l

TANCHULING COLLEGE, INC.

College of Nursing
Imperial Cour t Subdivision, Phase II,
Legazpi City 4500 Philippines
Tel. # (052) 480-6106/(052) 742-0098
http://www.tanchuling.edu.ph

CASE PRESENTATION

Patient’s profile
I. Identification Data:
Client name: M, M
Age/sex: 48/M
Father/Spouse Name M, M
Hospital Registration number N/A
Ward Male Gastro
Bed No N/A
Address Purok 5, Mercedes,Pilar Sorsogon
Education High school graduate
Occupation Construction worker
Marital Status Married
Religion Roman Catholic
Date of Admission October 20, 2023
Date of Discharge November 4, 2023
Diagnosis: Brain mass, HPN stage II, UTI
Surgery (if any) N/A
Date of Surgery N/A
II. History of Illness
Chief complaints Headache for 3 weeks
Present medical history complaints of Dizziness, Headache, HPN
dyspnea

Present surgical history NONE

Past medical history: history of any HPN, stage II UTI

hypertension, Diabetes mellitus,

asthma,COPDor other diseases.
Past surgical history: history of any surgery in the NONE
past.

1
 No. Family Members Age/Sex Occupation Relation to Patient Health Status Educational Attainment

1 M. M 42/F Housewife Wife No history of illness High school graduate

2 K. M No history of illness
13/F Student Daughter Undergrad

3 A. M 8/F Student Daughter No history of illness Undergrad

FAMILY HISTORY
PERSONAL HISTORY
Dietary Habits (vegetarian/ non vegetarian) Non-vegetarian

Addiction: history of smoking, drug addiction, Hx of smoking

alcohol consumption, etc Hx of alcohol consumption

Socio-economic status: Lower class

2
 LAB INVESTIGATION

Investigation Name Normal Values Patient’s Value Clinical significant

indicators

Brain CT-Scan (with Brain parenchyma is Heterogeneously enhancing Posterior fossa extra-axial
contrast) intact extra-axial mass with cystic mass suggestive of
10-30-2023 with no focal mass lesions component seen in left meningioma with malignant
or abnormal calcifications anterior cerebellar features.
seen. convexity
Midline structures are Mild hydrocephalus
undisplaced. Ventricles are slightly
dilated.

Hematology Hemoglobin Hemoglobin 148/L Hemoglobin, hematocrit and

10-25-2023 140 - 160/L Platelet counts are within the
normal values.
Hematocrit Hematocrit 0.45
0.40 - 0.54 White Blood Cell is above
the normal value.
White Blood Cell (WBC) White Blood Cell (WBC)
5.0-10.0 x 10/L 13.0

Platelet Platelet
150 - 450 x 10/L 185
Clinical Chemistry Fasting Blood Sugar Fasting Blood Sugar Results are within normal
10-21-2023 (FBS) 3.85 - 5.78mmol/L (FBS) 5.11 mmol/L value
Blood Urea Nitrogen blood Urea Nitrogen
(BUN) 2.0 - 8.33mmol/L (BUN) 2.90 mmol/L
Creatinine 62 -123 umol/L Creatinine 100.9umol/L
Blood Uric Acid (BUA) Blood Uric Acid (BUA)
212 - 454 umol/L 335.0 umol/L
Total Cholesterol Total Cholesterol
3.9 - 5.92 mmol/L 4.66 mmol/L
Triglycerides Triglycerides
0.45 - 1.88 mmol/L 0.97mmol/L
HDL 0.91-1.69 mmol/L HDL 1.40mmol/L
LDL 0 - 3.26 mmol/L LDL 3.08 mmol/L
SGOT(AST) 5 - 40 U/L SGOT(AST) 22.5 U/L
SGPT(ALT) 7 - 56 U/L SGPT(ALT) 14.10 U/L

Electrolytes Sodium Sodium Electrolytes were within the

10-21-2023 135.0 - 148.0 mmol/L 138.0 mmol/L normal range
Potassium Potassium
3.50 - 5.30 mmol/L 4.01 mmol/L
Chloride Chloride
98.0 - 107.0 mmol/L 107.3 mmol/L

3
Urinalysis Color : Yellow to amber Color : Yellow Albumin is abnormal.
10-22-2023 Transparency : Clear Transparency: Turbid Has few epithelial cells and
Specific Gravity : Specific Gravity : many bacteria.
1.005 - 1.030 1.020
pH: 4.5 - 8.0 pH : 6.0
Albumin: Negative Albumin : 2+
Glucose : Negative Glucose: Negative

WBC/hpf: <4 cells/hpf WBC/hpf : 45-50

RBC/hpf: <3 cells/hpf RBC/hpf : 15-20
Epithelial cell: Moderate Epithelial Cells : few
Bacteria: None Bacteria : Many
Mucus Thread: Few to
moderate
Casts: None to few

4
Physical Examination

General Appearance Findings

Body Built Endomorph

Height 150 cm
Weight 64 kg

Temperature: 36.5 ° C
Vital signs: Pulse: 83 bpm
Respiration: 18 bpm
B.P.: 140/90

Color of the Skin Bilaterally light in complexion

Head:
Shape and size of the skull: No presence of lesions, dandruffs
Scalp: (-) swelling, symmetrical
Face:
Eyes: symmetrical
Vision:
Eyebrow and eyelid: Good amount of hair
• Eyeball: Round and dark
• Conjunctiva: Clear and not sore
• Sclera: Whitish color
• Cornea and iris: N/A
• Pupil: N/A
• Lens: N/A

Ear:
• External ear: helix, anti-helix, tragus, antitragus,
• Tympanic membrane: scaphoid/triangular fossa, and external
• Hearing problem auditory canal are all present and well formed

Nose:
• External nares: Flared
• Nostrils: Flared

Mouth and pharynx:

• Mouth: Pale red Lips
• Teeth: Incomplete
• Tongue: Pale Pink
• Throat and pharynx: No abnormal perfusion, in the midline

General Appearance: Findings

Neck:
Thyroid gland: Not visible,not palpable and not bulging
Lymph node: Not palpable
Range of motion: dependent to control neck

5
Chest:
Breath sounds: (-) Grunting,
Lungs: no adventitious sound noted
Heart: No heart murmurs present

Abdomen:
Inspection: No lesions, swelling, redness and masses
Auscultation: Normal bowel sound noted
Palpation: No tenderness
Percussion: Tympanic sound

Extremities:
Upper: Upper and lower extremities are active range
Lower: of motion, no lesions, no swelling

Back: (-) redness, no presence of bed sores

Genital and rectum: no discharge (-) swelling of penis and scrotum

Systematic examination:
Central nervous system: extra-axial mass is seen in left anterior
cerebellar convexity.
Sensory system: Can respond to stimulation
Respiratory system: no difficulty of breathing observed
Normal respiratory rate and rhythm

Cardiovascular system: 84 bpm

Gastrointestinal system: (+) watery stool
Musculoskeletal system: Active range of motion
Genitourinary system: (+) urine output daily
Integumentary system: Normal

DISEASE CONDITION: BRAIN MASS (Meningioma)

Definition:
Brain mass or Brain tumor is an abnormal growth or mass of cells in or around your brain.
Meningioma is a tumor that grows from the meningeal layers, which cover and protect the brain
and spinal cord. Most of these tumors are grade 1, which means that they are benign. Some of
the meningiomas do not produce symptoms, and many of them are discovered incidentally
during imaging studies.

Causes:
Brain tumors that start as a growth of cells in the brain are called primary brain tumors. They
might start right in the brain or in the tissue nearby. Nearby tissue might include the membranes
that cover the brain, called meninges. Brain tumors also can happen in nerves, the pituitary
gland and the pineal gland. It isn't clear what causes a meningioma. Doctors know that
something alters some cells in your meninges to make them multiply out of control, leading to a
meningioma tumor.

Whether this occurs because of genes you inherit, hormones (which may be related to the more
frequent occurrence in women), the rare instance of prior exposure to radiation or other factors
remains largely unknown. There is no solid evidence to support the belief that meningiomas
occur because of cellphone use.

6
Sign and Symptoms:
Some people who have a brain tumor experience no symptoms, especially if it’s very
small.Signs and symptoms of a brain tumor vary depending on the tumor’s location, size and
type. They can include:

● Headaches that may be more severe in the morning or wake you up at night.
● Seizures.
● Difficulty thinking, speaking or understanding language.
● Personality changes.
● Weakness or paralysis in one part or one side of your body.
● Balance problems or dizziness.
● Vision issues.
● Hearing issues.
● Facial numbness or tingling.
● Nausea or vomiting.
● Confusion and disorientation.

Pathophysiology: Brain tumor (Meningioma)

Meningioma is a type of tumor that develops from the meninges, the membranes that surround
the brain and spinal cord 1. The exact cause of meningioma is not known, but possible causes
may include alteration or disorder of cells in meninges leading to the formation of tumor 1.
Meningioma tumors grow gradually without causing any symptoms, but as they grow, they may
compress or squeeze the adjacent brain, nerves, and vessels, leading to serious disability 2.

The symptoms of meningioma brain tumor usually come with no symptoms, but as the tumor
grows gradually, the patient may show the following symptoms: headache which gets severe
with time, change in vision causing double or blurred vision, hearing disability, ringing in ears,
loss of memory and difficulty in concentrating, weakness in arms and legs, loss of smell,
seizures, numbness, speech problems 1.

Imaging tests such as CT scan and MRI are used to diagnose meningioma brain tumor 1.
Treatment depends upon the size and rate of growth of the tumor, age, and overall health issues.
Surgery is preferred if the tumor is causing symptoms and is increasing its size. The doctor
removes the meningioma completely 1. Other treatment options include stereotactic
radiosurgery, fractioned stereotactic radiotherapy, intensity-modulated radiation therapy, and
proton beam radiation 1.

Meningiomas are the most common primary central nervous system (CNS) tumors [1]. They
are usually benign, slow growing neoplasms that are thought to arise from meningothelial
(arachnoid) cells (MECs) [1,2,3]. Despite having a reputation of a benign disease, these dural-
based tumors can lead to morbidity, presenting with a variety of non-specific, location
dependent symptoms. This review discusses the recent 2016 updates to the World Health
Organization (WHO) classification of CNS tumors, epidemiology, and etiological/risk factors
of meningiomas. This review also covers molecular characteristics and potential applications
for grading, clinical features, diagnostics, standard treatment regimens, and ongoing trials of
potential treatments.

MECs are a cellular component of the pia mater, arachnoid mater, and the trabeculae and septae
of the subarachnoidal space [4]. They make up a monolayer covering of the meninges and are
connected via tight junctions, gap junctions, and desmosomes, providing an interface between
7
neuronal tissue and the cerebrospinal fluid (CSF) [5]. Aside from providing a physical barrier to
the CNS and protecting it from mechanical damage, MECs also play a significant role in
immunological processes and the maintenance of homeostasis and host defense in the CSF
[6,7,8]. Through secretion of pro- and anti-inflammatory chemokines and cytokines, MECs are
able to initiate and quench immune reactions [6]. MECs also protect against infection and
neurodegeneration via phagocytosis of bacteria and apoptotic bodies, as well as
macropinocytosis of neurotoxic peptides and proteins, respectively [6,7,8]. MECs have
different embryologic origins depending on their anatomic locations. MECs found at the skull
base and cerebral convexity have mesoderm and neural crest origins, respectively [9]. This
difference affects the predominating histological subtypes of meningiomas that arise from these
cells and the distribution of recurrent somatic mutations [9]. Arachnoid cap cells make up the
outer layer of the arachnoid mater and arachnoid villi and with cytological similarities to
meningiomas cells, it is likely their cell of origin [10]. Meningiomas are tumors of the meninges
but they also occur rarely as primary tumors in the ventricles of the CNS and extracranial
organs such as the lungs [3,11], presumably from aberr

Diagnostic Evaluation:
The Brain CT scan indicated Posterior fossa extra-axial mass suggestive of meningioma with
malignant features. The results are within the normal quantity of Platelets present in the blood,
thus have elevated WBC counts which may exhibit infection or any alarming body changes.
The lab results point to the diagnosis, Brain mass (meningioma) and Urinary Tract Infection.

Ideal nursing care:

Consistent monitoring of vital signs. Assess the patient's neurologic status such as Level of
consciousness. Appropriate administration medication on the right time, route, and dosage.
Patient education to the client's parents on drugs, nursing intervention, hygiene, dietary intake,
output, and safety such as activity restriction that could cause head injury.

Rehabilitation:
Encouraging adequate food especially fluid intake, diet such as low in protein. cognitive
rehabilitation may be advised to improve cognitive functions such as memory. Coping to
changes in sensory sensitivity such as hearing problems caused by the disease.

EVALUATION
The chief complaint is a headache for three weeks.. An CT-scan depicting a posterior fossa
extra-axial mass suggestive of meningioma that is diagnosed as Brain mass. The client was also
diagnosed with stage II hypertension and a Urinary Tract Infection. The client is being treated
for the diagnosis of Brain mass, Stage II HPN and UTI.. Nursing interventions include
administration of medication and providing safety and comfort.

8
 NURSING CARE PLAN

Name of Patient: M.M Age: 48 years old Gender: Male Height: 150 cm Weight: 64kg

Diagnosis: Brain Mass (Meningioma) Doctor:

Nursing Problem : Pain

ASSESSMENT NURSING PLAN INTERVENTIONS RATIONALE EXPECTED OUTCOMES

DIAGNOSIS

Subjective Cues: Acute pain Short term goal: Independent Nursing Functions Short term goal:
characterized by facial Within 8 hours of shift, the
“tolong aldaw na makulog expression of pain such Within 8 hours of shift , -Monitored patient’s vital -To provide an accurate client demonstrates relief of
payo ko” as verbalized by as grimacing, and in the patient will be able signs status of the patient. Serve pain.
the patient. pain behavior. to verbalize decrease of as a pattern in the
pain diagnosis..

Objective Clues: Long term goal:

Vital Signs: After 8 hours of shift

T- 36.5°C the patient will be able -Observe for any sign of -to immediately provide -After 8 hours of shift, the
RR- 18 bpm to relieve pain. pain or discomfort nursing care patient has verbalized free of
PR- 83 bpm pain.
%SPO2-98%

>Head CT scan
Dependent Nursing Functions

-Discussed the meaning of -Discussion of the main

Brain mass problem decreases the
anxiety of the patient.

9
 -Administered medications -to reduce the patient’s
as prescribed such as pain
celecoxib, cefuroxime,
cetirizine etc.

Collaborative Interventions

-advised to increased fluid -to maintain fluid &

and food intake if not electrolytes balance
contraindicated

NURSING CARE PLAN

10
Name of Patient: M.M Age: 48 years old Gender: Male Height: 150 cm Weight: 64kg

Diagnosis: Brain Mass (Meningioma) Doctor:

Nursing Problem : Anxiety

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOMES

DIAGNOSIS

Subjective Cues: Anxiety related to Short term goal: Independent Nursing Functions Short term goal:
actual /perceived threat Within 8 hours of shift, the
“tolong aldaw na makulog to health as evidenced Within 8 hours of shift , -Monitored patient’s vital -To identify physical client was able to do the
payo ko, haditunon na by expression of fear.. the client will be able to signs responses associated with techniques taught such as
ako” as verbalized by the know some techniques both medical and deep breathing techniques to
patient. on how to lessen the emotional conditions. lessen anxiety.
anxiety such as deep
breathing exercise and
Objective Clues: verbalization of “dae na
ako mahadit kaining
Vital Signs: kulog kang payo ko” -Assess patient’s level of -Different levels of
T- 36.5°C anxiety anxiety will affect the Long term goal:
RR- 18 bpm coping mechanism of the -After 8 hours of shift, the
PR- 83 bpm client patient has verbalized free of
%SPO2-98% fear and is able to understand
the condition.
>Head CT scan Long term goal: Acknowledge awareness of -Acknowledgement of
patient’s anxiety feeling’s validates the
After 8 hours of shift feelings and
after the series of communicates acceptance
nursing intervention the of those feelings.
patient will be able to
eliminate anxiety.

-Instruct to do deep -This may help the client

breathing exercise to relax

11
 Dependent Nursing Functions

-Provide accurate -Discussion of the main

information about the problem helps the client
diagnosis to identify what is reality
based

Collaborative Interventions

-Establish a working with -Ongoing relationships

the patient through establish a basis for
continuity of care comfort in
communicating anxious
feelings.

12
 MEDICATION

Nursing
Name of Drug Dose/Route Classification Action Side effect Responsibilities

D5LR IV, 1L 10-12 gtts/min Hypertonic Solution provides electrolytes and Swelling of legs, fee,
calories, and is a source hands Drip factor monitored
of water for hydration fast irregular heart Insertion site monitored
beats

a vehicle for the Drip factor monitored

PNSS administration of Headache, nausea, Insertion site monitored
IV, IL 30 gtts/min Isotonic Solution parenteral drugs swelling hands,
legs, feet.

PO Non-steroidal Anti reduces inflammation in dizziness,

Celecoxib Inflammatory Drugs the body and pain abdominal pain, Assessed if the client can
(NSAIDS) headache tolerate the meds

stops you feeling or feeling sleepy at Administered meds

Cinnarizine PO 25mg TID Anti-histamine being sick (nausea or daytime accurately and timely
vomiting) putting on weight
treats allergy symptoms Administered meds
Citirizine PO 10mg BID Anti-Histamine like itchy eyes, sneezing, a Headache, dry accurately and timely

13
 stuffy nose or hives mouth, sore throat
Cefuroxime used to treat bacterial cough, fever,
750mg 1V q 8h Antibiotic infections in many different decrease urine Monitor side effects
parts of the body output
Ceftriaxone 2g IV OD Cephalosporin works by killing bacteria or fever, chest pain,
Antibiotics preventing their growth heart burn, rashes Monitor side effects
diarrhea
Paracetamol used to temporarily relieve tiredness
300mg IV q 10h Analgesic and mild-to-moderate pain and anaemia Monitor for allergic
Antipyretics fever heart disease reaction

Health education:

· Promoting safety and preventing injury risk - PAtients with brain mass are prone to injury due to several factors, such as impaired cognition, altered sensory
perception, and motor deficits. These can lead to falls, seizures and other accidents. Safety and injury prevention for patients with brain mass or tumors involves
implementing measures to minimize the risk of falls and ensuring a safe environment. This includes maintaining clear pathways, removing tripping hazards, providing
adequate lighting and lessen physical activities.

Brain mass information (meningioma) - Meningiomas are tumors that develop in the meninges, the tissue that surrounds and protects the brain and spinal cord.
Although most meningiomas are not cancerous, these tumors can cause problems as they grow and press against important parts of the brain or spinal cord 1. The
cause of meningiomas is not well understood, but may include both genetic (inherited) and environmental factors 1. Meningiomas can occur in any part of the lining
over the brain or spinal cord. Approximately 90 percent occur within the head: inside the skull, at the base of the skull, or just above the spinal cord (the brainstem) 1.
Meningiomas can also occur around the spinal cord or in an area called the optic nerve sheath, which protects the nerve connecting the eye to the brain 1. More rarely,
meningiomas can arise within the ventricles or the skull 1.
Meningiomas can be managed with observation, surgery, and/or radiation therapy 1. In some cases, active intervention may be delayed and will only start if the tumor

14
begins to grow.

Discharge plan:

A case of Marigundon, Manuel 48 years old, Male, Filipino was admitted on October 20, 2023 for complaints of Headache for 3 weeks and High blood
pressure with the final diagnosis of Brain mass, Hypertension Stage II and Urinary Tract Infection. Doctor Isip, MD ordered a may go home and a follow
up visit on November 4, 2023. The patient was given home medications and was advised to return for follow up check up on November 10, 2023.

Subjective:

“medjo maray maray na po ako.” as verbalized by the patient.

Objective:

- Received necessary care from the admission, during and through discharge.
- Received directions from the attending physician

- Vital signs are within normal ranges.

Analysis:

The patient who complains of 3 weeks Headache has lack understanding about the diagnosis but turned out to be a symptom. The client is in need for further
explanation regarding the discharge plan and his role in the progress of treatment at home, he was then advised for a follow up check-up.

Planning:

- After health teaching, the patient will be able to understand the interventions and safety precautions taught. He will also be able to identify the

15
 medications advised to take at home.

Intervention:

● M (Medications)
○ Celecoxib 200mg 1 cap q 12h
○ Cinnarizine 25mg 1 tab 3x a day
○ Cetirizine 10mg 1 tab 2x a day
● E (Environment)
○ Advised the patient to maintain a clean and safe environment at all times.
○ Instructed the patient to restrict activity that might cause head injury.
○ Advised patient to remove accidental/hazardous things at home like tripping cords, rocks etc.
● T (Treatment)
○ Advised the patient to continue consumption of adequate fluids and consumption of healthy foods like fruits and vegetables.
○ Advised the client to continue taking the medications prescribed by the physician at home.
○ Advised the patient to follow the scheduled follow-up check up.
● H (Health Teachings)
○ Encouraged the patient to maintain a clean and safe environment at all times for safety purposes.
○ Discussed the importance of take home medications given
● O (Out-Patient Referrals)
○ Instruct the client to have follow up check up with the physician.
● D (Diet)
○ Advised with increased water intake.

○ Informed clients about the importance of having plenty fruits and vegetables.

Evaluation:

Goal was met. “Mabalik nalang po ako sa schedule ko na follow-up,.” verbalized by the patient.

Summary:

16
Mr. Marigondon is a 48 years old with final diagnosis of Brain mass, Hypertension stage II and Urinary Tract Infection who presents with headache for
three weeks . The patient was admitted on October 20, 2023. Series of laboratory tests were requested which included Hematology, Clinical Chemistry,
Electrolytes , urinalysis and Head CTscan which resulted in finding of Posterior fossa extra-axial mass suggestive of meningioma with malignant features. The
patients has Vitals signs in normal range except for the Blood Pressure that is slightly elevated, the WBC count is above normal range, he was discharged on
november 4, 2023 and were advised for a follow-up check up. Patient has given take home medications and given discharge health teachings.

Bibliography:

Prepared by: Gracel H. Cañada

Visitacion O. Bumalay, RN, MAN, Ed.D.

Assistant Dean, College of Nursing

17