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238855567 case-study-ni-divine-nch

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238855567 case-study-ni-divine-nch

  1. 1. 1 | P a g e Get Homework/Assignment Done Homeworkping.com Homework Help https://www.homeworkping.com/ Research Paper help https://www.homeworkping.com/ Online Tutoring https://www.homeworkping.com/ click here for freelancing tutoring sites 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
  2. 2. 2 | P a g e 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. 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
  3. 3. 3 | P a g e 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). 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.
  4. 4. 4 | P a g e PHYSICAL EXAMINATION General: pale and weak appearance Vital signs:  Blood pressure: 90/70 mmhg  Pulse rate: 80 bpm  Respiratory rate: 28bpm  Temperature: 36.7C
  5. 5. 5 | P a g e 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 Abdomen: no tenderness noted to each region upon palpation EXTREMETIES Upper Left extremety: slowed movements noted Limited movements noted With decreased muscle strength against force and gravity Able to perform slight hand grip Upper right extremity: decorticate arm Stiff arm noted, unable to initiate movements Diminished muscle strength against force and gravity
  6. 6. 6 | P a g e Unable to perform hand grip Lower left extremity: slowed movements noted Limited movements noted, unable to fully bend knee With decreased muscle strength against force and gravity Lower right extremity: stiff leg and thigh noted, unable to initiate movements Diminished muscle strength against force and gravity GLASCOW COMA SCALE Eye opening 3 Motor response 6 Verbal response 2 TOTAL 11 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
  7. 7. 7 | P a g e 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. 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)
  8. 8. 8 | P a g e 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. PATHOPHYSIOLOGY
  9. 9. 9 | P a g e DIAGNOSTICS AND LABORATORYRESULTS 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:
  10. 10. 10 | P a g e 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. DRUG STUDY Classification Action Adverse effect Indication Why given to the patient? Nursing consideration Ranitidine 15mg q8 IV Anti-ulcer/ H2 blockers Inhibits the action of histamine at theH2 receptor site located primarily ingastric parietal cells, resulting in inhibition of  Diarrhea  Fatigue  Insomnia  Pain in the muscles  Anemia  Depression  Easy bleeding Stomach ulcer problems GERD Treating upper portion of the gastrointestinal bleeding To prevent further bleeding in the Gastro intestinal due to increased gastric secretions Assess pt for epigastric or abdominal pain and observe for the black tarry stools or emesis check for the color and characteristics of the residual in the NGT, observe for coffee ground
  11. 11. 11 | P a g e gastric acid secretion  Losing of hair  Rash  Nausea  Headache  Stomach pain  Vomiting  Changes in the visual aspect residual. Dexamethasone Glucocorticoid, Corticosteroid Suppresses inflammation and the normal immune response. It prevents the release of substances in the body that causes inflammation. Nausea, Stomach pain, Bloating; Muscle weakness; or Headache, Dizziness, Spining sensation Slow wound healing Endocrine disorders, Rheumatic disorders, Collagen diseases, Dermatologic diseases, Allergic statesc, Ophthalmic diseases, Gastrointestinal diseases, Respiratory diseases, Hematologic disorders, neoplastic Niseases, edematous states, Cerebral edema. Helps prevent white blood cells from traveling to areas of the body where they might add to swelling problems (such as around tumors). Due to its action of alteration of the immune system, the patient must receive measures in decreasing risk for acquiring infection such as frequent hand washing, wearing mask, body hygienic care etc. Cinnarizine 25g/tab ½ tab BID Anti- vertgo/Anti- emetics It acts by interfering with the signal transmission between vestibular apparatus of the inner ear and the vomiting centre of the hypothalamus . Drowsiness Nausea vomiting, Stomach upset Headache Dry mouth Weight gain Vision Control of vestibular symptoms of both peripheral and central origin and of labyrinthine disorders including vertigo, dizziness, tinnitus, nystagmus, nausea and vomiting. The drug was given to the patient to correct balance problem Due to one of the chief complaint of the patient is vomiting, this drug was ordered to prevent vomiting Prevent patient from injury : fall. Do not leave the patient alone Assist patient during changing of position to prevent sudden falls Place rolled blankets or pillows at the sides
  12. 12. 12 | P a g e problems which if consistent may cause heart burn or Gastro intestinal tract COURSE IN THE WARD 01-21-13/ 10:00am Risk for injury: fall 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
  13. 13. 13 | P a g e 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-------------------------------- 01-22-13/9:00am Risk for acquiring Nosocomial Infection related to prolonged hospital stay D: Soiled linens noted; Soiled clothings noted; 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 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: assisted on passive and active ROM;provided folded blankets and pillows under joints; assisted during changing of positions
  14. 14. 14 | P a g e R: participated during active ROM and cooperates during passive ROM-------------------- 01-24-13/9:00AM Ineffective airway clearance related to presence of thick clear mucus secretions 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 NURSING THEORY Lydia Hall’s CORE, CARE and CURE
  15. 15. 15 | P a g e 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. 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
  16. 16. 16 | P a g e 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. 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
  17. 17. 17 | P a g e 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. 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
  18. 18. 18 | P a g e 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 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
  19. 19. 19 | P a g e 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! 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
  20. 20. 20 | P a g e 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 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.
  21. 21. 21 | 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
  22. 22. 22 | P a g e 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 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.
  23. 23. 23 | 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.
  24. 24. 24 | P a g e 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. REFERENCE Pillitteri Adele, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, Volume 2, 5th edition
  25. 25. 25 | P a g e 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

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