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Alyssa WolfMarch 26, 2011Clinical Log 1Total Hours: 16Clinical Log 1Assessment/InterviewH&PPatient EB is a sixty one year old Caucasian female admitted to the University of Virginia for a scheduled right craniotomy and re-resection of the sphenoid wing Dural based mass. She has a history of a craniotomy for a resection of a WHO grade I meningioma in April 2008. It was noted at that time that the tumor had a high K167. She has had Gama Knife radiosurgery three times. She had it in January, March and November of 2009, which resulted in significant improvement in her meningiomas on the left side. The patient’s large right-sided sphenoid tumor however extended from her petrous ridge anteriorly to her orbit. There were three more discrete areas of recurrence, which have grown significantly over the past several months. In an MRI taken on 02/24/2011 findings showed that there were multiple enhancing meningiomas including three along the right inferior frontotemporal region. The most anterior meningioma was located just above the orbital roof and measure approximately 4.1x2.5x1.5 cm. Slightly more posterolaterally there was a 3.1x2.3x2.9 cm meningioma. The most posterior meningioma along the right temporal bone measures 4.6x2.0x1.9 cm. All three of these meningiomas have increased in size since November 2010. T2/FLAIR signal abnormalities in the right frontal and temporal lobes. The ventricles were normal in size and position and there was no evidence of acute or chronic infarct, intracranial hemorrhage or extra axial fluid collection. On 3/24/2011 she had at head CT with and without contrast before her surgery. There was edema and hemorrhage surrounding the temporal and frontal lobes at the resection sites. There was a small extra-axial fluid collection and gas underlying the craniotomy site. There was no evidence of midline shift or significant mass effect. Encephalomalacia in the right temporal pole and ex vacuo dilatation of the temporal horn of the right later ventricle were unchanged. Her main symptoms included intermittent headaches and chronic fatigue. EB is recovering from her craniotomy in the Neuro Intensive Care Unit. Psycho- Social HistoryThe patient is currently post-op day one from her craniotomy. She is a full code patient. Her husband is the advanced directive. EB is from West Virginia and lives with her husband in a one story home, which will be conducive to her recovery when she is discharged. She has no children. Her friends, sister and husband have been by the bedside throughout the day. She has no history of alcohol or illicit drug use and is not a cigarette smoker. AllergiesSertralineNeomycin- bacitracin-polymyxinCephalexinPast Medical HistoryHypertensionSeasonal allergic rhinitisAnxietySeizureMeningioma resection in 2008Past Surgical HistoryBrain Surgery of the Right SphenoidBrain Surgery: Gamma knifeAppendectomyCesarean sectionTubal LigationHome Medications1) Phenytoin, metoprolol, Xanax, Loratidine, HCTZCurrent StatusShift AssessmentPain Assessment- Once per shift, unless the patient is taking any pain medicationsThe patient is currently having pain. Pain is 4 of 10 on the UVA Pain Scale. It is chronic pain on the right lower quadrant on the back of her head. The patient was satisfied with her level of comfort, but we suggested she take a pain pill to prophylax for increasing post surgical pain. The patient is able to perform expected functional activity. She is on PRN analgesia.Neurological/HEENT: Neuro checks q2h. The pt was Alert and Oriented to person, place, and age/date. Movement was purposeful to pain. Pupils were equal, round and reactive to light. R& L pupils were 3. Impaired visions: diplopia from previous brain surgery. Poor dentition. Cranial nerves intact. RUE and RLE were a 4= against gravity in strength and movement was purposeful to pain. LUE and LLE were a 4 and movement was purposeful to pain. Absence of confusion. No mental status changes. Eyes clear, moist and free of edema or discharge. Oral mucosa moist, pink, intact. GCS= 15Respiratory: Breath sound clear and equal to all lung fields. Respirations are spontaneous, unlabored and chest excursion is symmetrical. Absence of cough or pain with inspiration. On room air, no oxygen. CV/PVS: Presence of S1, S2 without murmur or rub. Skin is warm and dry with brisk capillary refill. Absence of chest pain and peripheral edema, all pulses palpable. dorsalis pedal pulse weak. SCD’s on. ABD/Anus/Rectum: Abdomen soft and non-tender, bowel sounds present and normoactive in all four quadrants. Patient was nauseas. Last BM 3/36/2011. Integumentary: Skin is dry, intact and even tone. Pt is pale. Normal turgor and free of any lesions, bruising, or abrasionsWounds, lines drains: Right peripheral IV in the forearm with an 18 gauge needle with Sodium Chloride 0.9% 1,000 ml with potassium chloride 20 Meq infusion. Left lateral antecubital 18 gauge: removed 3/26/2011Closed/Suction Drain right scalp accordionLeft radial arterial line: removed 3/26/2011Foley Catheter: removed 3/26/2011All lines were Clean, Dry, intact and in date.Musculoskeletal/Mobility: Minimal assist. Pt able to ambulate with minimal assistance. ROM symmetrical in all extremities. Unsteady gate, GU: Foley Catheter, urine yellowPsychosocial: Pt was calm and cooperative. Braden Scale: 16Morse Fall Risk: 40Safety Needs: Correct ID band, side rails up, IV site check, call bell within reach, emergency equipment by bed.VS q2h remained stable throughout the shift.BP: 117/46 HR 96 RR 22 MAP 67 Temp 37Art line: BP 134/44 MAP 76Weight: 56.7 kg Total Intake: 1,086.3 Total Output: 1,018Functional Health PatternsFunctional Health PatternPattern DescribesHealth Perception/Health ManagementThe patient is compliant with her medication regimen at home. Pt. noticed a difference in the type of dilantin she was taking in the hospital compared to the medication she was taking at home. Pt wanted to know information about the medication she was receiving. EB has annual check ups and has had to attend multiple appointments for her previous surgeries.Nutritional/Metabolic Height and weight are appropriate. Skin, hair, nails intact Good nutritional intake when not in the hospital. Pt. was having trouble eating food due to nausea post surgery.Elimination Pt had a small BM in the morning. Foley Catheter was removed in the morning and patient was able to use the toilet by herself. Her I&O match, adequate UOP. Urine was yellow. Unable to assess stool color and character.Activity- ExercisePt enjoys snowboarding and lives close to a resort. Pt in the hospital has been out of bed, and walks to and from the bathroom. She is eager to try walking around the unit.Cognitive- PerceptualPt has diplopia. She has had this since her last brain surgery. She has no other sensory, hearing or taste problems. She received medication for her pain.Sleep-RestThe pt had been sleeping on and off throughout the day. She slept well throughout the night. The pt. felt well restedSelf Perception/ConceptPt. did not speak about herself very much. She was very quiet and calm. Pt wanted to be left alone to rest.Role RelationshipsPt. has a close connection with her friends and family. She was awake and alert when they were around. The pts husband sleeps in the room in a chair with her overnight.Sexuality- ReproductivePatient is sexually active with her husband. No childrenCoping/Stress ToleranceThe pt did not seem agitated or stressed. Pt has been through a similar procedure before, so her previous coping mechanisms seem to be adequately working for her.Value- BeliefUnable to assessStandard Assessment ToolsBraden Scale- It is a tool used to help nursing staff identify individuals who may be at risk for developing decubitus ulcers. The scale evaluates patients in the following areas: sensory, perception, skin moisture, activity level and shear and friction activities, and the patient’s ability to change positions. A numerical score is assigned to the patient. It the score is less than 19 than a care plan should be initiated to prevent this risk. The lower the Braden score the higher the risk for a pressure ulcer.Morse Fall Risk- Assesses patients risk factors for falls upon admission, fall, change in mental status or discharge or transferring to a new setting. A score is created based on an assessment of a history of falling, secondary diagnosis, use of ambulatory aids, IV/heparin lock, mental status and gait/transfer. A score greater than 45 places a patient on fall precautions. The higher the score is the greater the risk for falls. Glasgow Coma Scale- It is a neurological scale that records the level of consciousness of a patient. There are three tests that the scale uses; eye, verbal and motor responses. A minor brain injury is a GCS greater than 13. A moderate injury is a GCS between 9 and 12 and a severe injury is a GCS less than 8. EB had a GCS of 15 throughout the day. DiagnosisRight Pterional Craniotomy for resection of multiple meningiomasMeningiomas are the most common type of brain tumors and account for about one third of all brain tumors. They are typically more common in females with a 3:1 ratio. There are a multitude of risk factors for developing these type of brain tumors; ionizing radiation, tinea capitis, dental x-rays, atomic bomb survivors and radiation therapy for malignancies (Park & Black, 2010). Hormones have been suggested as playing a role in the development of meningiomas. Head injuries have been shown to increase the risk for meningiomas. Meningiomas are most commonly seen near the dura mater by the falx cerebir, tentorium cerebelli and dura adjaced to the venous sinuses (Park & Black, 2010). People become symptomatic based on the size and location of the tumor. Patients may have seizures, visual changes, optic atrophy, papilledema, unilateral visual loss, mild weakness of extraocular movements, hearing loss, mental status changes, bilateral leg weakness, ipsilateral arm, obstructive hydrocephalus and spontaneous hemorrhage. Many people are asymptomatic and discovery of the tumor is only made incidentally. The Worth Health Organization (WHO) classifies meningiomas. Patient EB had a WHO grade I meningioma. WHO grade I is a benign meningioma, which accounts for about 90% of all meningiomas (Park& Black, 2010). “ Histologically, expression of vimentin is common, while expression of glial fibrillary acidic protein and anti-leu- 7 expression are not. Fatty degeneration, hemorrhage, calcification and cyst formation can occur” (Park & Black, 2010). Two genes have been implicated in meningioma formation; NF2 and DAL-1. “ the product of the NF2 gene is a membrane cytoskeletal protein called merlin. Merlin is thought to act as a tumor suppressor gene, the absence of which promotes cell growth” (Park & Black, 2010). DAL1 is seen in about 60% of sporadic meningiomas. Brain tumors form from the activation of oncogenes and inactivation of tumor suppressor genes. In order to diagnose a meningioma, an MRI or CT scan needs to be performed. MRI is the preferred method of for diagnosis. On MRI the meningiomas show up as a “marginal dural thickening that tapers” and on a CT the meningioma is usually well defined. The tumors are smooth in contour. Treatment is a resection of the tumor if the tumor is in an accessible location. Resection of the tumor can be combined with radiation. Surgery is performed on patients who are symptomatic or whose tumors are expanding. Lab/Rationales for AbnormalitiesCO2: 19 Dehydration, hyperventilationGLU: 174 High because of steroid therapyCalcium: 8.1 Low, inadequate nutrition because of surgery, prolonged IV fluid therapyALKPHOS: 191 High, bone healing due to craniotomyWBC: 19.44 High May indicate an infection from surgeryHgb: 10.4 Low as a result of bleeding from surgery and drainage from resectionHct: 31.8 Low due to recent bleeding from surgery and drainage from resectionComplications resulting from tumor resectionPostoperative neurologic deficitsSeizuresCerebral EdemaDeep Venous ThrombosisPulmonary EmbolismPneumoniaMyocardial InfarctionArrhythmiasOutcomes/PlanningMedical plan/GoalsThe medical plan for this patient is to DC the hemovac, neuro checks every hour, VS every 2 hours, I&O q2h, reposition q2h, transfer her to the NIMU, maintain a systolic blood pressure under 160, have PT and OT consultations, taper the dexamethasone, start patient on famotidine for GI prophylaxis, labs drawn once daily, vancomycin while the drain is in place, DVT prophylaxis with SCDs and SubQ heparin and maintain HOB greater than 30 degrees. The patient should also be assisted with “pulmonary toilet”. Goals for her day of care were to remove her foley catheter and A-line, advance diet as tolerated and get the patient out of bed. As soon as my preceptor and I saw the patient in the morning, we let her know our goals for the day of treatment. I started off the morning removing her arterial line and performing a shift assessment. After finishing her assessment, I removed the patients Foley catheter and helped move the patient into the chair. Patients post op day one from a craniotomy are supposed to get out of bed and walk around with the help of a nurse to prevent blood clots or pneumonia. Walking helps promote recovery and relieve muscle stiffness. The patient wore SCD’s to prevent phlebitis. We provided the patient with a calm environment so that she could relax. Neurological checks were performed every hour to make sure there were no complications or changes in level of consciousness. The patient was to practice deep breathing to maintain lung expansion. The patient was given breakfast and lunch trays to try and advance her diet from clear liquids to regular food to improve her recovery. The patient’s vital signs were checked every two hours to monitor for any arrhythmias. The patient was given a multitude of medications to aid in her recovery and prevent complications. She was given Phenytoin (Dilantin) two times daily to prevent postoperative seizures. This medication decreased abnormal electrical signaling in the brain. The patient was given dexamethasone, a corticosteroid, to reduce inflammation from surgery. To prevent blood clots, the patient received a heparin injection. She was given metoprolol to control her high blood pressure. Vancomycin was given prophylactically to help prevent infection from the drain that was placed during surgery. The patient took zofram to control nausea related to the surgery and a Vicodin to control her pain levels. ImplementationPatient EB’s care followed the standard protocol according to current literature about the management of this disease process. She had all the diagnostic procedures performed to diagnose her disease and her craniotomy followed the standard procedure. It is important to teach the patient and the family to be actively involved in care. It is necessary that the patient understands and demonstrates adequate pain control. Many patients wait until their pain is unbearable to report pain and ask for medication. It becomes very difficult to decrease the pain levels when patients wait until the pain is excruciating. The patient should be taught how to maintain or improve motor, sensory, cognitive, pulmonary and hemodynamic functions. The patient will learn to meet ADL’s by herself or with the help from others. The patient needs to be taught how to maintain skin integrity, by changing positions and not putting too much pressure in one area. The patient needs to learn what signs and symptoms to report as well as incision care and medication administration. Upon leaving the hospital, the patient should get plenty of rest and should exercise in moderate amounts. The patient should not drive until the doctor permits and she should not lift anything over 10 pounds.General EvaluationI think the patients overall medical and nursing plans of care are excellent. The medical team implemented precautions to prevent any possible complications. They provided medications to prevent seizures, hypertension, blood clots and infections. I helped make sure that the patient did not have any other complications by taking VS q2h, performing neuro checks q2h and repositioning the patient q2h to prevent any pressure ulcers. The patient was given SCD’s to prevent DVT’s. The average cost of stay for a craniotomy patient is $12,701 and the average length of stay is five days. In a study Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis, the article stated that patients without complications admitted to the ICU tended to have a longer length of hospital stay and did not benefit more than patients who went straight to the NIMU. The average length of stay for patients admitted to the NIMU was three days as compared to those admitted to the ICU who stayed for 6. Being transferred straight to the NIMU saved an average of $8,000 (Beauregard & Friedman, 2003). This study is ongoing, but I think it would be interesting to learn whether or not it is absolutely necessary to send a postoperative craniotomy to the ICU. Legal Concern ExperiencedPatient EB was alert and oriented throughout the day with no changes in her level of consciousness. Her husband had been signing all of her consents for her. I thought that this was strange that her husband would be consenting for her procedures if she is capable of signing the consents herself. Clinical LeadershipI think the entire unit showed clinical leadership, especially my preceptor. Every morning at 0700 there is a meeting with the charge nurse and the rest of the nursing and PCA staff for the day. The charge nurse goes over all of the patients and the major concerns for each. Then everyone chooses which patients that they would like to have. I really enjoyed participating in these morning meetings. I think it’s a great time for everyone to discuss the goals for the day. The charge nurse told everyone that they were going to be short staffed In the afternoon. My preceptor volunteered to stay an extra four hours to prevent the unit from being short staffed and to help the other nurses. I noticed in the NNICU that all the nurses are very willing to help out with other patients. Nurses are constantly going into each other’s rooms to ask if anyone needs help. Anna Marie and I helped two nurses with admissions of patients onto the unit and other nurses came and helped us move our patients. I really enjoy the dynamic of how the nurses work and help each other on this munication/Interactions with the health care team, patients and familiesI think I did a good job of communicating with different members of the health care team. I was able to work with almost all of the nurses on the unit because my preceptor and I went into multiple rooms to help with other nurse’s patients. Two of the nurses on the unit asked me if I wanted to help with procedures or listen/see any abnormal findings on patient assessments. One of the nurses allowed me insert a foley catheter for her. As I stated earlier, I helped give meds, change the bed, bed baths for newly admitted patients needing quick treatment. I was able to sit in on doctors doing rounds on my patients. I really enjoy how the doctors on the unit not only listen to what the nurses have to say, but really value their input. During both of my shifts, I found that the doctors take suggestions from the nurses and ask their opinions about the patients care. ................
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