Therapeutic Class:

Nonsteroidal
Anti-Inflammatory Drugs
(NSAIDs)

Mode of Action Reduces prostaglandin synthesis via inhibition of the

cyclooxygenase pathway (both COX-1 and COX-2)

Ordered Dose and 25 mg IV

Route

Indications Treatment of acute postoperative pain in adults

Contraindications Hypersensitivity, history of gastrointestinal bleeding or

perforation, severe heart failure, severe hepatic failure,
or severe renal failure, and patients with a history of
asthma, rhinitis, nasal polyps, angioedema, or urticaria
associated with NSAIDs

148
Side Effects Upset stomach, nausea, constipation, diarrhea, gas,
dizziness, drowsiness, blurred vision, or headache

Adverse Effects GI: gastrointestinal erosions and ulcers that developed

dose-dependently
CV: chest pain, shortness of breath, and weakness on
one side of the body
Renal: decreased frequency or amount of urine, bloody
urine, and swelling of the abdomen, feet, ankles, or
lower leg
Neuro: dizziness, drowsiness, headache, and ringing in
the ears

Drug Interactions Heparins: Increased risk of hemorrhage (due to the

inhibition of platelet function and damage to the
gastroduodenal mucosa)

Fimasartan: Coadministration of Dexketoprofen and

Fimasartan may increase the risk or severity of renal
failure, hyperkalemia, and hypertension

Alcohol: Avoid consuming alcohol along with

Dexketoprofen as it could lead to increased drowsiness
and dizziness. It could also increase the risk

Nursing Assessment:
Responsibilities 1. Assess the patient's pain level before and after
administering dexketoprofen trometamol.
R: This is important to evaluate the effectiveness of the
medication in relieving pain.

2. Assess the patient's medical history.

149
R: Patient may have allergies or previous adverse
reactions to nonsteroidal anti-inflammatory drugs
(NSAIDs).

3. Assess the patient's vital signs, including blood

pressure, heart rate, and respiratory rate, before and
after administering dexketoprofen trometamol.
R: This is important to monitor for any adverse reactions
or side effects.

4. Assess the patient's renal and hepatic function before

and during treatment with dexketoprofen trometamol.
R: This is important to monitor for any potential adverse
effects on these organs.

Interventions:
1. Administer dexketoprofen trometamol as prescribed
by the healthcare provider.
R: This is important to ensure that the patient receives
the correct dosage of the medication.

2. Instruct the patient to take the medication with food or

milk.
R: To reduce the risk of gastrointestinal side effects.

Patient/Family Health Teaching:

1. Instruct the patient to take dexketoprofen trometamol
exactly as prescribed by the healthcare provider
R: To ensure that the patient receives safe and effective
treatment with dexketoprofen trometamol.

150
Generic Name metoclopramide
hydrochloride

Brand Name Placil

Classification Therapeutic Class: GI

stimulants
Pharmacologic Class:
Dopamine antagonist

Mode of Action Enhances response to acetylcholine of tissue in upper

GI tract, which causes the contraction of gastric muscle;
relaxes pyloric, duodenal segments; increases
peristalsis without stimulating secretions; blocks
DOPamine in chemoreceptor trigger zone of CNS.

Ordered Dose and 10 mg IV q8 RTC x 3 days

Route

Indications To prevent or reduce nausea and vomiting from

emetogenic cancer chemotherapy; To prevent or reduce
postoperative nausea and vomiting; To facilitate
small-bowel intubation; To aid in radiologic exam;
Delayed gastric emptying secondary to diabetic
gastroparesis; GERD

Contraindications Hypersensitivity to this product, procaine, or

procainamide; seizure disorder, pheochromocytoma, GI
obstruction

151
Side Effects Frequent (10%): Drowsiness, restlessness, fatigue,
lethargy.

Occasional (3%): Dizziness, anxiety, headache,

insomnia, breast tenderness, altered menstruation,
constipation, rash, dry mouth, galactorrhea,
gynecomastia.

Rare (less than 3%): Hypotension, hypertension,

tachycardia

Adverse Effects CNS: anxiety, drowsiness, dystonic reactions, fatigue,

lassitude, restlessness, seizures, suicidal ideation,
akathisia, confusion, depression, dizziness,
extrapyramidal symptoms, fever, hallucinations,
headache, insomnia, tardive dyskinesia.
CV: bradycardia, supraventricular tachycardia,
hypotension, transient HTN, HF.
GI: bowel disorders, diarrhea, nausea.
GU: incontinence, urinary frequency, erectile
dysfunction.
Hematologic: agranulocytosis, neutropenia.
Skin: rash, urticaria. Other: loss of libido, prolactin
secretion, gynecomastia, amenorrhea.

Drug Interactions DRUG:

May increase adverse effects of antipsychotic (e.g.,
haloperidol), promethazine, SNRIs (e.g., DULoxetine,
venlafaxine), SSRIs (e.g., citalopram, PARoxetine),
tramadol, tricyclic antidepressants (e.g., amitriptyline,

152
 doxepin). Strong CYP2D6 inhibitors (e.g., FLUoxetine,
PARoxetine) may increase concentration/effect.

LAB VALUES:
May increase serum aldosterone, prolactin.

Nursing Assessment:
Responsibilities 1. Assess the patient's vital signs, including blood
pressure, heart rate, and respiratory rate, before and
after administering metoclopramide hydrochloride.
R: This is important to monitor for any adverse reactions
or side effects

2. Assess the patient's gastrointestinal complaints, such

as nausea, vomiting, and persistent fullness after meals
R: By assessing the patient's gastrointestinal complaints,
healthcare providers can monitor the effectiveness of the
medication in relieving these symptoms and adjust the
treatment plan as needed.

Intervention:
1. Administer metoclopramide hydrochloride as
prescribed by the healthcare provider.
R: This is important to ensure that the patient receives
the correct dosage of the medication.

Patient/Family Health Teaching:

1. Instruct the patient to take the medication with food or
milk.
R: To reduce the risk of gastrointestinal side effects.

153
154
Surgical Management

Actual Surgical Management

Date Procedure Rationale Result Nursing

Responsibilities

09/14/23 Right The surgical procedure Date Reported: Before:

Frontotemporal known as right 09/20/23 1. Assess the patient's
Craniotomy Excision frontotemporal medical history, including
of craniotomy involves the Gross: any allergies or previous
Craniopharyngioma removal of a portion of A. Specimen labeled adverse reactions to
the skull in the “Craniopharyngioma” is anesthesia or
A surgical procedure frontotemporal region of composed of a 4 cm medications.
that involves the the brain. The excision aggregate of creamy R: This is important to
removal of a of Craniopharyngioma white to dark red-brown ensure that the patient is
craniopharyngioma, a is conducted to remove fragments. Some of the a suitable candidate for
rare type of a craniopharyngioma, a fragments are calcified. the surgery and to
noncancerous brain very uncommon benign prevent potential
tumor, through a right brain tumor. This B. Specimen labeled complications
frontotemporal procedure involves “Craniopharyngioma” is

155
craniotomy approach. utilizing a proper composed of 2. Evaluate the patient's
A craniotomy is a frontotemporal approximately 3 mL of neurological status,
surgical procedure in craniotomy method. bright yellow cloudy including level of
which a part of the The surgical process is fluid. consciousness, pupil size
skull is temporarily completed with the and reactivity, and motor
removed to expose administration of Microscopic: and sensory function.
the brain and perform general anesthesia, and A. There are nests and R: This is important to
an intracranial it is customary for the sheets of stellate cells establish a baseline and
procedure. patient to be admitted to that are surrounded ny monitor for any changes
the hospital for several palisade of columnar during and after the
days after the surgery. cells. surgery
The main objective of
the surgical procedure B. The specimen 3. Check the patient's
is to alleviate pressure contains few foamy vital signs, including
on the affected macrophages only. blood pressure, heart
structures while There is no atypical rate, and respiratory rate.
ensuring the highest cell. R: This is important to
level of safety during monitor for any potential
tissue removal. Diagnosis: complications and adjust
A. Consistent with the treatment plan as
Craniopharyngioma needed
4. Provide preoperative

156
B. Negative for atypical teaching to the patient
cell, presence of and family about the
macrophages only. procedure, including
Smears. what to expect before,
during, and after the
surgery.
R: This is important to
reduce anxiety and
promote understanding
of the surgery and its
potential risks and
benefits

During:
1. Monitor the patient's
vital signs, including
blood pressure, heart
rate, and respiratory rate.
R: This is important to
monitor for any potential
complications and adjust
the treatment plan as

157
needed.

2. Check for the patient's

neurological status,
including level of
consciousness, pupil size
and reactivity, and motor
and sensory function.
R: This is important to
monitor for any changes
during the surgery and to
ensure that the surgery is
proceeding safely

After:
1. Monitor the patient's
vital signs, including
blood pressure, heart
rate, and respiratory rate.
R: This is important to
monitor for any potential
complications and adjust

158
the treatment plan as
needed

2.Administer medications
as prescribed, including
pain medications,
antiemetics, and
antibiotics.
R: This is important to
manage pain and prevent
infection
3. Educate the patient
and family about
postoperative care,
including wound care,
activity restrictions, and
signs and symptoms of
complications.
R: This is important to
promote a successful
recovery and prevent
complications.

159
Possible Surgical Management

Procedure Rationale Nursing Responsibilities

Endoscopic Endonasal Endoscopic endonasal surgery is Before:

Transsphenoidal (EET) or applicable for the excision of tumors 1. Assess the patient's medical history,
Transcranial located near the cranial base of skull including any allergies or previous
base, as well as those at the adverse reactions to anesthesia or
Two surgical approaches used craniovertebral junction. Additionally, medications.
to access the pituitary gland and it can be utilized in the management R: This is important to ensure that the
skull base for the treatment of of sinus-related conditions. This patient is a suitable candidate for the
various conditions, including methodology enables the surgeon to surgery and to prevent potential
pituitary tumors and access these regions without complications
craniopharyngiomas. requiring extensive incisions or
cranial component excision. 2. Evaluate the patient's neurological
status, including level of
consciousness, pupil size and
reactivity, and motor and sensory
function.
R: This is important to establish a

160
baseline and monitor for any changes
during and after the surgery

3. Check the patient's vital signs,

including blood pressure, heart rate,
and respiratory rate.
R: This is important to monitor for any
potential complications and adjust the
treatment plan as needed
4. Provide preoperative teaching to the
patient and family about the procedure,
including what to expect before, during,
and after the surgery.
R: This is important to reduce anxiety
and promote understanding of the
surgery and its potential risks and
benefits

During:
1. Monitor the patient's vital signs,
including blood pressure, heart rate,
and respiratory rate.

161
R: This is important to monitor for any
potential complications and adjust the
treatment plan as needed.

2. Check for the patient's neurological

status, including level of
consciousness, pupil size and
reactivity, and motor and sensory
function.
R: This is important to monitor for any
changes during the surgery and to
ensure that the surgery is proceeding
safely

After:
1. Monitor the patient's vital signs,
including blood pressure, heart rate,
and respiratory rate.
R: This is important to monitor for any
potential complications and adjust the
treatment plan as needed

162
2.Administer medications as
prescribed, including pain medications,
antiemetics, and antibiotics.
R: This is important to manage pain
and prevent infection

3. Educate the patient and family about

postoperative care, including wound
care, activity restrictions, and signs and
symptoms of complications.
R: This is important to promote a
successful recovery and prevent
complications.

163
 CLUSTERED DATA CUES NURSING DIAGNOSIS PRIORITY

Health perception/health ● Does not take

management vitamins Risk for surgical site 3 - high prior
● Right infection
frontotemporal
craniotomy

Nutritional /metabolic ● Sodium -132.7 ( Deficient fluid volume 2 - high priority

135-145 mmol/L)
● Increased urinary
output
● Intake: 1370
Output: 2180

Elimination ● Polyuria Imbalanced Nutrition: Less 8 - low priority

● Vomiting Than Body Requirements

Activity/Rest ● General Fatigue 4 - moderate priority

weakness
Impaired Physical Mobility 5 - moderate priority

Cognitive/Perceptual ● Headache

164
● Blurry vision, Acute Pain 1 - high priority
● Peripheral field
vision loss, Decreased Activity 6 - moderate priority
● Nausea and Tolerance
vomiting
● Pain Risk for injury 7 - moderate priority
● Bilateral
hemianopia

165
 Nursing Care Plans

Acute Pain
Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma
Physician: Dr. R. Cabahug

Date and Cues Need Nursing Patient Intervention Implementa Evaluation

Time Diagnosis Outcome tion

S Subjective: C Acute pain Within 1 Perform a 1 September

E related to hour of quick and 17,2023
Patient O
P surgical nursing thorough @6:00 A.M
verbalized”
T G incision As intervention assessment GOAL
agay! nurse
E N evidenced the patient of the pain PARTIALLY
sakit kaayo
M by a will be MET
akong ulo I
B grimace relieved R: this is to
dri banda
E T face and and free of determine After
dapit, 8/10
R reports of pain and the location, rendering 1
ang I
pain will its hour of
kasakit”.
1 V intensity demonstrat characteristi nursing
7 Objective: E with a pain e a good cs, how intervention
, Scale of rest. long it will the patient

166
 2 ● Faci / 8/10. last and the is still
0 al severity of experiencin
P
2 grim Domain 12 the pain. g pain but is
3 ace E • Class 1 • now able to
● Incre Diagnosis Acknowledg 2 demonstrat
R
@5:00 A.M ased Code e and e a rested
C accept the
Resp 00132, state.
irator E Page 554 patient’s

y complain of
P
rate Rationale: pain

● Post T
op When there R: to
site U
is an recognize
John Keanu
A involvement the patient’s
A. Castro
of invasive perception
L St.N
procedure of the pain
such as and to

P surgery in establish a
the head it basis on
A
can cause how it
T certain affects him
symptoms
3

167
T and side Provide a
effects. nonpharma
E
Having a cological
R surgery can pain

N cause two manageme

types of nt
known
headache R: by

or pain providing

(Oxford), this type of

the first one treatment

is caused we can

by the avoid using

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the head that is not

this is ordered by

usually the

described physician

as a sore
Encourage 4
like type of
the patient
pain, while
to stay
the other

168
one is immobile on
caused by the site of
pressure pain
changes in
the head. R: to avoid

The trauma constant

after the elevation

surgery can and

cause irritation of

swelling the site that

and can causes pain

raise the
Provide
pressure 5
distraction
inside
causing R: to shift
pain. the focus of
the patient
References:
away from
Oxford the pain
University(2
018) After Provide
pharmacolo 6

169
Cranial gical
Surgery, treatment
retrieved: as ordered
September if pain is
25,2023 becoming
from: severe
https://www.
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R: this is to
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provide a
feedback
on how the
patient’s
body
responded
to the given
treatment

Document,
Report and
9

171
refer to the
physician

R: to inform
the
physician of
the
procedure
being done
to relieve
the patient
from the
pain

172
 Deficient Fluid Volume
Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma
Physician: Dr. R. Cabahug

Date and Cues Need Nursing Diagnosis Patient Intervention Imple Evaluation
Time Outcome mentat
ion

Subjective: N Deficient fluid volume Within the 8 1. Assess 1 September

S hours of intake 16, 2023 @
related to active loss
Objective: U nursing and 6:00 am
E occurring with intervention, output.
T the patient will R: This will
● Sodium excessive urinary
P have a allow the GOAL NOT
-132.7 R output. balanced nurse MET
T intake and objective data
(135-145
I output as in determining After 8 hours
E mmol/L) Domain 2 • Class 5 • evidenced by the patient’s of nursing
T decreased net loss of intervention,
● Increased Diagnosis Code
M output. fluid. the patient
urinary I 00027, Page 244 was not able
B 2. Assess 2 to have
output
O vital balanced
E ● Intake: Rationale: signs. intake and
N R: Vital signs output.
1370 Frequent urination
R may be
Output: A leads to a significant abnormal if
1 dehydrated
2180 depletion of bodily
L (i.e.
6 fluids, encompassing tachycardia
, / and/or

173
 water and hypotension)
2 M Robina
electrolytes, resulting
3. Assess 3 Marielle R.
0 E in a state of urine Galay, St. N
color
insufficient fluid
2 T and
volume. This concent
3 A ration.
condition denotes
R: Dark and
@ B that the body lacks an concentrated
urine can be a
appropriate quantity
11:00 PM O sign of
of fluids necessary for dehydration;
L patients
typical physiological
should
I functions. The term produce at
least 30mL of
"active loss" signifies
C urine/hour.
that this fluid
4. Adminis
deficiency is actively
ter
occurring due to the electrol 4
yte
continuous and
replace
substantial fluid loss ments
as
via frequent urination.
needed/
This highlights that as
ordered
excessive urination is
.
a characteristic R: Dehydration
can lead to
symptom of
electrolyte

174
craniopharyngioma, abnormalities,
it is important
likely stemming from
the nurse
the tumor's influence monitors for
this and
on hormone
provides
regulation, especially supplemental
replacements
the antidiuretic
when needed.
hormone (ADH)
5. Monitor
system. The tumor's
laboratr
proximity to the y
results,
hypothalamus and
especial 5
pituitary gland can ly
electrol
disturb the production
yte
or release of ADH, levels
(e.g.,
which plays a pivotal
sodium,
role in regulating potassi
um),
urine concentration.
and
(Edate and Albanese, report
any
2018)
abnorm
alities to
the
Reference:
healthc
Edate, S., & are
provider
Albanese, A. (2018a,
.

175
 February 11). R: Regular
monitoring of
Management of
electrolytes
electrolyte and fluid and other lab
values allows
disorders after brain
healthcare
surgery for providers to
detect
pituitary/suprasellar
abnormalities
tumours. Karger or imbalances
early.
Publishers.
https://karger.com/hrp
/article/83/5/293/1663
94/Management-of-El
ectrolyte-and-Fluid-Di
sorders

Risk for surgical site infection

Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma

176
Physician: Dr. R. Cabahug

Date Cues Need Nursing Patient Intervention Implementation Evaluation

& Diagnosis Outcome
Time

S Objective: H Risk for Within 6 Assess for the 1 September

E ● Does E surgical site hours of presence of 16,2023
P not A infection as nursing care, local infectious @6:00 A.M
T take L evidenced by The patient processes in
E vitam T incision of the will be able to the skin or GOAL
M ins H right detect the mucous PARTIALLY
B ● Right frontotemporal infection membranes. MET
E front P craniotomy. early, R: Signs and
R otem E allowing for symptoms After
poral R Domain 11 • rapid include providing 6
1 crani C Class 1 • treatment. localized hours of
6, otom E Diagnosis swelling, nursing care,
y P Code 00266, localized the patient is
2 ● Tem T Page 467 redness, pain able to
0 perat I or tenderness, maintain his
2 ure:3 O Rationale: loss of function normal wbc

177
 3 6.6° N S. aureus is in the affected and afebrile
C / responsible for area, and which
@ ● H approximately palpable heat. indicates no
Whit E half of all A client signs of
12AM e A craniotomy/cra colonized with infection.
bloo L niectomy S. aureus may
d cell T infections. A have
(WB H gram-positive staphylococci
C) bacterium that on the skin
coun M forms a biofilm without any
t: 8.0 A on native bone skin interruption
N is or irritation.
A Staphylococcu
G s aureus. Monitor white Ma. Andrew
E Other bacteria blood cell Nicole M.
M and fungi can (WBC) count. Añana, St. N
E also cause R: An 2
N infections, increasing
T though at a WBC count
much lesser indicates the
P rate. S has body’s efforts to
A colonized combat

178
T approximately pathogens.
T 30% of the This is referred
E human to as
R population. leukocytosis
N aureus, and is
usually in the composed
nares and primarily of
skin, and neutrophils.
colonized
people are Dispose of
more likely to soiled linens
become properly.
invasive S. R: Soiled
Infection with linens,
Staphylococcu particularly 3
s aureus. those
Although contaminated
pre-operative with bodily
screening for fluids, can
S. Although harbor
testing for pathogens such
Staphylococcu as bacteria,

179
s aureus viruses, and
carrier status fungi. Proper
is regularly disposal helps
conducted prevent the
prior to spread of these
orthopedic microorganisms
surgery, this , reducing the
strategy has risk of infection
not been to both the
consistently healthcare
adopted in provider and
neurosurgery clients.
for patients
who require a Investigate the
craniotomy/cra use of
niectomy (De medications or
Morais, 2021). treatment
modalities that
Reference: may cause
De Morais, S. immunosuppre
DB. (2021). ssion.
Immunopathog R:

180
enesis of Antineoplastic
Craniotomy agents,
Infection and corticosteroids, 4
Niche-Specific and so on can
Immune suppress
Responses to immune
Biofilm. function.
Retrieved Corticosteroids
September 27, and tumor
2023 from necrosis factor
https://www.fro inhibitors are
ntiersin.org/arti two types of
cles/10.3389/fi medications
mmu.2021.625 that can
467/full#:~:text increase a
=Approximatel client’s chances
y%20one%20 of acquiring a
half%20of%20 fungal infection
craniotomy,rat
e%20(8%2C% Wear gloves
2017). when handling
the client’s

181
body fluids.
R: Gloves
provide an
effective barrier
for hands from
the microflora
associated with
client care.
Gloves should
be worn when a
healthcare
worker has
contact with
any client 5
secretions or
excretions and
must be
discarded after
each client care
contact.

Change

182
dressing and
bandages that
are soiled or
wet.
R: An aseptic
technique is
used when
cleansing the
skin; dressings
are changed as
prescribed by
the surgeon,
usually on the
second through
the fifth
postoperative
days in
postsurgical
wounds.

183
 Fatigue
Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma
Physician: Dr. R. Cabahug

Date & Time Cues Need Nursing Patient Intervention Implem Evaluation
Diagnosis Outcome entation

184
 S Subjective A Fatigue Within 3 hours Evaluate the 1 September 16,
Cues: related to of nursing patient’s 2023 @7AM
E C
decrease intervention, the description of
P Objective T metabolic patient will be fatigue: severity, GOAL UMET
Cues: energy able to changes in
T I
- Generali production as verbalize ease severity over time, After 3 hours of
E zed V evidenced by of fatigue and aggravating nursing
weaken generalized demonstrate factors, or intervention the
M I
ess weakness ability to alleviating factors. patient was not
B noted T associated engage in able to verbalize
- Headac with sellar ADL’s without R: This system eased feeling of
E Y
supracellar tiredness allows the nurse fatigue and
he
R / craniopharyng to weigh against tiredness can
- Blurry ioma brain changes in the still be felt
R
surgery patient’s fatigue during bed bath.
vision
1 E level over time. It
- RR: 25 is important to
6, S
Domain: 4 conclude if the
cpm
T Class: 3 patient’s level of
Dx Code: fatigue is
2
00093 constant or if it
0 varies over time.
Rationale:
2
Fatigue is an Assess the 2
3 exhaustion patient’s ability to
and perform ADLs,
decreased instrumental
@ 4 AM capacity for activities of daily
physical and living (IADLs), and
mental work demands of daily
at typical living (DDLs). Jannieh Mitch P.
level, and it is Buenalor, St. N
common in R: Fatigue can

185
patients at 3 restrict the
months after patient’s ability
brain surgery. to participate in
Several self-care and do
factors that his or her role
caused responsibilities
fatigue after in the family and
surgery such society, such as
as; side working outside
effects of the home.
anesthesia
sedative Observe 3
drugs given physiological
(The Brain reactions to
Tumor activities such as
Charity, any alterations in
2021). BP, respiratory
rate, or heart rate.
R: Depending on
References disease
progression,
The Brain nutrition, fluid
balance, and
Tumor number of
opportunistic
Charity. diseases,
tolerance varies
(2021, greatly.

July Restrict 4
environmental
23). stimuli, especially
during planned

186
Fatigue times for rest and
sleep.
and R: Vivid lighting,
noise, visitors,
brain numerous
distractions, and
tumour litter in the
patient’s physical
s. The surroundings
can limit
Brain relaxation,
disturb rest or
Tumour sleep, and
contribute to
Charity. fatigue.

Retriev Always raise the 5

side rails of the
ed patient.
R: raising the
Septe side rails to
patients with
mber fatigue serves
important
27, purposes such
as; preventing
2023, falls, and patient
safety.
from
Teach energy 6
https:// conservation
methods
R: educating the

187
assets. patient on energy
conserving
thebrai methods can
help the patient
ntumou to adhere to the
therapy and
rcharity utilize energy to
do only the
.org/liv important
activities.
e/medi
Encourage an 7
a/filer_ exercise
conditioning
public/ program as
appropriate such
99/96/9 as; raising one leg
or arm at a time
9966a5 R: Fatigue
caused by
b-5081 deconditioning
and prolonged
-48fc-a bed rest can be
reduced through
1c6-0b improved
functional
b0109d capacity using
aerobic and
7c5c/fa muscle-strengthe
ning exercises.
tigue_a

Encourage 8

188
nd_brai verbalization of
feelings about the
n_tumo impact of fatigue.
R:
urs_v2 Acknowledgment
that living with
0_-_cle fatigue is both
physically and
ar_print emotionally
challenging
.pdf helps in coping.

Make the patient 9

aware of the signs
and symptoms of
overexertion with
activity.
R: Changes in
heart rate,
oxygen
saturation, and
respiratory rate
will reflect the
patient’s
tolerance for
activity.

189
Impaired Physical Mobility

Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma
Physician: Dr. R. Cabahug

Date and Cues Need Nursing Patient Intervention Implementa Evaluation

Time Diagnosis Outcome tion

S Objective: A Impaired Within 2 Determine September

E -General C Physical hours of the 16, 2023
P weakness T Mobility nursing diagnosis
T -Blurry I related to intervention that @ 6 AM
E vision V decreased s, the contributes 1
M -Peripheral I activity patient will to GOAL
B field vision T tolerance be able to immobility. UNMET
E loss Y associated participate R: These
R -Bilateral / with in activities conditions After 2
hemianopia R sensory-per of daily can cause hours of
1 E ceptual living physiologic nursing
6, S impairment (ADLs) and al and intervention
T desired psychologic s, the

190
 2 Domain 4 – activities. al problems patient was
0 Class 2 – that not able to
2 Diagnosis seriously participate
3 Code impact in activities
00085 physical, of daily
@ 4 AM social, and living such
Rationale: economic as morning
Decreased well-being. care. When
Activity asked if he
Tolerance: Note factors needed
Sensory-pe affecting help in
rceptual current wiping his
impairment situation body he
s, such as (e.g., replied with
blurry surgery, 2 “oo, kamo
vision, fractures, na bahala.”
peripheral amputation,
field vision tubings
loss, and [chest tube,
bilateral Foley
hemianopia catheter, IV
, can tubes,

191
significantly pumps])
impact a and
patient's potential
ability to time
move and involved
navigate (e.g., few
their hours in
environmen bed after
t safely. surgery
These versus
visual serious
impairment trauma
s may lead requiring
to long-term
difficulties in bedrest or
detecting debilitating
obstacles, disease
judging limiting
distances, movement).
and R: Identifies
maintaining potential
balance, all impairment 3

192
of which s and
can determines
contribute types of
to intervention
decreased s needed to
activity provide for
tolerance. client’s
safety.
Reference:
Lang, Assess
Cassidy, "A client’s
REVIEW developme
OF ntal level,
THERAPE motor skills,
UTIC ease and
INTERVEN capability of
TIONS movement,
FOR posture, 4
VISUAL and gait.
IMPAIRME R: To
NT AFTER determine
STROKE" presence of

193
(2020). characteristi
Undergradu cs of client’s
ate Honors unique
Theses. 33. impairment
https://digsc and to
holarship.u guide
nco.edu/ho choice of
nors/33 intervention
s.

Determine
degree of
perceptual
or cognitive
impairment
and ability
to follow
directions.
R:
Understandi
ng the
patient's

194
capabilities
allows for
the
promotion 5
of
independen
ce to the
greatest
extent
possible. It
helps
identify
areas
where the
patient can
actively
participate
in self-care
and
decision-ma
king.
6

195
Identify
energy-con
serving
techniques
for ADLs,
Kristine Joy D.
which limit Dela Cruz, St.N
fatigue,
maximizing
participation
.
R: The
ability to
perform
ADLs
independen
tly is closely
tied to an
individual's
sense of
autonomy
and dignity.
Energy-con

196
serving
techniques
enable
individuals
to remain
self-sufficie
nt, which is
essential for
their mental
and
emotional
well-being.

Encourage
participation
in self-care.
R:
Enhances
self-concept
and sense
of
independen

197
 ce.

Decreased Activity Tolerance

Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma
Physician: Dr. R. Cabahug

Date and Cues Need Nursing Diagnosis Patient Intervention Imple Evaluation
Time Outcome mentat
ion

Subjective: A Decreased activity After 4 hours - Assess September

S ● Pain scale C tolerance related to of nursing for the 16, 2023 @
of 8/10 T impaired physical care, the client cause 3:00 am
E Objective: I mobility as evidenced will be able to of the
● General V by pain scale of 8/10, achieve an activity
P weakness I general weakness, increased toleranc GOAL NOT
● Decrease T and decrease mobility conditioned e. MET
T dmobility Y due to surgery. physical state. R: The reason
due to / why the After 4 hours
E surgery E Rationale: patient cannot of nursing
X Decreased muscle engage in intervention,
M E control and strength, activities will the patient

198
 R activity intolerance, guide planning was not able
B C and impaired physical and to achieve
I mobility are all highly interventions. an incerased
E S correlated. Impaired The care plan conditiooned
E physical mobility has will have a physical
R negative effects on different focus state,
both physical and on whether the
1 psychosocial cause is
functioning. physical,
6 Deconditioning and psychological,
, loss of function or
across all areas, a motivational.
2 rise in the risk of
falling, a disturbance - Assess
Rhizza Mae
0 in body image, a ability
Bridget F.
change in mood, and and
Arcenal, St.
2 limitations on toleranc
N
activities of daily e to
3 living (ADL) and engage
social interaction are in
@ all potential outcomes activitie
(Zhao et al., 2020). s.

199
11:00 PM R: This
Reference: information
Zhao, J., Chau, J. P. provides a
C., Zang, Y., Lo, S. H. baseline for
S., Choi, K. C., & planning care.
Liang, S. (2020,
August 21). The - Assess
effects of sitting tai possible
chi on physical and contribu
psychosocial health ting
outcomes among factors
individuals with to
impaired physical intolera
mobility. Medicine. nce.
https://www.ncbi.nlm. R: Other
nih.gov/pmc/articl factors that
es/PMC74 enhance
47489/#:~:text=Impair intolerance
ed%20physical% 2 need to be
0mobility%20is%20st addressed and
rongly,both% treated as part
20physical%20and% of the care

200
20psychosocial%2 plan.
0functions.
- Encour
age
activity
progres
sively
such as
sitting
up in
bed,
sitting
on the
side of
the bed
and
dangle
legs,
standin
g up
with
assistan

201
 ce, mar
ching in
place,
sitting in
the
chair for
meals,
walking
a few
steps
with
rest in
betwee
n and
the
opportu
nity to
sit
down.
R: The patient
might tolerate
it much better

202
if activities are
increased
slowly. It
provides more
time for the
body to adjust.

- Perform
range of
motion
(ROM)
as
tolerate
d.
R: ROM
exercises
increase
circulation and
help prevent
contractures.

203
Risk for Injury
Name of Patient: K.A.M Age: 19M Ward: St. Joseph Bed#: 320
Chief Complaint: Blurring of vision Diagnosis: Sellar Suprasellar Craniopharyngioma
Physician: Dr. R. Cabahug

Date Cues Need Nursing Patient Outcome Intervention Impleme Evaluation

and Diagnosis ntation
Time

S Subjective: A Risk for injury Within 8 hours of Regularly assess 1 September 17,
E “Murag hanap C as evidenced nursing the patient’s vision 2023 @ 7:00am
P man akong T by: headache, intervention, the and inquire about
T mata ,ug I nausea and safety of the any changes or
E murag V Peripheral field patient will be worsening of ‘GOAL MET”
M malipong pa I vision loss. maintained as blurriness.
B ko usahay.” T evidenced by Monitor the patient After 8 hours
E As verbalized Y Domain 11 absence of for signs of of nursing
R by the patient. Class2 injury. nausea and intervention
E Diagnosis vomiting. the safety of
16 X Code 00035 the patient
C Page 480 Rationale: was
2 E Early detection of maintained as
0 R Rationale: changes in vision evidenced by
2 Objective: C A headache or increases in absence of
3 headache I can decrease nausea can injury.
•blurry vision, S concentration, prompt timely
•peripheral E impair intervention,
@ field vision judgment, and preventing further
loss P shorten complications.
12:00a •Nausea A reaction times,
m BP: T increasing the Continuously 2

204
90/60mmHg T risk of injury Monitor vital signs,
E (American particularly blood
R Migraine pressure, as
N Foundation, changes can be
2020) associated with
Nausea can both symptoms.
cause
dizziness and
vomiting, Rationale:
which can lead Regular
to dehydration assessments help
and electrolyte to identify any
imbalances. changes in the
This can patient's condition
further impair and inform the
the patient's effectiveness of
stability and interventions.
coordination, Monitoring vitals
increasing the can help identify
possibility of a underlying causes
fall or injury or complications.
(Mayo Clinic,
2019). Ensure the 3
Loss of patient’s
peripheral environment is
vision can free from
impair spatial obstacles and
awareness hazards.Keep
and navigation essential items
greatly, within easy reach
making it of the patient.
difficult for the Use a night light to
patient to help the patient

205
notice and navigate in dim
avoid light.
obstacles,
increasing the Rationale:
risk of Preventing falls
accidents and and injury is
injuries essential as
(Glaucoma blurred vision can
Research affect balance and
Foundation, navigation
2020).
Administer 4
antiemetics as
References: prescribed for
American nausea.
Migraine Consult with the
Foundation. healthcare
(2020). provider for
Understanding medications that
Migraine: might be
Impact on contributing to
Daily Life. blurred vision and
Retrieved from discuss possible
https://america alternatives.
nmigrainefoun
dation.org/reso Rationale:
urce-library/un Managing nausea
derstanding-mi and reviewing
graine-impact- medication can
on-daily-life/ help alleviate
symptoms and
Mayo Clinic. prevent injury.
(2019).

206
Dehydration. Educate the 5
Retrieved from patient on the
https://www.m importance of
ayoclinic.org/di reporting any
seases-conditi changes in vision
ons/dehydratio or increases in
n/symptoms-c nausea.Instruct
auses/syc-203 the patient on
54086 safety measures,
such as using a
Glaucoma walking aid and
Research moving slowly,
Foundation. especially when
(2020). getting up.
Glaucoma and
Reading. Rationale:
Retrieved from Empowering the
https://www.gl patient with
aucoma.org/liv knowledge can
ing/glaucoma- promote self-care
and-reading.p and injury
hp prevention.

Encourage 6
adequate fluid
intake, and offer
small, bland meals
to combat nausea.

Rationale:
Maintaining
hydration and
nutrition can help

207
manage nausea
and support
overall well-being.

Position the 7
patient in a
comfortable and
relaxed position,
with the head
elevated, to
alleviate nausea.
Offer reassurance
and support,
addressing any
anxieties or
concerns.

Rationale:
Comfort measures
and reassurance
can help alleviate
distress and
improve the
overall sense of
well-being.

Raise the 8
side rails

Rationale:
to keep the
patient safe during
periods

208
Complete
purposely hourly 9
rounding and
ensuring the
call-light is within
reach.

Rationale:
This allows the
nurse to check on
the patient
frequently and
assist the patient
in getting anything
that is needed
thereby reducing
potential risk of
injury.

Transfer the 10
patient to a room
near the nurses’ Ziajara Grace G.
station. Biruar, St. N

Rationale:
Determining which
patients are most
likely to fall is
essential to
prepare and

209
anticipate nearby
location and
provide more
constant
observation and
quick response to
call needs.

210
Nursing Theories

Jean Watson: Theory of Human Caring

Jean Watson is an American nurse theorist, a nursing professor, and

founder-director of The Watson caring Science Institute. She was born in 1940’s
in west Virginia U.S.A, graduated from the Lewis gale school of nursing during
1961 and earned her bachelor’s degree in 1964 and became a PhD in
educational psychology and counseling in 1973. Her philosophy is about how a
nurse addresses and expresses the care of their patients. She believes a holistic
approach to health care is the center for the practice of caring in nursing.
According to her, caring can be demonstrated and practiced by nurses such as
caring for patients that promotes their growth. Her theory discusses the 10
carative factors: forming humanistic-altruistic value systems, instilling faith-hope,
cultivating sensitivity to self and others, developing a helping-trust relationship,
promoting an expression of feelings, using problem-solving for decision-making,
promoting teaching-learning, promoting a supportive environment, assisting with
gratification of human needs, and allowing for existential-phenomenological
forces. But her theory has four major concepts and these are: human being,
health, environment/society and nursing. Wherein a human being is a valued
person to be cared for, respected and nurtured to be understood and assisted on
their needs. Human health is about the physical, mental and social function of a
person. Society is where one should behave and what goals one should strive

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toward. And lastly nursing is the science of a person that provides intervention
towards human health illness.

As a student nurse aspiring to become a professional nurse in the future. We are

positioned to be the center of their healing process. When talking about this
theory, patients with Tumor related illnesses need special and intensive care,
especially for those patients who are mentally and physically tired of their
illnesses. This disease requires intensive treatment and is reversible that could
improve the person’s life. As student nurses, it is our duty to make them express
their discomfort so they would not feel neglected just because of what they are
going through. When we are dealing with a patient with craniopharyngioma, we
need some of the 10 carative factors as our foundation in caring. In the
application of this theory, the student nurse will be able to show genuine interest
for the patient’s wellness and wellbeing, provide hope to the patient, provide an
authentic caring relationship towards them by showing support, use
problem-solving method for making decisions, understand the client’s perception
of what they are facing, assisting the patient with the gratification of human
needs where we view the patient holistically, and at the same time attending to
the hierarchical ordering of needs of the client

Lydia Hall Care, Core, Cure theory

Lydia Eloise Hall born on September 21, 1906 New York City U.S.A, she was a
nursing theorist who developed the 3C’s model of nursing. Lydia Hall worked as

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the first director of the Loeb Center for nursing, her experience as a nurse was in
clinical nursing, nursing education and research. In the late 1960s, Lydia E. Hall
developed the Care, Cure, and Core Theory of Nursing because of her
psychiatric work and experiences at the Loeb Center. She advocated for
community members to be involved in healthcare issues throughout her career.
She defined nursing as “a participation in care, core and cure aspects of patient
care, where care is the main function of the nurse and core and cure are shared
with the members of the health team”. The three Cs contain the three
independent but connected patterns that can help in the patient’s health: The
Core aspect of her theory describes an individual to whom nursing care is
directed and the individual's behavior because of their feelings and value system.
The Cure aspect is the attention given to patients by medical professionals; these
are the actions that are focused towards the treatment of the patient. And the
Care concerns nurturing the patient, providing comfort measures, and giving
instructions to the patient, this includes educating the patient, helping in their
needs where they are unable to.

As a student nurse this theory can be applied to people that have cases of brain
related injury or disease because we can use and utilize Lydia Hall’s three Cs.
Where we are Tending to the patient while at the hospital is one of the main
objective as an aspiring nurse that is why we must perform our duties by carrying
out the care to the patient who are diagnosed with craniopharyngioma and other
brain related illness by giving them the medications to their complication such as
managing their risk for having a seizure by giving antiepileptic drugs and other
elements and illness that hinders their healing process, the discharge plan that
they need in order to improve their overall health outside when they get
discharged which touches the cure concept so that they can be out of the facility
early and improve health as a person. Her theory not only puts the focus on the
patient’s illness but also looks at the patient as a whole by providing care via a
holistic approach.

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VIII. Discharge Planning

METHOD HEALTH TEACHINGS RATIONALE

Medicine 1. Take medication as This is to aid patients in taking

prescribed, including their prescribed medication and
the correct dosage, to ensure that they are aware of
timing, and frequency. when to discontinue taking the
medication.
In addition, it enables them to
learn about the significance of
medication regimen and the
efficacy of each prescription
(Banner, n.d.).

2. Educate the patient’s To inform them about the

family about the therapeutic effects of the drugs
importance of each for fast recovery and to be
medication and its aware of the side effects.
possible side effects.

Exercise 1. Encourage patients to Rest and sleep are essential for

get sufficient rest and patients recovering from
sleep. surgery in order to promote
healing, immune system

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 function, pain management,
mental health, energy
conservation, and hormonal
equilibrium. The healing
processes of the body are
aided by sleep, allowing for
quicker tissue repair and
regeneration. In addition, it
strengthens the immune
system, preventing infections
and decreasing pain
dependence. Adequate rest
aids in the reduction of tension,
anxiety, and mood swings,
promoting a successful
recovery.

2. Ensure a safe home A safe home environment is

environment, necessary to prevent injury, and
minimizing fall risk, assistive devices may be
and arrange for needed depending on the
necessary assistive patient’s physical condition after
devices. surgery.

3. Encourage passive To reduce fatigue resulting from

range of motion such deconditioning and extended
as piriformis stretch. bed rest.

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Treatment 1. Schedule follow-up Regular follow-up treatments
appointments for are essential to monitor healing,
wound checks, suture manage any complications, and
removal, and assess the need for further
evaluation of recovery interventions or therapy.
progress.

Hygiene 1. Instruct on gentle hair Preventing infection is crucial

and scalp care around for healing, especially around
the surgical site to the surgical site.
prevent infection.
Advise on regular
hand hygiene.

Outpatient 1. Schedule follow-up Ongoing medical monitoring

appointments with the and adjustment of treatment
neurosurgeon and plans are essential for
other specialists as managing any long-term effects
needed. and ensuring optimal recovery.

Diet 1. Recommend a Proper nutrition and hydration

balanced diet, are key components in the
adequate hydration, healing process, especially
and potentially, post-surgery.
nutritional

216
 supplements, such
as:

Protein Foods: Lean meats Protein is crucial for tissue

like chicken or turkey, fish, repair and immune function.
eggs, dairy products,
legumes, and plant-based
protein sources like tofu and
tempeh.

Fruits and Vegetables: Rationale: These foods are high

A variety of colorful fruits in vitamins, minerals, and
and vegetables, including antioxidants which can aid in
berries, citrus fruits, leafy healing and maintaining overall
greens, and cruciferous health.
vegetables like broccoli and
Brussels sprouts.

Whole Grains: Whole grains provide essential

Quinoa, brown rice, whole nutrients and are a good source
wheat bread, oats, and of energy.
barley.

Healthy Fats: Healthy fats are essential for

Avocado, olive oil, fatty fish, brain health and can help
nuts, and seeds. reduce inflammation.

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 Hydration/Fluids: Adequate hydration supports
Water, herbal teas, and overall bodily functions and aids
broths. in the healing process.

Limit Foods: These can contribute to

Processed foods, sugary inflammation and other health
snacks, and drinks, and high issues.
sodium foods.

IX. Prognosis

According to Torres (2023), Craniopharyngiomas are rare, benign tumors of the

central nervous system. Craniopharyngiomas are epithelial tumors that begin in
the brain's suprasellar region and spread to include the hypothalamus, optic
chiasm, cranial nerves, third ventricle, and major blood vessels. Also,
craniopharyngiomas are determined by their size, histologic type, surgical
technique, and degree of hypothalamic and endocrine deficiency. At 5 years, the
overall survival rate of craniopharyngiomas ranges from 80 to 95%. The
occurrence of craniopharyngioma is relatively rare, with a yearly incidence
ranging from 0.5 to 2 cases per one million individuals. While these tumors can
manifest at any age, they are commonly associated with pediatric cases,
comprising about 1.2 to 4% of all intracranial tumors. Nevertheless, it's worth
noting that approximately half of all craniopharyngioma diagnoses occur in adults

In relation to our patient, he underwent postoperative craniotomy which was done

because of his diagnosis Sellar Suprasellar Craniopharyngiomas. The patient
has medications such as Desmopressin, Omeprazole, Tranexamic Acid,
Cefoxitin, Ceftriaxone sodium, Levetiracetam, Mannitol, Dexamethasone,
Paracetamol, Sodium Chloride, Dexketoprofen trometamol and Metoclopramide

218
hydrochloride which aids in the management of ongoing conditions, the treatment
of acute illnesses, and general long-term health and wellbeing. The patient has a
fair prognosis and a high chance of survival if this sickness is treated with a
variety of medicinal, surgical, and nursing procedures. The patient's prognosis,
on the other hand, will be poor if the tumor is left untreated and grows in size,
which might result in endocrine issues, neurological complications, and other
consequences that can be fatal that can cause death.

X. Review of Related Literature/Studies

Primary ectopic parasellar craniopharyngioma: a case report

Craniopharyngioma is a benign epithelial tumor that develops from the
embryologic squamous epithelial remains of the craniopharyngeal duct or
Rathke's pouch. Majority of the tumor have both the intra and suprasellar
components. There are studies that showed an ectopic recurrence of
craniopharyngioma that may occur in the surgical path, so in this article they
reported a case of a primary right parasellar ectopic craniopharyngioma that was
treated by nasal endoscopy. In their study the client was a 49 year old female
who had a complaint of dizziness and blurring of vision for more than 10 days,
she went under a neurological exam and showed no abnormal signs. Then an
MRI was performed and it showed a tumor that was at 33mm. for treatment
purpose she was transferred to the neurosurgery department, Craniocervical
computed tomography angiography shows a localized defect of the sphenoid and
right occipital slope in the sphenoid sinus, with a low-density shadow in the
corresponding area and local envelopment of the right internal carotid artery.
Then the patient underwent transnasal neuroendoscopic resection to the right
parasellar space. They used a 0.01 percent adrenaline saline tampon to push
aside the turbinate and nasal septum on both sides in order to provide enough
space to operate the endoscope. Then by using the 30° endoscope they

219
removed the tumor, it was cut open releasing an opaque soy sauce color and
revealing a brown deposit in the cyst. They did a complete resection of the cyst
wall; fluid gelatin was injected into the bleeding site to stop the present bleeding.
After the reconstruction no cerebrospinal fluid leakage was noted. Second day
after her operation the MRI showed that there was no residing tumor found and
after 6 months from an MRI was then repeated showing no residual tumor and
finally after 12 months of follow up checkup tumor was no longer present in her.
According to their study craniopharyngioma is a benign tumor that occurs in the
intrasellar or suprasellar region in the brain they stated that there are 2 types the
primary and secondary, wherein the primary is the rare craniopharyngioma than
the secondary ad it arises due to the absence of any previous surgery. CT scan
and MRI are the first choice in order to determine the diagnosis for this rare
disease. They stated that her case which is a Primary ectopic parasellar
craniopharyngioma is an extremely rare case which would require an extensive
test in order to reveal a diagnosis to avoid a misdiagnose since this case has
little information. They recommend that patient with this case should undergo a
regular MRI checkup after their surgery to ensure that no relapse will occur which
leads to further complication

Ectopic recurrence craniopharyngioma: series report and literature review

Craniopharyngioma is an infrequent central nervous system neoplasm
that predominantly manifests in the sellar-suprasellar region and is generally
considered non-malignant. Surgical resection represents the principal therapeutic
approach; nevertheless, achieving complete resection poses a formidable
obstacle, increasing the likelihood of recurrent occurrences and disease
progression. The event of distant spread is a significantly uncommon yet
significant problem, necessitating the identification and administration of
appropriate therapeutic interventions. The literature review identified a total of 63
instances of ectopic recurrence of craniopharyngioma, which included the case of
our patient. The age of onset in the pediatric and adult cohorts spans from 2 to 14
years old and 17 to 73 years old, respectively.

220
 Similarly, the time gap from tumor commencement and ectopic recurrence
ranges from 0.17 to 20 years in the pediatric group and 0.3 to 34 years in the adult
group. The attainment of complete removal of the tumor is not effective in
preventing the occurrence of ectopic recurrences. The predominant pathology
observed in cases of ectopic recurrence of craniopharyngioma is the
adamantinomatous variety. The frontal lobe is the most frequently observed
location for ectopic recurrence. Based on the etiology, it was observed that 35
cases exhibited seeding via the surgical method, while 28 points demonstrated
instilling through the cerebrospinal fluid (CSF) pathway. The implementation of a
meticulous surgical process has the potential to mitigate the likelihood of ectopic
recurrence. At the same time, adopting structured postoperative monitoring can
yield significant insights for therapeutic interventions.

The Role of Surgical Approaches in the Multi-Modal Management of Adult

Craniopharyngiomas

Craniopharyngiomas are classified as benign neoplasms of the central

nervous system, constituting 2-5% among all primary intracranial malignancies.
The presence of tumors near neurological systems such as the pituitary gland,
hypothalamus, and optic apparatus can lead to considerable morbidity. Although
the effectiveness of adjuvant chemotherapy and radiation is limited, the primary
approach in treatment still revolves around achieving the most extensive surgical
removal possible. Contemporary surgical methodologies have seen
advancements in customizing endoscopic endonasal, transcranial, or
combination methods to attain optimal resection of craniopharyngiomas.
Managing craniopharyngiomas necessitates a comprehensive strategy
encompassing various disciplines, including neurosurgery, otolaryngology,
endocrinology, ophthalmology, radiation oncology, and neuro-oncology. The
endoscopic endonasal technique has significantly transformed the field of

221
surgery, while adjuvant radiotherapy and targeted medicines have emerged as
feasible alternatives for managing remaining malignancies.

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