INTRODUCTION

The brain stem is the part of the brain connected to the spinal cord. It is located in the
lowest part of the brain, just above the back of the neck. The brain stem is the part of the brain
that controls breathing, heart rate, and nerves and muscles used in seeing, hearing, walking,
talking, and eating.

The tumors may be benign (not cancer) or malignant (cancer). It can erupt to any parts of
the body and includes the brain. Brain tumors grow and press on nearby areas of the brain. They
rarely spread into other tissues. Malignant brain tumors are likely to grow quickly and spread
into other brain tissue. When a tumor grows into or presses on an area of the brain, it may stop
that part of the brain from working the way it should. Both benign and malignant brain tumors
can cause symptoms and need treatment. Brain stem tumors account for 10 percent of pediatric
brain tumors. The peak incidence is between ages 5 and 10. A Brainstem Glioma tumor develops
in the part of the brain known as the brainstem (located in between the fourth ventricle and the
aqueduct of the sylvius, where the brain connects to the spinal cord). This tumor usually
originate from the left side of the brain and most are located in the pons. These tumorous
growths can be very aggressive. Cranial nerve or long tract signs are usually associated with the
pontine and cervicomedullary lesions and hydrocephalus sometimes occurs with tectal lesions.

The 12 year old female patient who was diagnosed of having Brainstem Glioma through
MRI (magnetic resonance imaging) was handled and been observed for 4 consecutive days.
Right side body weakness, difficulty swallowing, aphasia (difficulty speaking) and vertical
movement of the both eyes, which serves as her channel of communication, are some of the
clinical manifestations she is now suffering from.

The student nurse believes that her condition may serve as a better source of knowledge
about what Brainstem Glioma really is and how it gradually affects the individual who possesses
it. Moreover, appropriate assessment, nursing diagnosis, and interventions may revealed
throughout the 4 consecutive days that may contribute for the widening of nursing critical
thinking in rendering effective quality care for the other patients who experiencing this rare
condition, thus this case was chosen to put in a case study.

1|Page
DEMOGRAPHIC DATA

NAME: P.C.V.

AGE: 12 years old

GENDER: Female

BIRTH DATE: October 19, 2000

ADDRESS: Quezon City

NATIONALITY: Filipino

RELIGION: Roman Catholic

NURSING HISTORY

PRESENT HISTORY

2 months ago before the current admission, according to the mother, the patient informed
her about the difficulty of moving right upper and lower limbs associated with nausea and
vomiting (not projectile) consultation was done and with prescribed multi-vitamins to take. 1
month after, above symptoms still persist with difficulty swallowing thus resulting for her first
admission. After 1 week hospitalization, difficulty of moving her right upper and lower limbs
increases and still associated with nausea and vomiting (not projectile), difficulty swallowing
and with slurred speech. Impaired balancing was observed by the mother thus prompted for the
second and present admission.

PAST HISTORY

The patient is not yet experiencing infectious diseases like chickenpox, measles,
pneumonia and tuberculosis aside from coughs & colds and mumps. Undergone no operations
and surgeries, have no accidents such as vehicular, falls and trauma. She was hospitalized last
December 2012, as her first confinement due to the same complaints (right side body weakness,
difficulty swallowing, nausea and vomiting) which lasted only for a week. She had incomplete
immunization having only OPV 1, 2, 3 and Boosters.

FAMILY HISTORY

She has no family history of cancer and cysts according to the mother’s knowledge only
anemia (mother) and hypertension (father).

2|Page
PERSONAL AND SOCIAL HISTORY

Born 9 months old baby girl by non- smoker, non- alcoholic, anemic, 35 year old mother
with the help of “hilot” at home.

Currently at her grade 6 level, the youngest among the 10 children.

3|Page
PHYSICAL EXAMINATION

General: pale and weak appearance

Vital signs:
 Blood pressure: 90/70 mmhg

 Pulse rate: 80 bpm

 Respiratory rate: 28bpm

 Temperature: 36.7C

FACE:

Eyes: pale conjunctivae noted

responses to voices
active pupil noted (2-3mm)
Vertical movement of both eyes noted during conversation
No inflammation and discharge noted

Nose: with thick clear discharge in moderate amount

No inflammation noted
With NGT inserted at the left nares, intact

Ears: Symmetrical
No discharge, no inflammation noted

Mouth: pale and dry lips noted

Dry oral mucosa noted
With thick clear mucus secretions in moderate amount
Unable to open wide freely
Unable to show and move tongue freely
Makes incomprehensible sounds only

TRUNK

Chest: increased chest expansion noted upon breathing at rest

Use of accessory muscles noted when breathing at rest
With crackles noted at the left lung upon auscultation

4|Page
Abdomen: no tenderness noted to each region upon palpation

EXTREMETIES

Upper Left slowed movements noted

extremety: Limited movements noted
With decreased muscle strength against force and gravity
Able to perform slight hand grip

Upper right decorticate arm

extremity: Stiff arm noted, unable to initiate movements
Diminished muscle strength against force and gravity
Unable to perform hand grip

Lower left slowed movements noted

extremity: Limited movements noted, unable to fully bend knee
With decreased muscle strength against force and gravity

Lower right stiff leg and thigh noted, unable to initiate movements
extremity: Diminished muscle strength against force and gravity

GLASCOW COMA SCALE

Eye opening 3
Motor response 6
Verbal response 2
TOTAL 11

5|Page
GORDON’S FUNCTIONAL HEALTH PATTERN (Pertinent information according to
mother)

1. NUTRITIONAL AND METABOLIC PATTERN

They usually have 1-2 meals a day. Due to financial constraints, they often eat noodles or coffee
and rice as their meal before going school. Sometimes, they only eat one meal a day.
The patient is fond of eating junk foods and soft drinks when at school.

2. ELIMINATION PATTERN
Defecates 0-1x a day with formed brownish stool in moderate amount with no complaints
of difficulty and pain
Voiding yellowish urine in moderate amount complaining o pain an difficulty

3. ACTIVITY AND EXERCISE PATTERN

School activities and playing outside the home with friends are her daily activity
The patient walks to school early in the morning and then walks back home at lunch.

4. SLEEP AND REST PATTERN

The patient sleeps usually 9pm and wakes-up 4am.
Seldom sleeps on the afternoon.

5. REPRODUCTIVE AND SEXUAL PATTERN

Telarch : 12 years old
The patient is not yet having menstruation

6. ROLES AND RELATIONSHIP PATTERN

Youngest among the 10 children
Lives with her 4 siblings and with mother
Studying in a public school, grade IV student

7. COPING STRESS TOLERANCE

School activities is her primary stressor and playing outdoors is her way to be relived

8. VALUES /BELIEFS PATTERN

The patient is an active Sunday school students attending every Sunday morning.

6|Page
 RISK FACTORS
MODIFIABLE RISK FACTORS
1. Malnutrition
Cells in any part of the body are converted to abnormal cells when there is no proper
supply of nutrition. Abnormal cells lost their function and ability resulting to an impaired
growing cell or a tumor. As this cell is abnormally growing, it suppresses the function of the
nearby tissues. The tumor growing in the brainstem results to mobility and balance problem,
speech and visual problem and also may results nausea and vomiting which those are the primary
functions of the brainstem and its nearby tissues (such as medulla and).
2. Frequent exposure to radiation (Cellphone)
Radiation alters the cell formation converting it to an abnormal one. Cellphone is usually
used during call that is place just parallel to the ear. The radiation might affect the inner tissues it
is parallel from, specifically the brainstem. The tumor in the brainstem which resulted from the
frequent exposure to the radiation will start to improperly grow affecting the surrounding tissues.
The surrounding tissues may not function well as evidenced by the manifestation that can be
observed (impaired mobility, aphasia, nausea and vomiting, and difficulty swallowing) due to the
suppression because of the growing tumor.
3. Anemic Mother
During pregnancy, the circulation of the blood of the mother circulates to the growing
fetus as well. Anemia is a hematological problem that is decreased amount of the Red blood
cells. Red blood cell is the component of blood which carries oxygen and nutrition to be passed
to the tissues for well functioning. Due to that during pregnancy of the mother, circulating Red
blood cells is not enough for the mother, as well as for the growing fetus inside the utero. Less
oxygen and less nutrition is supplied to the fetus and that could not be enough to support the
formation of the organs and body parts of the fetus. Formation of abnormal cell may occur due to
this deficiency and as the child is growing, the tumor simultenuously growing getting
nourishment from its surrounding tissue.

7|Page
PATHOPHYSIOLOGY

8|Page
DIAGNOSTICS AND LABORATORY RESULTS

JANUARY 03, 2013

PROCEDURE: MRI OF THE HEAD(plain and contrast)

RESULT:  Expansive tumor moderate lesion in the pons and extending slightly
to the left midbrain peduncle. 4.6x4x4.6cm
 With compression deformity of the 4th ventricle
 No dilatation of the 3rd ventricle
 No hemmorhage extravasation
 Brainstem glioma with slight compression of the 4th ventricle
Interpretation:

Due to the presence of the tumor, the function of the brainstem is altered. Brain stem is
responsible for muscles used in seeing, hearing, walking, talking, and eating. This is why the
patient manifests, right side body weakness, slurred speech and with difficulty swallowing. The
eye movement is also affected.

JANUARY 14, 2013

PROCEDURE: CBC
RESULTS: Normal Val. Results
Hemoglobin 120-160 146
Hematocrit 0.37-0.47 0.44
WBC 5-10 11.2
Neutrophils 0.40- 0.75 0.85
Lymphocytes 0.20-0.45 0.47
Platelets 150-450 315
Interpretation:

All blood components have normal results aside from the increased lymphocytes which may
conclude that the patient have infection occurrence in the body and probably it might be because
of the presence of the tumor.

JANUARY 18, 2013

PROCEDURE: SERUM Na, K+, CL

RESULT: Normal val. Results
Na 136-146 134
K 3.6-5.5 4.84
CL 95-103 97.1
Interpretation:

The above data show normal results thus the patient is having no electrolyte imbalances.

9|Page
 DRUG STUDY

Classification Action Adverse Indication Why given to Nursing consideration

effect the patient?
Ranitidine Anti-ulcer/ H2 Inhibits the  Diarrhea Stomach ulcer To prevent Assess pt for epigastric or
15mg q8 IV blockers action of  Fatigue problems further bleeding abdominal pain and
histamine at  Insomnia in the Gastro observe for the black
theH2 receptor Pain in the GERD intestinal due to tarry stools or emesis
site located muscles increased gastric
primarily  Anemia Treating upper secretions check for the color and
ingastric parietal Depression portion of the characteristics of the
cells, resulting in  Easy gastrointestinal residual in the NGT,
inhibition of bleeding bleeding observe for coffee ground
gastric acid  Losing of residual.
secretion hair
 Rash
 Nausea
 Headache
 Stomach
pain
 Vomiting
 Changes in
the visual
aspect

Dexamethasone Glucocorticoid, Suppresses Nausea, Endocrine Helps prevent Due to its action of
Corticosteroid inflammation Stomach disorders, white blood alteration of the immune
and the pain, Rheumatic cells from system, the patient must
normal Bloating; disorders, traveling to receive measures in
immune Muscle Collagen areas of the decreasing risk for
response. It weakness; diseases, body where acquiring infection such
prevents the or Dermatologic they might add as frequent hand washing,
release of Headache, diseases, to swelling wearing mask, body
substances in Dizziness, Allergic problems (such hygienic care etc.
the body that Spining statesc, as around
causes sensation Ophthalmic tumors).
inflammation. Slow diseases,
wound Gastrointestinal
healing diseases,
Respiratory
diseases,
Hematologic
disorders,
neoplastic
Niseases,
edematous
states, Cerebral
edema.
Cinnarizine Anti- It acts by Drowsiness Control of The drug was Prevent patient from
25g/tab ½ vertgo/Anti- interfering Nausea vestibular given to the injury : fall.

10 | P a g e
tab BID emetics with the vomiting, symptoms of patient to
signal Stomach both correct Do not leave the patient
transmission upset peripheral balance alone
between and central problem
vestibular Headache origin and of Assist patient during
apparatus of labyrinthine Due to one of changing of position to
the inner ear Dry mouth disorders the chief prevent sudden falls
and the including complaint of
vomiting Weight vertigo, the patient is Place rolled blankets or
centre of the gain dizziness, vomiting, this pillows at the sides
hypothalamus tinnitus, drug was
. Vision nystagmus, ordered to
problems nausea and prevent
vomiting. vomiting
which if
consistent
may cause
heart burn or
Gastro
intestinal tract

11 | P a g e
COURSE IN THE WARD

01-21-13/ 10:00am Risk for injury: fall related to

right side body weakness
01-22-13/9:00am Risk for acquiring Nosocomial D: Soiled linens noted;
Infection related to prolonged Soiled clothings noted;
hospital stay
01-23-13/9:00AM Impaired mobility related to
right side body weakness
D: diminished muscle strength
to force and gravity at the
right arm and leg as evidenced
by unable to initiate
movements; with decreased
muscle strength to force and
gravity on the left arm and leg
as evidenced by limited and
slowed movements of the left
arm and leg; --------------------
A:placed on the center of the
bed; placed rolled blanket and
pillow at the sides;assisted
during change of position;
instructed relatives not to
leave the patient alone
R: prevented from injury as
evidenced by no incidence of
falls--------------------------------
Exposed to cross
contamination through the
nurses who are taking care of
her who are going in and out
of the different wards;
Room is untidy as noted;
With roommates having
infectious diseases such as
pneumonia, coughs and colds
A:performed hand washing
before and after handling the
patient; used mask all the
time;provided AM care,
removed excessive blankets,
pillows and clothes near the
patients-------------------------
R: have decreased risk for
acquiring infection as
evidenced by receiving
measures to prevent spread of
microorganisms
D:diminished muscle strength
to force and gravity at the

12 | P a g e

01-24-13/9:00AM Ineffective airway clearance
related to presence of thick
clear mucus secretions
right arm and leg as evidenced
by unable to initiate
movements; with decreased
muscle strength to force and
gravity on the left arm and leg
as evidenced by limited and
slowed movements of the left
arm and leg; --------------------
A: assisted on passive and
active ROM;provided folded
blankets and pillows under
joints; assisted during
changing of positions
R: participated during active
ROM and cooperates during
passive ROM--------------------
D: productive cough noted;
clear thick nasal and oral
discharge;crackles on the left
lung upon
auscultation;increased chest
expansion noted----------------
A: provided bronchial tapping;
provided postural drainage
during asleep;assisted on
frequent changing of
position;assisted on proper
blowing of the nose
R: able to remove moderate
amount of nasal discharge and
able to expectorate small
amount of oral mucus
secretions-------------------------

On January 23, 2013, 9:00am, the NGT of the patient was noted having coffee ground clogged
residue. The nurses was aware and the doctors as well. Draining of the residue was ordered and
the patient was on her NPO status. At the end of the 8 – hour duty, Coffee ground residual was
drained in 50ml amount and it continues.

On January 24, 2013, 8:00am, the residual is still coffee ground yet draining in small amount.
NGT was removed and inserted new one before 12 noon. Still the patient is on NPO status

13 | P a g e
NURSING THEORY

Lydia Hall’s CORE, CARE and CURE

Hall believes on 3 domain parts of an individual. CORE- the established relation of the
health provider to the patient, CARE-the rendered bodily care and the CURE- involvement of
the medical knowledge to the care given.
Establishment of relation with the patient is part of the initial action of the student nurse
to the patient. This is to win rapport with the patient and may lead to effective care to be given
which can be achieve with the participation of the client. Care must be rendered appropriately
utilizing proper assessment to come up to the prioritized nursing diagnosis and be able to
distinguish what nursing interventions are really needed such as prevention of injury and
infection, assistance during mobility, and simply providing spiritual care through short prayers.
Collaborative care is involved as well as the doctors administer orders like medications and
procedures for the wellness of the patient.

14 | P a g e
NURSING CARE PLAN #1

ASSESSMENT

SUBJECTIVE

“hindi nya nga kaya galawin yung kanang kamay at paa nya, tapos hirap din nya igalaw
yung kaliwang paa ant kamay nya. Dahan- dahan nya lng naigagalaw.” – stated by the mother

OBJECTIVES

o Upper Left extremeties:

o slowed movements noted
o Limited movements noted
o With decreased muscle strength against force and gravity
o Able to perform slight hand grip
o Upper right extremities:
o decorticate arms
o Stiff arms noted, unable to initiate movements
o Diminished muscle strength against force and gravity
o Unable to perform hand grip
o Lower left extremities:
o slowed movements noted
o Limited movements noted, unable to fully bend knees
o With decreased muscle strength against force and gravity
o Lower right extremities:
o stiff legs and thighs noted, unable to initiate movements
o Diminished muscle strength against force and gravity

DIAGNOSIS

Risk for injury: Fall related to right side body weakness

PLANNING

At the end of 8- hour duty, the patient will be prevented from injury as evidenced by no
incidence of falls.

INTERVENTIONS

1. assisted on changing of positions

R: assistance will provide balance during changing of positions to prevent unnecessary

movements that may cause sudden falls resulting to injury.

15 | P a g e
2. placed on the center of the bed

R: to provide enough space at her side for sudden turnings that may occur without support. The
space o the side will decrease the risk of falling of the bed that can cause injury.

3. provided rolled blankets and pillows at the sides.

R: rolled pillows and blankets is an alternative if side rails are not available. These serve as a
barrier/stopper when sudden movements and turning of the patient may occur.

4. instructed relatives not to leave the patient alone

R: supervision is needed to oversee the risky movements of the patient and he/she may provide
the immediate action when injury might happen.

EVALUATION

At the end of 8- hour duty, the patient was prevented from injury as evidenced by no
incidence of falls. Goal met.

16 | P a g e
NURSING CARE PLAN #2

ASSESSMENT

SUBJECTIVE

“hindi nya nga kaya galawin yung kanang kamay at paa nya, tapos hirap din nya igalaw
yung kaliwang paa ant kamay nya. Dahan- dahan nya lng naigagalaw.” – stated by the mother

OBJECTIVES

o Upper Left extremeties:

o slowed movements noted
o Limited movements noted
o With decreased muscle strength against force and gravity
o Able to perform slight hand grip
o Upper right extremities:
o decorticate arms
o Stiff arms noted, unable to initiate movements
o Diminished muscle strength against force and gravity
o Unable to perform hand grip
o Lower left extremities:
o slowed movements noted
o Limited movements noted, unable to fully bend knees
o With decreased muscle strength against force and gravity
o Lower right extremities:
o stiff legs and thighs noted, unable to initiate movements
o Diminished muscle strength against force and gravity

DIAGNOSIS

Impaired mobility related to right side body weakness

PLANNING

At the end of 8 – hour duty, the patient will be able to promote strength and muscle tone
of the strong parts of the body and strengthen the weak body parts.

INTERVENTIONS

1.Assited in Passive ROM to the right upper and lower extremities

R: Passive ROM help to maintain the muscle tone of the limbs thus strengthen the extremeties.

2. Assisted to do active ROM to the Left upper and lower extremities

17 | P a g e
R: active ROM keeps the muscles of the extremities moving to keep it functional for mobility
also Maintaining / improving joint function and muscle strength

3. provided folded blankets and pillows under joints

R: to reduce the risk of injury to the joints to maintain its function for mobility

4. assisted on frequent changing of position

R: Eliminates pressure on the tissue and increase circulation. The increased circulation to will
strengthen the body parts for its function during mobility.

5. placed rolled blankets and pillows at the sides, instructed relatives not to leave patient alone

R: an alternative for side rails (due to its unavailability) to prevent injury due to falls. If injury
occurred, bones, joints and muscles are the primary affected which may add to the impaired
mobility of the patient.

EVALUATION

At the end of 8 – hour duty, the patient was able to promote strength and muscle tone of
the strong parts of the body and strengthen the weak body parts. Goal met!

18 | P a g e
NURSING CARE PLAN #3

ASSESSMENT

SUBJECTIVE

“Mag-iisang Linggo n nga kami dito eh…tapos naka-ilang balik na din kame dito sa
hospital.” – stated by the mother

OBJECTIVES

o Soiled linens noted

o Soiled clothings noted
o Exposed to cross contamination through the nurses who are taking care of her who are
going in and out of the different wards
o Room is untidy as noted
o With roommates having infectious diseases such as pneumonia, coughs and colds

DIAGNOSIS

Risk for acquiring Nosocomial Infection related to prolonged hospital stay

PLANNING

At the end of 8 – hour duty, the patient will have decreased risk for acquiring Nosocomial
Infection as evidenced by having prevention of spread of microorganisms.

INTERVENTIONS

1. use mask when being exposed to the patient

R: this is to prevent microorganisms to spread through airborne and droplet which if from the
nurse may spread to the patient then will cause infection and vice versa.

2. performing handwashing and alcohol rubbing before and after handling the patient

R: handwashing alleviates microorganisms to prevent it to spread that may cause infection

3. Assisted during AM care (Bed bath, change of clothing and diaper, change of linens, oral
hygiene)

R: to alleviate microorganisms living on the patient’s skin and on the soiled linens and clothes
which if being spread may result to infection

4. folded and kept excessive blankets, pillows and clothes away for the patient

19 | P a g e
R: microorganisms live on any material things. Removing the excessive blankets, pillows and
clothes will keep the patient away from the microorganisms it contain thus preventing the spread
of infection.

EVALUATION

At the end of 8 – hour duty, the patient have decreased risk for acquiring Nosocomial
Infection as evidenced by having prevention of spread of microorganisms.

20 | P a g e
NURSING CARE PLAN #4

ASSESSMENT

SUBJECTIVE

“maplema nga yung ubo nya. Parang ang lagkit ng plema nya.” – stated by the mother

OBJECTIVES

o Pale conjunctivae noted

o Pale and dry lips noted
o Dry oral mucosa noted
o Productive cough noted
o With nasal and oral thick clear mucus secretions
o Crackles on the left lung noted upon auscultation
o Increased chest expansion noted upon breathing at rest
o Respiratory rate of 28bpm

DIAGNOSIS

Ineffective airway clearance related to presence of thick clear mucus secretions

PLANNING

At the end of 8- hour duty, the patient will be able to remove and expectorate moderate
amount of thick clear mucus secretions.

INTERVENTIONS

1. Provided bronchial tapping

R: to mobilize the thick mucus secretions and to loosen its attachment to the airways thus may
have easy expectoration.

2. Assisted on frequent changing of position

R: frequent changing of position is also a way to mobilize the thick clear secretions strongly
attached to the airways. This may help to loosen the attachment of the secretions thus resulting
for easy secretions

3. Provided postural drainage during asleep

R: to maximize the force of gravity by pulling the secretions to accumulate in one place resulting
easy removal and expectoration.

4. Assisted on proper blowing of the nose

21 | P a g e
R: proper blowing of the nose may help to release/remove more amounts of thick clear nasal
secretions.

EVALUATION

At the end of 8- hour duty, the patient was able to remove moderate amount of nasal
secretions and expectorate moderate amount of thick clear oral mucus secretions. Goal met.

22 | P a g e
HEALTH TEACHINGS (For the relatives)

1. NUTRITIONAL AND METABOLIC PATTERN

Instructed to placed the patient always in semi fowlers position during feeding to prevent
aspiration, clogging of the osteorized food in the tube, and preventing backflow as well.

Warm the osteorized food before feeding to prevent irritation in the gastro intestinal tract.

2. ELIMINATION PATTERN
Instructed family to assess the characteristics of the stool of the patient (color,
consistency) to know if there is incidence of internal bleeding (if with dark tarry stools) then
aware nurses

3. ACTIVITY AND EXERCISE PATTERN

Taught and instructed to assist patient in active and passive exercises to preserve the
muscle tone and functions of the body

Taught on how to proper move the patient during changing of position; must have
simultaneous lifting and moving of the upper and lower part of the patient’s body to prevent
additional complications to the spinal cord.

Instructed to change position of the patient every 2 hours to prevent formation of pressure
ulcers

4. COGNITIVE
Advised to have consistent conversation with the patient and used closed questions due to
her difficulty speaking. Or use point-to-where conversation to know the complaints of the patient

Instructed to orient every now and then the patient about the date, time, place and person
to maintain her mind functioning.

5. VALUES /BELIEFS PATTERN

Encourage to keep praying with the patient

6.SAFETY
Taught how to have alternative side rails due to its unavailability; place rolled blankets or
pillows at the side of the patient and do not leave the patient alone to prevent incidence of falls

7. INFECTION CONTROL
Taught about the importance of frequent hand washing before and after handling the
patient, maintaining environment clean like keeping away excessive things (blankets, pillows,
shirts etc) near the patient, and everyday body hygiene (Bed bath, oral care using soft bristle
toothbrush )

Instructed to use only soap and water during bed bath not alcohol to prevent dryness of
the skin. Also may apply mild lotion to the skin.

23 | P a g e
REFERENCE

Pillitteri Adele, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family, Volume 2, 5th edition

Assessment made Incredibly Easy! (3rd Ed.) . (2005). Philadelphia: Wolters Kluwer Company

The Bantam Medical Dictionary (2000), Edition of Market House Books Ltd, revised 3rd edition,
Bantam Books New York

OCTAVIANO, E.F. (2008). Theoretical Foundations of Nursing: The Philippine Perspective.

Philippines: Ultimate Learning Series

IGNATAVICIUS. D.D (2006). Medical Surgical Nursing. Philippines: Elsevier Saunders

http://www.stjude.org/stjude/v/index.jsp?vgnextoid=b86c061585f70110VgnVCM1000001e0215
acRCRD

http://www.scribd.com/doc/64966412/DRUG-STUDY-Dexamethasone

http://nursingcrib.com/news-blog/drug-study-ranitidine/

http://www.knowcancer.com/tumor/brain-stem-glioma/

http://www.scribd.com/doc/52673160/RANITIDINE-DRUG-STUDY

http://techmaza.in/rantidine-classification-indications-side-effects/

http://www.healthplus24.com/drugs/cinnarizine.aspx#_Hlk221801136

http://www.genrxinfo.net/drugs/Dexamethasone.htm

24 | P a g e