I.

Introduction

A surgery is one of the most stressful procedures a patient could undergo. There
are numerous types of surgeries, each one tailored to fit a certain purpose, may it be to
deliver a child ( i.e. cesarean section), remove a part ( i.e. craniectomy), to visualize and
gain access to a structure within ( i.e. craniotomy) or to repair a defect ( i.e. cranioplasty).

This is a case of Master Labrador, Ralph, 12 years old, who was admitted last
May 2, 2008 at Cebu Doctors’ University Hospital to undergo a cranioplasty. Two years
ago the patient sustained an epidural hematoma from motor-vehicular accident in Argao.
He was brought to Cebu Doctors’ University Hospital last February 26, 2006 and
underwent craniotomy and evacuation of epidural hematoma. He was advised to undergo
a cranioplasty six months after recovery but was only able to come back for compliance
due to financial reasons.

A cranioplasty is a surgical repair of a cranial defect. Cranial defects may result

from fractures, infections, surgical procedures ( cranial bone biopsy, craniotomy) or a
cranial deformity. Indications for the procedure include protection from external trauma,
alleviation of pain or seizures and cosmetics. The artificial cranium may be fashioned
from the autogenous bone grafts, metal ( e.g. tantalum) or acrylic material ( e.g.
methylmethacrylate). Methylmethacrylate is the preferred material for cranioplasty,
except in cases of wound infection, in which autogenous grafts are better accepted.

In cranioplasty, the scalp is incised over the defect. The defect may be trimmed as
necessary. Methylmethacrylate is mixed according to the manufacturer’s directions. The
surgeon then molds the material to fit the defect. Acrylic is removed from the
polyethylene bag and allowed to harden. Excess material may be trimmed with rongeurs
or power saw. A craniotome may be used to smooth the rough spots. Holes are drilled in
the periphery of the acrylic plate and the cranial defect. The plate is placed over the
defect and secured by the stainless steel wired passed through the holes and the wound is
irrigated and closed.

1
 This case study was chosen because of the challenge that it posed- it involves the
head and skull which contains the central processing unit of the body, a single mistake
could be fatal and could turn a life upside down if not end it.

At the end of this case study, the student nurse expects to expand her knowledge
regarding the surgical procedure known as cranioplasty, and refine her skills in caring for
a patient who has undergone the said surgical procedure.

2
II. Objectives

General Objectives:

After 3 days of student nurse-patient interaction, the student nurse will be able to
learn more about cranioplasty, effectively provide holistic caring care and inculcate
positive attitude while caring for a patient who has undergone the said procedure.

After 3 days of student nurse-patient interaction, the patient will be able to learn
more and cope with the surgical operation cranioplasty, avoid complications that may
arise post-operatively and incorporate lifestyle modifications until he returns to his
optimum level of functioning.

Specific objectives:

After 3 days of providing holistic caring care and facilitating student nurse-patient
interaction, the student nurse will be able to:
1. perform a thorough assessment of a school-age child in his present condition, and
discuss the physical, social and cognitive characteristics of a school-age child
2. identify the signs and symptoms presented by the patient in relation to the
causative factor of the condition
3. avoid complications which may arise from the surgical procedure
4. implement a comprehensive plan of care for the patient who has undergone
cranioplasty, and
5. evaluate the interventions provided in the given span of time for efficiency and
effectiveness.

After 3 days of receiving holistic care and participating in student nurse-patient

interaction, the patient and his significant others will be able to:
1. establish trust towards the student nurse

3
2. cooperate in procedures performed to the patient for the management and
treatment , such as medication administration and vital signs taking
3. manifest a decrease in the signs and symptoms associated with the surgical
procedure, such as pain
4. perform, with minimal assistance from the student nurse and significant others,
activities of daily living
5. terminate the therapeutic student nurse-patient interaction at the end of the given
span of time

4
III. Nursing Assessment
1. Personal History
1.1 Patient’s profile
Name: Ralph de los Reyes Labrador
Age: 12 years old
Sex: Male
Civil Status: Single
Religion: Roman Catholic
Date of admission: May 2, 2008
Room no.: 422
Complaints:
Diagnosis:
Physician: Dr. Milo Vergara

1.2 Family and Individual Information, Social and Health History

Master Labrador, Ralph, the eldest son of Mrs. Labrador, was admitted last
May 2, 2008 at 11:49am.
Two years prior to admission, patient sustained an epidural hematoma from a
motor-vehicular accident in Argao. He was in his grandparents; care back
then. He was riding his bicycle in the highway when a bus came speeding
towards his direction. He was admitted for the first time at Cebu Doctors’
University Hospital last February 26, 2006 and underwent evacuation of
hematoma and craniotomy. He was in comatose for three to four days but
regained consciousness and was stabilized and in good condition when
discharged.
Patient’s mother was advised to bring back her son six months after for a
cranioplasty but they were not able to comply due to financial constraints.
Few days prior to admission, they had raised enough money thus subsequent
admission.
Ralph is completely immunized. He had chickenpox at seven years old. He
has no maintenance medications and no vitamins. Family history reveals

5
 hypertension on the maternal and paternal sides and bronchial asthma on the
paternal side.
He has no food and drug allergies. He is asthmatic. Last asthma attack was
two years ago and was managed with ventolin syrup.

1.3 Level of Growth and Development

1.3.1 Normal Development
Physical Changes
Physiologically, the school-age years or middle years begin with the
shedding of the first deciduous tooth and end at puberty with the acquisition of the
final, permanent teeth ( with the exception of wisdom teeth). The period of middle
childhood is a time of gradual growth and development with more even progress
in both physical and emotional aspects.
School-age children’s annual average weight gain is approximately 3-5 lb.
(1.3-2.2 kg); the increase in height is 1-2 inches (2.5-5 cm). Children who did not
lose the lordosis and knock-kneed appearance of toddlers during the preschool
period lose these now. Posture becomes erect.
Their body proportions take on a slimmer look, with longer legs, varying
body proportion and a lower center of gravity. The most pronounced changes that
indicate increasing maturity in children are a decrease in head circumference in
relation to standing height, a decrease in waist circumference in relation to height
and an increase in leg length related to height. Facial proportions change as the
face grows faster in relation to the remainder of the cranium. The skull and brain
grow very slowly during this period and increase little in size.
Maturity of the gastrointestinal system is reflected in fewer stomach
upsets, better maintenance of blood glucose levels , and increased stomach
capacity, which permits retention of food for longer periods. Physical maturation
is evident in other body tissues and organs, as well. Bladder capacity is generally
greater in girls than in boys. The heart grows more slowly during the middle years
and is smaller in relation to the rest of the body than at any other period of life.
Heart and respiratory rates steadily decrease and blood pressure increases during

6
ages 6 to 12. Heart rate ranges from 70 to 80 beats per minute, respiratory rate 15
to 25 breaths cycles per minute, and an average blood pressure of 112/60 mmHg.
Psychocosial Development
Freud described middle childhood as the latency period, a time of
tranquility between the oedipal phase of early childhood and the eroticism of
adolescence. During this time, children experience relationships with same-sex
peers following the indifference of earlier years and preceding the heterosexual
fascination that occurs for most boys and girls in puberty.
According to Erickson, a sense of industry or a stage of accomplishment is
achieved somewhere between age 6 and adolescence. School-age children are
eager to develop skills and participate in meaningful and socially useful work.
Interests expand in the middle years, and with a growing sense of independence ,
children want to engage in tasks that can be carried through to completion.
Reinforcement in the form of grades, material rewards, additional privileges and
recognition provides encouragement and stimulation. Peer approval is a strong
motivating power.
The danger inherent in this period of development is the occurrence of
situations that might result in as sense of inferiority. When the reward structure is
based on evidence of mastery, children who are incapable of developing those
skills are at risk for feeling inadequate and inferior. No child is able to do
everything well, and children must learn that they will not be able to master every
skill they attempt.
Children need and want real achievement. When they have access to tasks
that need to be done, that they are able to do well despite individual differences in
their innate capacities and emotional development, and for which they are suitably
rewarded, children achieve a sense of industry.

Cognitive Development
When children enter the school years, they begin to acquire the ability to
relate a series of events to mental representations that can be expressed both
verbally and symbolically. This is the stage Piaget describes as concrete

7
operations, when children are able to use thought processes to experience events
and actions. The rigid, egocentric view of the preschool years is replaced by
mental processes that allow children to see things from another’s point of view.
During this stage, children develop an understanding of relationships
between things and ideas. They progress from making judgments based on what
they see to making judgments based on what they reason. They master the
concept of conversation, develop classification skills and their ability to read
becomes the most significant and valuable tool for independent inquiry.

Sexuality
Preadolescence is the period of approximately 2 years that begins at the
end of middle childhood and ends with the thirteenth birthday. Because puberty
signals the beginning of the development of secondary sex characteristics,
prepubescence typically occurs during preadolescence.
There’s no universal age at which children assume the characteristics of
prepubescence. The first physiologic signs appear at about 9 years of age and are
usually clearly evident in 11-12 years old children.
Boys experience little visible sexual maturation during preadolescence.
Pubic hair present across pubis, penis lengthens, breast enlargement occurs and
there’s dramatic linear growth spurt.

1.3.2 The Ill School-Age Child

One of the biggest problems facing a school-age child with an illness or
physical challenge is time lost from school. This threatens not only academic
achievement but also the child’s relationships with his or her peers. It may make
him or her the “odd person out” with respect to making friends or joining gangs.
Whether children are confined to home or hospitalized, helping them keep in
contact with friends can help foster socialization that is important for continued
development.

8
 In caring for a school-age child who is ill, choose short term activities that
can be completed independently. Be careful not to insult a child with tasks that are
obviously not age-appropriate.
Master Labrador, Ralph was admitted last May 2, 2008 with the following
vital signs: heart rate was 100 beats per minute, respiratory rate 25 breath cycles
per minute, temperature of 36.5 degress Celsius and blood pressure of 90/60
mmHg. Upon admission he weighed 28.3 kg. Primary assessment revealed a scar
at the right parieto-temporal area and on approximately 5-6 cm scar on the left
periumbilical region of the abdomen.
Patient was observed to be outgoing, cooperative and socially able to
relate to nurses and student nurses. He had questions and wasn’t shy about them.
Aside from his mother, he had his aunts to accompany him during the
whole length of hospital stay.

9
 2. Diagnostic Results
Complete Blood Count ( May 7, 2008)
Results Normal Values Significance
Hemoglobin 13.1 g/L 12-16 g/L normal
Hematocrit 39.5 % 36-45 % normal
WBC count 13.70 10^3/uL 4.5-13.0 10^3/uL normal
Neutrophil 45 % 25-70 % normal
Basophil 0 0-3 % normal
Eosinophil 7 0-8 % normal
Lymphocyte 47 20-65 % normal
Monocyte 1 0-9 % normal
Bands 0 0% normal
Atypical PNDG normal
lymphocyte
Blasts PNDG normal
Red Cell Count 4.9 10^6/uL 10^6/uL normal
MCV 80.5 78-102 fL normal
MCH 26.7 25-35 pg normal
MCHC 33 31-36 g/L normal
MPV 6.69 4.50-100 cL normal
RDW 14.1 0-100 % normal
Platelet 344 140-440 10^3/uL normal

Hematology ( May 7, 2008)

Blood type: O+ Results Normal Values Significance
Bleeding Time 5’22’’ 2.3-9.5 min. sec. normal
Clotting 12’13’’ 5-15 min.sec. normal

Prothrombin Time (May 7, 2008)

Results Normal Values Significance
Control 14.9 sec normal
PRO time 12.7 10-13 sec. normal
% activity 107.2 70-120 % normal
LNR 0.94 < 1.2 normal

CT Scan on Head ( May 7, 2008)

Impression:
1. S/P Right parietal craniotomy

10
 2. Focal encephalomalacic changes at the left frontal lobe. Please correlate
clinically.

3. Present Profile of Functional Health Pattern ( Pre-operative)

3.1 Health Perception

Ralph sees his present condition as good. He and his mother has no
worries regarding his current health status. His last asthma attack was two years ago and
they’re thankful it hasn’t recur since after the accident. He perceived complete
immunization and is not taking any vitamins.

11
 3.2 Nutritional- Metabolic Pattern
Patient eats three full meals of rice, fish and sometimes chicken and red meat. He eats
these during breakfast, lunch and dinner. He usually eats junkfood and drinks ice juice or
ice candy during snack time. He drinks up to 1.5 liters of water a day and rarely takes in
fruit juices, milk or coffee. He does not take any vitamins or food supplements. Upon
admission, his weight was 28.3 kg.

3.3 Elimination Pattern

Ralph does not have any problem in urinary elimination ( oliguria, polyuria, dysuria,
retention, etc.) as far as he could remember. He is able to urinate up to a maximum of
seven times a day, with around 60 mL of urine per voiding. He defecates brown, semi-
formed stool often every other day. He does not use laxatives nor diuretics.

3.4 Activity-Exercise Pattern

Patient plays table tennis at school. He has no difficulty performing activities of daily
living. He does not experience shortness of breath during playing. Upon pre-operative
assessment, his vital signs were: temperature of 36.5 degrees Celsius; pulse rate of 84
brats per minute; respiration of 20 breath cycles per minute and blood pressure of 90/60
mmHg.

3.5 Cognitive/Perceptual Pattern

Ralph speaks mostly in Cebuano. He knows Tagalog and claims to be proficient in
English. He is able to read and write. He has no hearing aids or eyeglasses; however he
reports that he cannot hear well with his right ear. He can sense heat, cold, sharpness, and
dullness. He can determine rough and smooth surfaces, as well as application of pressure
on all extremities.
Patient reports that since the accident, he has short-term memory lapses and there are
times that he has difficulty summoning the right word/name for an event/object.

3.6 Rest/Sleep Pattern

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Prior to hospitalization, the patient sleeps at around 8pm and wakes up at 7 am the next
day. He has no difficulty falling and staying asleep. Upon hospitalization, patient is able
to sleep at 9-9:30 pm, and sometimes 10 pm due to vital signs taking and other routine
procedures. His mother stated that the patient is unusually restless during the night and is
probably anxious about the upcoming procedure.He usually takes short nap at home,
usually after arriving from school.

3.7 Self-Perception Pattern

Ralph is well-adjusted. He stated that he is somewhat anxious for tomorrow’s surgery but
his mother has helped calm him down. He expressed his desire to go home and play with
his siblings

3.8 Role-Relationship Pattern

Ralph speaks well, with coherent thoughts, and facial expressions with gestures that are
appropriate. He lives with this mother in Argao and has two siblings, all boys and all
younger than him, His parents are separated. His mother stated that Ralph is hard-headed
and often, wants to go his own way.

3.9 Sexuality and Reproductive Pattern

Ralph is in the prepubescence period. He admits to having noticed growth of hair
under the axilla and pubic hair across the pubis but other than that he refuses to
divulge details.
3.10Coping-Stress Tolerance Pattern
Ralph plays basketball after school. Whenever he feels down, he watches television
or play with his brothers at home.

3.11Value-Belief System
Ralph is a Roman Catholic and is taught by his mother to pray and attend mass every
Sunday. He stated that he is thankful to God for not taking him two years ago. He
jokingly said that the accident may be a wake-up call for him to stop being hard-
headed and a burden to his mother.

13
4. Present Profile of Functional Health Pattern (Post-operative)
4.1 Health Perception
Ralph considers his present state of health as well but recuperating. He
and his mother both know that as long as he takes care of himself and follow the doctor’s
orders he will heal in time and prevent complications of the surgery.
4.2 Nutritional-Metabolic Pattern
The patient was to have diet as tolerated upon full awakening as ordered
by his doctor. He still eats the same meal at breakfast, lunch and dinner. He eats bread
and crackers for snacks. He drinks 1200- 1680 ml of water a day. He still does not take
any vitamins or food supplements. After the operation, his weight was slight decreased to
28 kg. He was prescribed Oxacillin 750 g IVTT every 6 hours, an antibiotic as
prophylactic management to prevent infection and Mefenamic acid 500 g 1 cap every 8
per orem for pain management.
4.3 Elimination Pattern
Ralph still does not have urinary elimination problems after the surgical
operation.He voids 5-6 times per day, with around 60 ml of urine per voiding. He
defecates brown, semi-formed stools every other say. He doe not use laxatives nor
diuretics.
4.4 Activity-Exercise Pattern
The patient does not do any strenuous physical activities, avoids leaning
over and straining too much for fear of post-operative complications. Upon return to the
ward, his vital signs are: temperature of 37 degrres Celsius, respiratory rate of 18 breaths
per minute, pulse rate of 85 beats per minute and blood pressure of 90/60 mmhg.
4.5 Cognitive-Perceptual Pattern
Patient was drowsy after the surgical operation but regained alertness after
several hours of sleep. No significant sensorineural changes have been noted. His
cognitive functioning is intact.
4.6 Rest-Sleep Pattern
No significant changes in sleep pattern has been noted post-operatively.
He tales interspersed naps in the morning and afternoon.

14
 4.7 Self-perception Pattern
Ralph is relieved now that the operation is over. He knows that if he
follows his medication regimen and stays in the hospital for a few days to recuperqate, he
will eventually heal and return to his usual level of functioning.
4.8 Role-relationship Pattern
Patient expressed his longing to be home and play with his brothers. His
hospital stay has started to bore him already.
4.9 Coping-stress tolerance Pattern
The patient has no other option left now to cope with stress except talking
with his mother and aunts and watching television.
4.10 Value-Belief system
Ralph prays fervently for healing. He expressed his gratitude to the Lord
for keeping him safe during and after surgery.

5. Pathophysiology and Rationale

5.1 Normal Anatomy and Physiology
Structure Protecting the Brain
The brain is contained in the rigid skull, which protects it from injury. The
major bones of the skull are the frontal, temporal, parietal and occipital bones. These
bones join at the suture lines.

15
 Figure 1. The Human Skull

The meninges, the fibrous connective tissues that cover the brain and spinal cord,
provide protection, support and nourishment to the brain and spinal cord. The layers of
the meninges are the dura, arachnoid and pia mater.
Dura mater- the outermost layer; covers the brain and the spinal cord. It is tough,
thick, inelastic, fibrous, and gray. There are four extensions of the dura: the falx cerebri,
which separates the two hemispheres in a longitudinal plane; the tentorium, which is an
unfolding of the dura that forms a tough, membranous shelf; the falx cerebelli, which is
between the two lateral lobes of the cerebellum; and the diaphragm sellae, which
provides a roof for the sella turcica. The tentorium supports the hemispheres and
separates them from the lower part of the brain. When excess pressure occurs in the
cranial cavity, brain tissue may be compressed against the tentorium or displaced
downward, a process called herniation. Between the dura mater and the skull in the
cranium, and between the periosteum and dura in the vertebral column, is the epidural
space, a potential space.
Arachnoid- the middle membrane; an extremely thin, delicate membrane that
closely resembles a spider web. It appears white because there is no blood supply. It
contains the choroids plexus which is responsible for the cebrospinal fluid production.
Subdural space is between the dura and arachnoid layer and subarachnoid space is
between the arachnoid and pia layers and contains the cerebrospinal fluid.
Pia mater- the innermost membrane; a thin, transparent layer that hugs the brain
closely and extends into every fold of the brain’s surface.

Figure 2.

16
5.2 Schematic Diagram

Predisposing Factor Precipitating Factor

Congenital anomalies Motor-vehicular accidents

Bone infection Craniotomy
Tumor in the head Craniectomy
Family history of brain cancer Cranial bone biopsy
Signs and Symptoms
stroke
Defect in the cranial bone as
shown in the CT scan; in the
patient’s case defect was on the
right pariental bone

Softness of the area of defect

upon palpation

Scar on the area of previous

17patient’s case,
surgery ; in the
scar on the right parietal area of
the scalp
 Surgical Medical Management Nursing Management
Management
Antibiotic therapy to Elevate head of bed 30 degrees
Cranioplasty to repair prevent infection
the cranial bone defect Encourage deep breathing
Analgesia for pain exercises
management
Promote cleanliness and
proper handwashing

Encourage increased fluid

intake

Teach divertional activities to

help manage pain

Optimum Level of Functioning

5.3 Cranioplasty secondary to a Craniotomy to Evacuate an Epidural Hematoma

A cranioplasty, as mentioned earlier, is a surgical repair of a defect of the cranium.
Cranial defects result from fractures, infections, surgical procedures or a congenital
deformity.
Ralph Labrador is a 12 year old child who had undergone craniotomy two years
ago to evacuate an epidural hematoma. He was supposed to come back 6 months after
a complete recovery from the previous surgical procedure but was not able to due top
financial constraints.
An epidural hematoma results from arterial bleeding into the space between the
dura and the inner table of the skull. It is often caused by a fracture o fthe temporal

18
bone, which houses the meningeal artery. Epidural hematomas may be characterized
by the presence of a “lucid interval” that lasts for minutes during which the client is
talking and walking. This follows a momentary unconsciousness that occurred within
minutes of injury. Following the lucid interval, the symptoms progress rapidly with
potential catastrophic intracranial pressure elevation and structural changes. An
epidural hematoma is a neurosurgical emergency.
Ralph Labrador obtained the epidural hematoma from a motor-vehicular accident
two years ago and he underwent craniotomy to evacuate the epidural hematoma and
save his life. Post surgery he was in coma for 4 days. He woke up the next day
confused . Two years post-surgery, he and his mother noticed a change in his
academic performance level and short-term memory lapses. He also has difficulty
hearing with his right ear and complains of having difficulty summoning the right
word for a certain event or object.
After a severe traumatic brain injury, the patient is always expected to exhibit
abnormalities secondary to the injury obtained. The previously mentioned deficits
exhibited by Ralph Labrador all belong to the temporal lobe’s function. The temporal
lobe is responsible for the complicated memory patterns and is the auditory center for
sound interpretation. It is also in this lobe that the Wernicke’s area for speech is
found. This association area plays a significant role in higher-level brain function. It
enables processing of words into coherent thought and recognition of the idea behind
written or printed languages.

19
 Cranioplasty was performed to repair the cranial defect on Ralph’s right parietal
bone, a defect obtained from the emergency surgical procedure performed on him two
years ago. This cranioplasty will help protect his brain from the traumatic injuries in
the future and reinforce the function of his skull.
Figure 3. Hematoma

20
5.4 Signs and Symptoms
Classical Signs Clinical Signs Rationale
Pre-operative Post-operative
Defect in the cranial Manifested; defect Not manifested The defect shown on
bone as shown in on right parietal the CT scan was a
the CT scan bone remnant of the
previous surgery the
patient may have
undergone.
-pg. 1050; Medical-
Surgical Nursing by
Ignatavicius
Scar on the area of Manifested; on right Manifested The defect shown on
previous surgery parietal area of scalp the CT scan was a
remnant of the
previous surgery the
patient may have
undergone.
-pg. 1050; Medical-

21
 Surgical Nursing by
Ignatavicius
Softness of the area Manifested; on right Not observable In craniotomy, a
of defect upon parietal area of scalp burr hole is made to
palpation serve as an opening
through which blood
or fluid may be
evacuated.
Cranioplasty is often
done after.
-pg. 367 Pocket
Guide to the
Operating Room by
Goldman

IV. Nursing Interventions

1. Care Guide for Patients who have undergone cranioplasty

Nutrition and Fluids

Clients should be assisted to take in at least 2,500 ml of fluids a day unless
conditions contraindicate this amount. Although there is no evidence that excessive doses
of vitamins or minerals enhance wound healing, adequate amounts are extremely
important. The nurse should ensure that clients receive sufficient protein, vitamins C,A,B,
B5 and Zinc.
Because an inadequate intake of calories, protein, vitamins and iron is believed to
be a risk factor for pressure ulcer development, nutritional supplements should be
considered for nutritionally compromised patients. Monitor weight regularly to help assess
nutritional status.

Preventing Infection

22
 There are two main aspects of controlling wound infection: preventing
microorganisms from entering the wound and preventing transmission of blood borne
pathogens to or from the client to others. Standard precautions include wearing of gloves
when touching blood and body fluids and when handling items soiled with blood or body
fluids; and washing thoroughly of hands after removing gloves.
Head dressing should be inspected each day post-operatively until it is removed on
the third post-operative day. Head dressings should not be disturbed for the first 24 hours
unless inordinate bleeding requires that they must. Health care professionals and significant
others should touch or change the dressing only when wearing sterile gloves and using
sterile instrument.

Positioning
The head of the bed is elevated 30 degrees to decrease intracranial pressure. To
promote healing, patient should be positioned to keep pressure off the wound. Patient
should be assisted to be as mobile as possible to enhance circulation. Deep breathing
exercises while sitting is also advised to prevent accumulation of respiratory secretions.

23
 Brunswick Lens Model Measures to:
A. Psychologic deficit:
Anxiety (Pre-operative) A. reduce Anxiety
-restlessness -acknowledged fear
-client reported increased feeling -encouraged patient to verbalize
of tension or as mother stated: feelings
Seen patient , “overexcitement” -spent some time with the patient 98 %
Mast. Ralph -client does foot shuffling -encouraged guided imagery resolu
Labrador,sittin -”kulbaan gamay” as verbalized -provided touch, massage -tion
g on bed by the patient Of
watching B improve Sleep Pattern Psychologi
B. Physiologic deficit: disturbed - clustered nursing activities c
sleep pattern - minimized fluid intake during
- client now sleeps late than his night time
usual bed time -restricted intake of caffeine-
-mother stated tat client is containing foods and fluids
unusually restless during the -supported continuation of
night probably due to anxiety patient’s bedtime rituals and physiologic
television without -client reported increased feeling problems
- encouraged patient to verbalize
IV. He is 12 years of tension or as mother stated: experienced by
feelings
old and is for “overexcitement” the patient
cranioplasty. C. improve knowledge on
C. Knowledge deficit cranioplasty
I.Anxiety:restlessness related to fear of
-patient frequently asks questions unknown outcomes of surgery -evaluated capabilities and
regarding the procedure II.Disturbed sleep pattern: sleeping later readiness to learn
-patient is only 12 years old than his bedtime related to fear of -reviewed information regarding
-none of the family members is unknown outcome of surgery injury process and after effects
in the medical field and none III. Knowledge deficit : frequent asking of -showed the patient a picture of
questions regarding the surgical procedure the skull and brain and explained
could give a simple explanation cranioplasty related to lack of
of what he is about to go through explanation from significant others in simple terms the surgical
procedure

Actual state cues Nursing Diagnoses Nursing Actions Desired Outcome

Objectives Goal
Of patient’s After 8 hrs. of student nurse –patient interaction,
condition the patient will be able to : After 3 days of student
1. demonstrate decrease in anxiety as evidenced by nurse-patient interaction,
decrease in restless ness patient will be able to attain
2.improve sleep pattern as shown by sleeping optimum level of
during his usual bedtime functioning
3.verbalize purpose of the procedure

24
 Brunswick Lens Model
(Post-operative) Measures to:

A.Physiologic Overload:Alteration in
Seen patient , comfort
Mast. Ralph -intermittetn pain on right parietal
Labrador,sittin area of head; pain started hours after
g on bed arriving from the OR;it is described
watching as mildly stinging, aggravated by
sudden head movement, relieved by
rest and treated with Mefenamic acid
1 cap q8h po
-patient rated pain as 5 in a pain scale
0f 0-10 wherein 0 stands for no pain
and 10 as most painful
television without
IV. He is 12 years
old and is for B.Risk for ineffective breathing
pattern
cranioplasty.
-patient has bronchial asthma and
has undergone surgery for hours
under general anesthesia
-respiratory rate 18 breaths per
minute
C.Risk for infestion
-patient is post-cranioplasty with
head dressing reinforced with
sterile pads
A. promote comfort
-positioned patient so that his
affected side will not receive much
pressure
-perforemded massage but not on
affected part
-encouraged deep breathing
exercises
-promoted rest 98 %
-administered medications per resolu
doctor’s order -tion
Of
B maintain respiratory function
-placed patient in a semi-prone position
-suctioned trachea
-elevated head of bedas prescribed
-administered nothing per orem until active physiologic
coughing and swallowing reflexes returned problems
experienced by
I.Alteration in comfort:pain related C. maintain vital signs within normal range
the patient
to disruption of tissue integrity -monitored site for signs of infection
secondary to surgical procedure -instructed patient to report presence of salty
II.Risk for ineffective breathing taste
pattern related to post-operative -instruceted patient to avoid coughing,
cerebral edema blowing nose
III.Risk for infection related to -used aseptic technique when handling
wound obtained during surgery dressings
-administered prophylaxis per doctor’s order

Actual state cues Nursing Diagnoses Nursing Actions Desired Outcome

After 8 hrs. of student nurse –patient interaction, the
Of patient’s patient will be able to :Objectives Goal
condition 1. demonstrate decrease in pain sensation as evidenced by a painAfter 3 days of student
scale rating as 1 in a pain scale of 0-10 nurse-patient interaction,
2.maintain adequate respi.function as evidenced by respi.rates in patient will be able to attain
normal levels optimum level of
3.exhibit absence of infection as evidenced by vital signs in
normal range functioning
25
Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008
Nursing Care Plan (pre-operative)
Needs/Problems Nursing Scientific Objectives of Nursing Actions Rationale
Cues Diagnosis Basis Care
A. Physiologic Anxiety: Anxiety or After 8 hours of Measures to:
deficit: restlessness fear of the student nurse-
I. Anxiety related to unknown is patient
-restlessness fear of real. interaction, the
-client reported unknown Feelings patient will be
increased feeling outcome of are real and able to:
of tension or as surgery changes in 1.demonstrate a 1. reduce anxiety
mother stated: vital signs decrease in
“overexcitement” may anxiety as a. acknowledge fear -It is helpful to bring out
-client does foot suggest the evidenced by a feelings so they can be
shuffling when the degree of a decrease in discussed and dealt
nurse and his patient’s restless ness with.-
mother talked to anxiety pg.745,NCPs,Doenges
him about the before a b.encourage patient to -It is helpful to bring out
upcoming surgery certain verbalize feelings feelings so they can be
procedure. discussed and dealt
It is helpful with-
To bring pg.745,NCPs,Marilyn
26
 out these c.spend some time Doenges
feelings out with the patient -continuous support may
in the open help patient regain
so they can internal locus of control-
be d.encourage guided pg.746,NCPs,Doenges
discussed imagery -promote release of
and dealt endorphins and reduce
with anxiety-
- pg. e. provide pg.745,NCPs,Doenges
745,NCPs, touch,massage -aids in meeting basic
Marilyn human need decreasing
Doenges sense of isolation-
pg.745,NCP,Doenges-
pg.745,NCPs,Doenges

Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
27
Room no. : 422 Sex: Male Date: May 8, 2008
Nursing Care Plan (pre-operative)
Needs/Problems Nursing Scientific Basis Objectives of Care Nursing Actions Rationale
Cues Diagnosis
B.Physiologic Disturbed The effect of the After 8 hours of Measures to:
deficit: sleep pattern: change in sleep student nurse-
sleeping later patterns in patient interaction,
II. Disturbed sleep than his children prior to the patient will be
pattern bedtime and after an able to:
related to fear elective surgery 2.improve sleep
of unknown has not been pattern as shown by
outcome of evaluated sleeping during his 2. improve sleep
surgery objectively. usual bedtime pattern
Sleep in hospital a. cluster nursing - to give client
may influence activities time to rest with
biological less disturbance-
processes related pg.744,NCPs,Do
to circadian enges
rhythm. It is b. minimize fluid - to prevent
reasonable to intake during night frequent urination
assume that time during the night
hospitalized when patient is
children have supposed to sleep
28
disturbed sleep pg.744,NCPs,Do
patterns prior to enges
and following c. restricted intake of - Caffeine
elective surgery. caffeine-containing lengthens the
We hypothesize foods and fluids time it takes to
that melatonin fall asleep,
will improve reducing your
sleep patterns total sleeping
prior to and time-pg.5; Get
following Z’s now;
surgery, by Geoffrey
reducing sleep Burchfield
latency and d.supported -Children need a
extending total continuation of familiar and
sleep time. We patient’s bedtime pleasant routine
also hypothesize rituals and these are
that this bedtime rituals
improvement which can help
will have children sleep on
positive impact time- pg.37; Get
on anesthetic Z’s now;
stress measures Geoffrey
and on recovery. Burchfield
29
 e. - encouraged - The source of
-pg.50,Beyond
patient to verbalize uneasiness or
the Relaxation
feelings anxiety, which is
Response by
often a cause of
Herbert Benzon
sleep disturbance,
is not always
known or
recognized. It is
helpful to bring
out feelings so
they can be
discussed and
dealt with.-
pg.745,NCPs,Do
enges

Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008
Nursing Care Plan (pre-operative)

30
Needs/Problems Nursing Scientific Basis Objectives of Care Nursing Actions Rationale
Cues Diagnosis
C.Knowledge Knowledge An anxious After 8 hours of Measures to:
deficit: deficit: patient could use student nurse-
frequent some emotional patient interaction,
asking of support and an the patient will be
-patient frequently questions explanation of able to:
asks questions regarding the what he is about 3.verbalize in his
about the procedure surgical to go through. own level of
-patient is only 12 procedure They need a understanding the 2. improve -permits
years old related to lack simple purpose and knowledge on presentation of
-none of the family of simple explanation, prognosis of the cranioplasty material based on
members is in the explanation appropriate for procedure he is a. evaluate individual needs
medical field and from their level in about to undergo capabilities and pg.225,NCPs,Doe
none could give a significant order to alleviate readiness to learn nges
simple explaination others their anxiety.- -aids in
of what he is about pg.50,Beyond the establishing
to go through Relaxation realistic
Response by b. review information expectations and
Herbert Benzon regarding injury promotes
process and after understanding of
effects current situation
and nedds-
31
 pg225,NCPs,Doe
nges
c. show the patient a -provides a visual
picture of the skull stimuli for
and the brain and learning-
explain in simple pg.225,NCPs,Doe
terms the surgical nges
procedure

atient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008
Nursing Care Plan (post-operative)

32
Needs/Problems Nursing Scientific Basis Objectives of Care Nursing Actions Rationale
Cues Diagnosis
Physiologic I.Alteration in Naked nerve After 8 hours of Measures to:
overload: comfort:pain endings found in student nurse-
I.Alteration in related to the tissue are patient interaction,
comfort disruption of called pain the patient will be
tissue receptors.Once able to:
intermittetn pain on integrity an injury/break 1.demonstrate 1. promote comfort
right parietal area secondary to in the skin decrease in pain
of head; pain surgical occurs, they send sensation as a. position patient so -to avoid
started hours after procedure nerve impulses evidenced by a pain that his affected side stimulation of the
arriving from the and chemicals to scale rating as 1 in will not receive much nerve triggering
OR;it is described the brain a pain scale of 0-10 pressure pain sensation-
as mildly stinging, indicating the pg.368,NPG,Doe
aggravated by presence of pain nges
sudden head b. perform -serves as a
-pg.210,
movement, relieved massage but not on distraction
Essentials of
by rest and treated affected part technique-
human anatomy
with Mefenamic pg.315-316,MCN
and physiology
acid 1 cap q8h po by Adelle
by Elaine Marieb
-patient rated pain Pelliteri
as 5 in a pain scale c.promote adequate -rest promotes
0f 0-10 wherein 0 rest healing and
33
 stands for no pain growth-
and 10 as most pg.211,NCPs,
painful Doenges
-alleviates pain-
pg.212;NCPs;Do
enges
e. administer -alleviates pain-
medications per pg.212;NCPs;
doctor’s order Doenges

Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008
Nursing Care Plan (post-operative)

34
Needs/Problems Nursing Scientific Basis Objectives of Care Nursing Actions Rationale
Cues Diagnosis
II.Risk for Risk for After surgery the 2. maintain 2.maintain
ineffective ineffective frequency of adequate respiratory function
breathing pattern breathing post-operative respiratory function
pattern related complications as evidenced by a a. place patient in a -the position
-patient has to post- monitoring is respiratory rate at semi-prone/ lateral facilitates
bronchial asthma anesthesia based on the normal range position respiratory gas
and has undergone complications patient’s clinical exchange-
surgery for hours status. Causes of pg.2184;
under a general anesthesia- med.surg;
anesthesia related death are
-respiratory rate of usually linked to b. suction trachea and Brunner and
18 breath cycles per the respiratory pharynx Suddarth
minute system. These -removes
include secretions
insufficient pg.2184;
intubation or med.surg;
proper Brunner &
ventilation which Suddarth
results in
hypoxia, which c. elevate head of bed -provides
is a deficiency of 20-30 degrees as adequate lung
35
oxygen reaching prescribed and expansion
the tissues of the promote purse-lip pg.2184;
body. breathing exercises med.surg;
Complications Brunner &
are mostly Suddarth
related to
General d. administer nothing -prevents
Gaseous-state by mouth until active aspiration
anesthesia and coughing and -page 2154; Med
may include swallowing reflexes Surg; Brunner &
laryngospasm, are demonstrated Suddarth
bronchospasm,
aspiration,
intubation injury,
pulmonary
edema,
respiratory arrest

.-pp. 378-
381,Stoelting,
R.K,
Pharmacology &
Physiology in
36
 Anesthetic
Practice

Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008
Nursing Care Plan (post-operative)
37
Needs/Problems Nursing Scientific Basis Objectives of Care Nursing Actions Rationale
Cues Diagnosis
III.Risk for Risk for The patient 3. exhibit absence 3. maintain vital
infection infection undergoing of infection as signs within the
related to neurosurgery is evidenced by vital normal range
-patient is post- wound at risk for signs within the
cranioplasty with obtained infection related normal range a. monitor site for -these signs
head dressing during to brain redness, tenderness, indicate infection
reinforced with surgery exposure, bone bulging, separation, at the site-
sterile pads exposure and foul odor med.surg;
presence of IV Brunner
lines for fluid
administration. b. instruct patient to -this can be
Risk is increased report presence of caused by CSF
for those who post-nasal drip or leaking down the
undergo lengthy salty taste throat
intracranial pg.2188;
procedures.-page med.surg;
2187; Med.Surg. Brunner &
Ng.; Brunner and Suddarth
Suddarth c. instruct patient to -can cause CSF
avoid coughing, leakage by
sneezing or blowing creating pressure
38
 nose on operative site
pg.2188;
med.surg;
Brunner &
Suddarth
d. use aseptic -prevent
technique when contamination
handling dressings and infection
-page 2188; Med
Surg; Brunner &
Suddarth
e. administer -prevent
prophylaxis per infection--page
doctor’s order 2188; Med Surg;
Brunner &
Suddarth

Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008

Drug Therapeutic Record

Drug / Dose Classification / Indications / Principle of Care Treatment Evaluation

39
 / Frequency Contraindications
Mechanism
/ Route / Side-effects
Mefenamic Classification: Indications: 1. Advise patient 1. Keep a record and The patient was
acid 500 g 1 - nonsteroidal anti- - mild to moderate and significant monitor frequency, able to verbalize a
cap every 8 inflammatory drugs pain others that drug is location, duration, decrease in pain
per orem ;analgesic only for short term character, onset and sensation on a pain
Mechanism:- Mefenamic Contraindications: use and may intensity of pain. scale of 0-10, with
acid binds the - hypersensitivity aggravate condition 2 Perform back 0 as “no pain” and
prostaglandin synthetase to the drug if use is prolonged. massage, and not on the 10 as “most
receptors COX-1 and 2. Tell patient to injured site. painful,” from 5,
COX-2, inhibiting the Side-effects: take drug as 3. Perform deep “moderate pain” to
action of prostaglandin CNS: dizziness, prescribed and not breathing exercises. 3, “tolerable pain.”
synthetase. As these vertigo, headache, to increase dose or 4. Provide adequate rest.
receptors have a role as a somnolence dosage interval 5. Provide distractions
major mediator of Gastrointestinal: unless ordered. to take patient's mind off
inflammation and/or a nausea, vomiting 3. Advise the the pain.
role for prostanoid Genitourinary: patient to inform 6. Discourage
signaling in activity- urinary retention, the prescriber if constrictive clothing.
dependent plasticity, the urinary frequency taking OTC drugs
symptoms of pain are Respiratory: since interactions
temporarily reduced. respiratory may occur.
depression
Source: pp. 405-406; Nursing Drug Handbook 2006, 26th Edition; Lippincott, Williams and Wilkins

Oxacillin 750 g Classification: Indications: 1. Check for 1. Monitor vital No evidence of

IVTT every 6 hours - anti-infective - treatment and allergies to the drug. signs. suppuration on
narrow spectrum prophylaxis for 2. If large doses are 2. Tell patient to superficial
beta-lactam infections of the given, therapy is take the entire wounds. The
antibiotic of the respiratory tract, prolonged, or patient quantity prescribed patient has
40
 penicillin class. EENT, skin, soft is at high risk, even if he feels manifested a
tissue, GIT, biliary, monitor for signs and “better.” normal
Mechanism: abdominal bone and symptoms of super 3. Encourage bed temperature
- inhibits cell wall joints, UTI infection. rest. 36.8 degrees
synthesis, promoting 3. Tell patient not to 4. Advise patient to celsius; skin is
cell wall / osmotic Contraindications: confuse drug with take a well-balanced warm to touch,
instability; usually - hypersensitivity to other penicillins that diet. noted with
bactericidal penicillins, lactation, sound alike. 5. Promote proper sweating, with
renal insufficiency 4. Instruct patient to hand washing, no flushing
report discomfort at hygiene, and and no chills.
Side-effects: IV insertion site. environmental
Central Nervous 5. Advise patient to sanitation.
System: headache, notify prescriber
dizziness about loose stools or
Cardiovascular: diarrhea.
phlebitis
Gastrointestinal:
pseudomembranous
colitis, nausea,
vomiting, diarrhea,
abdominal cramps
Source: pg. 168; MIMS, 108 Edition and pp. 105-107; Nursing Drug Handbook 2005, 25th Edition; Lippincott, Williams and Wilkins
th

41
Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008

SOAPIE No. 1

S- “Kulbaan gamay,” as verbalized by the patient

O- client does foot shuffling when the nurse and his mother talkied to him about the
procedure; client is restless

A- Anxiety: restlessness related to fear of unknown outcome of surgery

P- to reduce anxiety

I- acknowledged fear; encouraged patient to verbalize feelings ; spent time with the
patient; encouraged guided imagery; provided touch, massage

E- “Mahadlok ko okay wala akong mama ana gud. Dili siya makasud kuyog nako ingon
ang nurse ganina,” as verbalized by the patient

42
Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008

SOAPIE No. 2

S- “5 ang kasakit,” as verbalized by the patient referring to the pain scale 0-10 wherein 0
stands for “no pain” and 10 for “most painful”

O- client tries to move slowly; client barely moves/ turns head

A- Alteration in comfort: acute pain related to disruption of skin, tissue, muscle and
blood vessel integrity secondary to the surgical procedure

P- to promote comfort

I- positioned patient so that affected side will not receive much pressure; performed
massage but not on affected side; encouraged deep breathing exercises; promoted
adequate rest; administered medication per doctor’s order

E- “Din a kayo sakit. 1 na,” as verbalized by the patient referring to the pain scale 0-10
wherein 0 stands for “no pain” and 10 for “most painful”

43
 Patient’s name: Ralph Labrador Age: 12 years old Physician: Dr.Vergara Nilo
Room no. : 422 Sex: Male Date: May 8, 2008

Play Therapy

Developmental Change Type of Play Objective of play Implemental Play Evaluation

School age (6-12 years) Competitive After 15-20 “Questions and Patient was able
-the period in which the quiet games minutes of Ladder” to follow the rules
child’s body proportions and activities student nurse- of the game. He
take on a slimmer look, -although patient Materials needed: was able to
with longer legs, varying play at this interaction, the -a snake ladder answer the
body proportion and a stage is patient will be board student nurse’s
lower center of gravity. highly active, able to: -2 chips with review questions.
Freud described this school-age different colors He lost the game
period as a time of children also 1. follow the rules -cards containing but he stated that
tranquility between the enjoy quiet of the game different he enjoyed it just
Oedipal phase of early solitary 2. demonstrate his questions like the way he
childhood and eroticism games or reading skills and Mechanics of the enjoyed the
of adolescence. During games they sportsmanship game: original snake and
this time children can play with 3. learn more 1. student nurse ladder game.
experience relationships their best about cranioplasty will serve as the
with same sex peers buds. School through the patient’s playmate
following the age children student nurse 2. each of them
indifference of earlier become 4. express how he will have a chip
years and preceding the fascinated feels towards the that’ll represent
heterosexual fascination with complex upcoming surgery them on the s & L
that occurs for most board, card or board
boys and girls in computer 3. the patient gets
puberty.-pg.356-380; games. to choose
Fundamentals of Adherence to questions from
Nursing; Barbara Kozier the rule is cards that he can

44
 fanatic.- pg. ask the SN;
Psychosocial task: 479; Wong’s questions vary
industry vs. inferiority pediatric from personal to
Nursing by inquiries about
Industry- or stage of Hocken berry the surgery
accomplishment; they 4. the SN gets to
are eager to develop question patient
skills and participate in as a review if the
meaningful and socially patient listened to
useful work; they the SN’s answers
acquire a sense of 5. success in
personal and anwering
interpersonal advances the chip
competence to the next level ;
Inferiority-when the failure will lead to
reward structure is based falling from the
on evidence of mastery, ladder
children who are
incapable of developing
skills are at risk for
feeling inadequate; they
must learn that they will
not be able to master
every skill they attempt.

V. Evaluation and Recommendation

45
 Healthy children and adults often heal and recover more quickly than older people

who are more likely to have chronic diseases that hidner healing. Emotional support from

significant others has also proved to be helpful in shortening recovery time for the patient.

Being a 12 year-old, without any significant medical condition that could possibly hinder

healing and with a supportive mother and aunts, the patient has a better prognosis.

Up to this point, the best recommendation in this case would be to encourage the

patient and his significant others to follow all the doctor’s orders and take in the prescribed

medications for an appropriate menght of time. Regarding the deficits manifested by the

patient after the accident, the significant other is advised to show more patience in dealing

with Ralph and if possible, forewarn the teacher of his difficulty in hearing with his right ear

and short memory lapses because these may have been affecting his academic performance in

school.

46
VI. Evaluation and Implication of the Case Study to:

Nursing Practice

This case study nurtures the student nurse’s ability to integrate knowledge, attitude
and skills taught in the classroom, into the actual clinical set-up. It provides the student nurse
a comprehensive view about the field of medical diseases and their surgical intervention and
broadens knowledge in giving holistic care to the patient. It benefits not only the patient and
significant others but the student nurse as well.

Nursing Education
This case study is as vital as classroom teaching as a clinical exposure in nursing
education as it broadens the student nurse’s knowledge even more. It is an additional force in
promoting nursing education as it better helps the nurse understand the disease condition and
updates one’s knowledge about the management of the disease .

Nursing Research
This case study enhances the student nurse’s research ability as one strives to have a
comprehensive and thorough investigation about the case. The student nurse utilizes the
maximum resources available and is able to use them effectively in making good and
comprehensive research. This case study can be used as a source for further researches.

VII. Bibliography

47
Brunner and Suddarth; Medical-Surgical Nursing; 10th edition; JB. Lippincott Company,2008

Doenges,Moorehouse, et al; Nurse’s Pocket Guide: Diagnosis, Intervention and Rationale; 9th

edition; FA Davis Company, 2004

Doenges,Moorehouse, et al; Nursing Care Plans: Guidelines for individualizing patient care;

FA Davis Company, 2004

Grolier Incorporated; Grolier Encyclopedia of Knowledge; Academic American

Encyclopedia, 1998

Hockenberry, Marilyn J., et al; Wong’s Essential of Pediatric Nursing; 7th edition; Mosby Inc.

2005

Kozier, Barbara, et al; Fundamentals of Nursing; 7th edition; Pearson Education, Inc, 2004

Marieb, Elaine N.; Essentials of Human Anatomy and Physiology; 7th edition; Pearson

Education, Inc, 2003

Smeltzer, Suzanne C., et al; Medical-Surgical Nursing; 10th edition; JB Lippincott Company,

2004

48
49
50