Republic of the Philippines

Western Mindanao State University

College of Nursing
Zamboanga City
Tel. No. (062) 9911040 loc.111, (062) 9931339, (062) 9902706

COMPREHENSIVE CLINICAL CASE STUDY IN THE

CARE OF PATIENT WITH PROBLEM IN THE
CENTRAL NERVOUS SYSTEM
“CYSTIC ASTROCYTOMA”

In partial fulfillment for requirement of

MSN INTENSIVE PRACTICUM

1st Semester S.Y. 2019-2020

Presented to:

DR. NURSIA M. BARJOSE

PROF. ANTONIO D. PATIŇO, JR.

Presented by:

Airene G. Santiago, R.N.

 THE NURSING PROCESS

A. Assessment Phase

1. Biographical Data

Name : Mr. Venzuelo, A.

Age : 13 years old

Date of Birth : November 12, 2006

Gender : Male

Height : 148 cm

Weight : 42 kg

Religion : Catholic

Ethnicity : Zamboangueño

Civil Status : Child

Address : Lumiyap, Divisoria,

Zamboanga City

Diagnosis : Cystic Astrocytoma Regrowth,

Left Frontotemporal

Attending Physician : Ryan Abutazil, M.D.

2. Clinical History

a. Past Health History

Client has complete immunization in his respective health center,

breastfed until 7 months with complementary feeding started at 6 months, and

currently on a diet as tolerated, with no experiences of serious disease condition,

and has active activities daily by going to school, participating in class activities

and interacting playfully with classmates.

b. History of Present Illness

Client is starting to experience body weakness especially on right side of

the body with occasional episodes of headaches and dizziness. CT scan was

done and result shows that his intracranial mass has grown back. He was

admitted on September 2, 2019 and underwent surgery specifically Craniotomy

Left Frontotemporal for Excision of Cystic Astrocytoma Regrowth that lasted for 5

hours and 45 minutes on September 9, 2019.

Two years ago prior to this present admission, he experienced the same

signs and symptoms and already had his first Craniotomy with excision of

intracranial mass and was advised to monitor for mass regrowth by having CT

scans repeatedly every 4-6 months. Hence, the present regrowth was detected.
 c. Family Health History

Client is the eldest of two siblings, born to a 33 year-old mother via Normal

Spontaneous Vaginal Delivery at a hospital with no complications. Both of his

parents are nonsmokers, but are occasional drinkers and has no history of mass

growths or cancer.

3. General Assessment

Table 1. The data shows assessment of the patient utilizing Faye Abdellah’s 21 Nursing Problems

Faye Abdellah’s 21 Nursing Problems Ability to Meet Needs

1. To maintain good hygiene and
physical comfort
2. To promote optimal activity,
exercise, rest and sleep.
3. To promote safety through
prevention of accident, injury, or other
trauma and through prevention of the
spread of infection.
4. To maintain good body mechanics
and prevent and correct deformity.
5. To facilitate the maintenance of a
supply of oxygen to all body cells.
6. To facilitate the maintenance of
nutrition for all body cells.
Yes. The client is always well-
groomed, observing daily hygienic
activities.
No. The client can not involve himself
in strenuous plays/activities as well as
has trouble getting sound sleep at
times as he sometimes experiences
dizziness and headache.
No. The client is prone to fall because
of episodes of dizziness.
No. The client is observed to not follow
proper body mechanics at times like
picking up things by bending at the
waist but does not have any body
deformity.
Yes. The client has normal oxygen
saturation with no observed and
reported episodes of difficulty of
breathing.
Yes. The client has a good appetite
with no hesitations in eating nutritious
foods especially fruits and vegetables.

7. To facilitate the maintenance of
elimination.
8. To facilitate the maintenance of fluid
and electrolyte balance.
9. To recognize the physiologic
responses of the body to disease
conditions-pathologic, physiologic, and
compensatory.
10. To facilitate the maintenance of
regulatory mechanisms and functions.
11. To facilitate the maintenance of
sensory function.
12. To identify and accept positive and
negative expressions, feelings, and
reactions.
13. To identify and accept
interrelatedness of emotions and
organic illness.
14. To facilitate the maintenance of
effective verbal and nonverbal
communication.
15. To promote development of
productive interpersonal relationships.
16. To facilitate progress toward
achievement and personal spiritual
goals.
17. To create or maintain a therapeutic
environment.
He is limited from eating too much junk
foods as the parents believe that it may
make him immunocompromised and
may aggravate his disease condition.
Yes. The client has no difficulty
urinating and moving his bowel.
Yes. The client drinks one to two liters
of water per day, and during his
hospitalization, his laboratory work-up
on electrolytes are within normal range.
Yes. The client and significant others
are aware about some of the signs and
symptoms of his disease condition.
Yes. The client had no episodes of
hyperthermia.
Yes. The client can use all of his
senses (sight, hearing, smell, taste,
touch) accurately.
Yes. The client knows the different
emotions of a person towards him or
towards others.
Yes. The client can verbalize when he
is feeling happy, sad and afraid in
different situations.
Yes. The client can show how he is
feeling at the moment with support of
nonverbal communication that
coincides with his emotions.
Yes. The client depends on his parents
and confesses to them about what is
bothering him and easily trusts people
he encounters who he believes to have
a positive intent for him.
Yes. The client and his family are
religious church-goers. He prays
everyday too accordingly.
Yes. The place where the client lives is
observed to be free from noise and
pollution as it is situated at the
innermost part of a barangay where
there are few vehicles passing by and
people living in the area knows and
have harmonious relationship with
each other.

18. To facilitate awareness of self as
an individual with varying physical,
emotional and developmental needs.
19. To accept the optimum possible
goals in the light of limitations, physical
and emotional.
20. To use community resources as an
aid in resolving problems that arise
from illness.
21. To understand the role of social
problems as influencing factors in the
cause of illness.
Yes. The client knows what he wants in
simple aspects like food and clothes he
prefers to ear and wear respectively for
the day, and he knows the reason why
sometimes he feels sad or afraid and
what can ease those emotions.
Yes. The client is optimistic that he can
fully recover from his disease condition
so that he can go back to school and
interact with his friends with no
limitations on physical activities.
Yes. The client’s parents always seek
medical attention when they observe
deviations from the patient’s health.
The patient has to undergo CT scan
every 4-6 months to monitor for
regrowth of his mass resulting to
financial problems which the parents
seek assistance from other relatives
who are willing to help, government
officials and charity organizations.
Yes. The client recognizes the
importance of why he has limitations in
foods and activities.
Table 2, Physical Assessment Tool
Measurement Norms Actual Finding Interpretation/Analysis
Hair should be evenly Patient was almost
distributed; exceptions bald because of
are normal balding the surgery, but
Hair pattern to persons of tiny hairs are
NORMAL
advanced age. Hair beginning to grow
thins with age. Scalp evenly except on
free of lesions and the surgical
pediculosis. incision site.
FACE
Eyelash present and
Eyelashes Eyelash present,
curving outward, no NORMAL
no crusting noted
crusting
Palpebral fissure
Eyelids symmetrical, upper Papebral fissures
NORMAL
eyelid normally covers are symmetrical
one half of upper iris
Lid Margins No Lesions No lesion noted NORMAL
Normally does not
Eyeball No protrusion
protrude beyond NORMAL
noted
frontal bone
Palpebral conjunctiva
is smooth, glistening,
pinkish-peach in color Palpebral
Conjunctiva with minimal blood conjunctiva is
NORMAL
vessels. Bulbar smooth and
conjunctivas over pinkish.
globes are clear, white
sclera visible
Sclera Should be smooth and Smooth and white
NORMAL
white
Eye Movement Globe is firm and non- Firm and non-
NORMAL
tender tender
Normal shape and Helix is level with
presence of imaginary line. All
landmarks, Helix of ear landmarks
is level with imaginary present. Intact and
Ears line drawn through the no lesions in both
NORMAL
inner and outer ears
canthus to occiput.
Intact, no lesion,
consistent with skin
color
No foreign objects, No redness or
Ear Canal free from redness or lesion noted. Ear
NORMAL
drainage. Earwax may canal with minimal
be visible earwax.
 Using Whisper Test: Able to hear 5 out
Hearing repeats all words 5 on both words
whispered in each ear NORMAL
Activity at a distance of 1-2
feet
Symmetrical, no nasal Nose is
Nose flaring, no drainage. symmetrical
NORMAL
Non-tender, no without any
masses. drainage.
Midline symmetrical, Symmetrical.
Mouth (Lips) skin intact, pink and Moistness noted
NORMAL
moist. No unusual
odor
Pink, moist, intact Moist and pink
Gums mucosa with no mucosa, no NORMAL
bleeding bleeding noted
Teeth white, not loose Primary teeth are
Teeth with good occlusion with no loose ones NORMAL
and in good repair noted.
Tongue pink and Moist tongue
Tongue moist. Mucosa intact noted NORMAL
with no lesion
Erect midline, no No lumps,
lumps, bulges or masses, bulges or
masses. No swelling swelling noted.
Neck or hypertrophy in mid NORMAL
to lower half of anterior
neck. Thyroid is not
visible.
Chest symmetrical. No Chest symmetrical
sterna or intercoastal noted. Chest X-ray
retraction or bulging. result shows clear
Consistent skin color lung fields
and hair distribution.
THORAX AND Skin intact, no scars.
Expansion equal. No NORMAL
LUNGS deformities. Normal
lung fields, cardiac
size, mediastinal
structures, thoracic
spine, ribs and
diaphragm
Regular heart rate or Heart rate ranges
Heart rhythm. No aortic from 75-92 beats NORMAL
murmurs per minute
Abdominal skin intact Abdomen not
with no lesions or distended, non
Abdomen masses. Imbilicus tender with no NORMAL
inverted and midline. lesions or redness
No abdominal noted.
 distention. Abdomen
soft and non-tender.
Movemnets
coordinated; right side
dominant and slightly Movements are
more coordinated. No coordinated but
Upper Weakness of the body
lesions, tenderness only limited due to
is brought about by the
Extremities and palpable mass. body weakness
disease condition.
Turgor is used to with no lesions
assess hydration noted.
status but is normal
with aging.
Equal in size and Arms equal in
shape. No lesions and size. No lesions Patient’s disease
wounds. Palpable and abnormal condition affects the
brachial and radial movements noted central nervous system,
Arms pulse. Muscle soft, in but needs to be specifically the brain
relaxed state. No assisted when which controls every
abnormal movements changing positions movement of the body.
or when having to Thus, body weakness is
go to another experienced.
place
There are five fingers Complete fingers
Palm and on each hand. on both hands.
Demonstrate strong Palm pinkish,
NORMAL
Dorsal Surface hand grasp. Dorsal crease lines
surface pink, crease present.
lines present.
Symmetrical to the Symmetrical in
Lower body. No lesion. shape, size and
Muscles appear equal movement with no
NORMAL
Extremities and with good muscle lesions and
tone. No tenderness or redness noted.
mass.
Able to move freely Patient has a good
Range of
without discomfort range of motion
NORMAL
Motion with the aid of his
parents.
Posture should be Posture is Guarded posture
erect with the head guarded. indicates that patient is
midline Movements are experiencing pain.
Posture and Gait-all movements well coordinated,
should be coordinated arm swings in
Gait and rhythmic, arms position and stride
swing in position, length is
stride length appropriate.
appropriate
Personal Clean and neat. No Patient is neat and Patient’s guardians
body or bad breath well-groomed. No observe proper body
Hygiene and odor. foul odor or bad hygiene and grooming.
 Grooming breath noted, no
signs of infection
also noted on
incisional site.
Patient is 13 year Adolescents think on a
old who always higher level, identifying
stays at home what is true. They try to be
mostly reading and independent and at this
watching stage.
Age instructional shows,
Adolescent and sometimes
Appropriation engaging in plays
with minimal
physical exertion.
He stopped
schooling for the
meantime.
Understandable, Patient can
moderate pace; verbalize what he The patient is coherent
Verbal exhibits thought wants to say and and verbally responsive.
association; logical has no difficulty in
behavior sequence, makes understanding
sense, the sense of what others is
reality. saying too.
Non-verbal Calm and cooperative Patient is calm and
cooperative with The patient is not restless.
communication good eye contact.

GUIDE FOR BMI

<16 Malnourished
16-19 Underweight
20-25 Normal
26-30 Overweight
31-40 Moderately
to Severely
Obese Patient is on diet
Nutritional >40 Morbidly as tolerated
Obese Height is 148 cm
Status NORMAL
Weight is 42 kg
Can ingest food BMI is 19.17
without difficulty in
chewing, swallowing
and digesting; can
tolerate foods orally
without aide
(e.g.enteral feeding)
Intact and uniform skin Surgical incision
color with slightly with sutures
Disruption in the body’s
darker exposed areas. present on
Skin 1st line of defense
Mucous membranes frontotemporal
makes client prone to
and conjunctiva pink. area with no
invading pathogens
redness or
causing infection.
swelling noted.
Laboratories
Table 3. Laboratories
Procedure /
Date Norms Result Interpretation/Analysis
Laboratory
Complete Blood Count
September Hemoglobin 115-155 g/L 141 g/L NORMAL
7, 2019 0.35-0.45 0.40 volume
Hematocrit NORMAL
volume % %
Red Blood Cells 4.7-6.2 10^12/L 4.9 10^12/L NORMAL
White Blood
5.5-15.5 10^9/L 6.5 10^9/L NORMAL
Cells
Neutrophils 40-70 % 56 % NORMAL
Lymphocyte 20-45 % 34 % NORMAL
Eosinophil 0-10 % 3% NORMAL
Basophil 0-1 % 1% NORMAL
Platelet Count 150-350 10^/uL 272 10^/uL NORMAL
MCH 11-14% 12.4 pg NORMAL
MCHC 28.0-33.0 g/dL 31.8 g/dL NORMAL
MCV 32.0-35.0 g/dL 33.2 g/dL NORMAL
Blood Chemistry
September Sodium 137-145 mmol/L 138 mmol/L NORMAL
7, 2019 Potassium 3.5-5.1 mmol/L 3.9 mmol/L NORMAL
OTHERS
September
7,2019
Chest PA NORMAL
4. Problem Identification and Prioritization
Table 5. Identified problems arranged according to priority with rationalization.
Nursing Diagnosis Cues Justification
1. Acute Pain related to Subjective cues: According to Maslow’s
related to trauma to “Ta dwele pa syempre Hierarchy of Needs,
skin, tissues and nerves tienebes mio kabesa pti Physiological needs
el operasyon maam.” comes first. When a
person feels pain, it
Objective cues: disrupts his comfort.
 Pain score of 7/10 Thus, he cannot satisfy
 Facial Grimace his physiological needs
 Uneasiness (proper oxygenation,
 Irritability good appetite, enough
 Guarded behavior sleep) well.
2. Impaired skin integrity Subjective cues: Ranks as second as
related to surgical site “ Second time ya este affects patient’s physical
incision. mio operasyon na aspect which still
kabesa ara maam.” belongs to the first
hierarchy of Maslow’s
Objective Cues: Hierarchy of Needs. The
 sutures on wound causes feelings of
surgical site anxiety to the patient.
 healing wound on Thus, it’s healing is
frontotemporal important in improving
area his comfort.
 wound has no
redness and
discharges noted
3. Risk for infection Subjective cues: Ranks third among
related to presence of “Pirmi ba se ele ta agara problems identified. It still is
surgical wound. disuyu kabesa maam. a part of Maslow’s
Ta tiene yo myedo bka Hierarchy of Needs in
man impeksyon el irida.” Physiological aspect.
Keeping the wound free
from infection results to a
Objective Cues: timely wound healing so
 observed patient the patient can go back to
to unconsciously doing activities of daily
holds his head living as soon as possible.
 healing wound
on frontotemporal
area
4.Risk for fall related to Subjective cues:
generalized weakness “Hinde yo tanto ta
pwede kamina
embuenamente solo-
solo maam. Nesisita yo
ayuda di mama pti papa
pti unrato lang iyo ta
kansa.”
Ranks as the fourth
problem as it affects
patient’s safety which is
second among Maslow’s
Hierarchy of Needs.
Overcoming the problem
will help the patient avoid
occurrence of accidents
especially fall.

Objective Cues:
 fatigability
 weak-looking
 spends most of the
time sitting or lying
on the couch

5. Disturbed body image Subjective cues: Ranks fifth as it belongs to

related to absence of “Okay lang man kumigo Love and Belongingness
hair brought about by hinde anay entra aspect of Maslow’s
surgical wound. eskwela maam kay baka Hierarchy of Needs
wherein the patient must
tenta lang kumigo mio
have the feeling of
mga classmates kay belongingness and
kalbo iyo.” acceptance.
Objective Cues:
 Bald
 Always touching
head unconsciously
 Stays indoors most
of the time

6. Knowledge Deficit Subjective cues: Is the least among

related to unfamiliarity of “Ta tiene kame myedo prioritized problems since
disease condition. manda kunele kome pati fear of the unknown makes
ase kosa-kosa maam the client and significant
kay baka mas keda others anxious and
hesitant. Providing them
grande el disuyu tumor o with adequate knowledge
baka sapa el tahi na will allow better
kabesa o baka man participation in the
bleed adentro.” treatment. Thus,
complications will be
Objective Cues: prevented and quality of life
 Request for will be improved.
information
 Statement of
misconceptions