CASE STUDY

CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION

San Pablo, Tarlac City

CASE STUDY FORMAT

I. IntroductionII. Objectives

Nurse centeredIII. Nursing Process

A. Data Basea. Nursing health history A

1. Demographic data2. Chief complaint3. History of present illness4. Past medical history5. Family history6. Social and personal history7. Review of system

b. Nursing health history B1. General Description Of Client2. Health Perception-Health Management Pattern3. Nutritional-Metabolic Pattern4. Elimination Pattern 5. Activity-Exercise Pattern6. Sleep-Rest Pattern7. Cognitive-Perceptual Pattern8. Self-Perception – Self-Concept Pattern9. Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Pattern

c. Physical examinationd. Laboratory Findingse. Review of anatomy and physiologyf. Pathophysiology (highlight patient manifestation)

B. NCPC. Drug StudyD. Medical and Nursing ManagementE. METHOD

II. Evaluationa. Narrative evaluation of the objectivesb. Patient condition upon discharge

III. RecommendationIV. References/Bibliography

CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION

San Pablo, tarlac city

CASE STUDY FORMATI. Introduction

a. Introduction about patient/background

Age

Gender

Address

b. Significance/relevance to the concept

c. Background knowledge

Definition

Causative agent

Clinical manifestation

Mode of transmission

d. Current/target population

e. Risk factors/contributing factors

f. Prognosis and complications

II. Nurse centered

a. Objectives

NURSING HEALTH HISTORY A

Demographic data

Patient:Date: Ward: Bed:Age: Sex: C/S: Religion:Examiner:Informant:

I. Chief complaint

I. History of present illness

II. Past medical history (include dates and complications, if any)A. Pediatric and Adult Illness

Mumps Pertussis HPNMeasles Rheumatic Heart DiseaseChicken Pox Pneumonia HepatitisRubella Tuberculosis Others

B. Immunizations/Tests

BCG HEP B For PneumoniaDPT Measles OthersOPV For Flu

C. Hospitalizations

D. Injuries

E. Transfusions

F. Obstetrics/gynecologic History

G. Medications

H. Allergies

II. Family history

AGE List:Parents, Spouse, Children

Health Status or Cause of

Death

Diseases Present in the FamilyL D

L = Living TB = Tuberculosis HPN = Hypertension OB = ObesityD = Deceased DM = Diabetes Mellitus CA = Cancer J = Jaundice

HD = Heart Disease MI = Mental Illness KD = Kidney Disease O = Others

III. Social And Personal History

Birthplace: Birthday:Education: Ethnic Background:

Age and Sexes of Children (if any):

Client’s position in the family:

ResidenceHome Environment:

OccupationNature of present occupation: (stresses, hazards, etc.)

Financial Support System:

Habits (tobacco/alcohol use, others):

Diet (meal distribution, others)

Physical Activity/Exercise, if any:

Brief Description of Average Day:

IV. Review of system

General Description:Weight Loss: __________ Fatigue: ____________ Anorexia: ____________

Night Sweats: ____________ Weakness: __________

Skin:Itch: _________________________ Bruising: ________________________Rash: ________________________ Bleeding: ________________________Lesions: ______________________ Color Change: ____________________

Eyes:Pain Itch Vision LossDiplopia Blurring Excessive TearingGlasses/Contact Lenses

Ears:Earaches Discharge Tinnitus Hearing Loss

Nose: Obstruction Epistaxis Discharges

Throat and Mouth:Sore Throats Bleeding Gums Tooth Aches Decay

Neck:Swelling Dysphagia Hoarseness

Chest:Cough Sputum: (Amount & Character) HemoptysisWheeze Pain on Respiration Dyspnea: Rest/ExertionBreast: Lumps Pain Bleeding Discharge

CVS:Chest pain Palpitation Dyspnea on exertion EdemaPND Orthopnea Others: _________________________

GIT:Food tolerance Heartburn Nausea JaundiceVomiting Pain Bloating Excessive GasConstipation Change in BM Melena

GU:Dysuria Nocturia Retention Polyuria DribblingHematuria Flank painMale: Penile Discharge Lesion Testicular pains others:Female: Menarche: (age) LMP: (date) Cycle: _____ others:

Extremities:Joint pains varicose veins ClaudicationEdema Stiffness Deformities

Neuro:Headaches Dizziness Memory Loss FaintingNumbnessTingling Paralysis: ____________ Paresis: _________Seizures Others: ______________________________

Mental Health Status:Anxiety Depression InsomniaSexual Problems Fears

NURSING HEALTH HISTORY B

a. General Description Of Client

b. Health Perception-Health Management Pattern

c. Nutritional-Metabolic Pattern

d. Elimination Pattern

e. Activity-Exercise Pattern

f. Sleep-Rest Pattern

g. Cognitive-Perceptual Pattern

h. Self-Perception – Self-Concept Pattern

i. Role-Relationship Pattern

j. Sexuality-Reproductive Pattern

k. Coping-Stress Tolerance Pattern

l. Value-Belief Pattern

PHYSICAL EXAMINATION

GENERAL SURVEY:

Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______

Skin: Color: __________ Turgor: ___________ Bruises: __________

State of Hydration: _____________

Eyes: Sclera: _____________________ Pupils: ______________________

Respiratory: Easy Breathing in Distress No Distress

VITAL SIGNS:

HR ___________ / min Temperature: ____________

BP Supine R/L arm ___________ mmHg Capillary Refill: ____________

Sitting R/L arm ___________ mmHg RR: _____________________

Standing R/L arm ___________ mmHg

Others: ______________________________

BODY POSITION/ALIGNMENT:

Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________

Alignment: Appropriate Inappropriate

MENTAL ACUITY:

Oriented coherent appropriately responsive others: ___________

Disoriented incoherent inappropriately responsive

SENSORY/MOTOR RESTRICTIONS:

Amputation deformity paresis paralysis fracture

Gait hearing disorder speech others: ______________________

EMOTIONAL STATUS:

Euphoric Depressed Apprehensive

Angry/Hostile Others: ___________________________

MEDICALLY IMPOSED RESTRICTIONS:

CBR w/out BRP_____ BR w/ BRP_____ OOB – Chair_____ Restricted Ambulation _____

OTHER HEALTH RELATED PATTERNS:

Fatigue Restlessness Weakness Insomnia Coughing

Dyspnea Dizziness Pain Others: ______________________

ENVIRONMENT:

Room Temperature: Adequate Inadequate

Lighting: Adequate Inadequate

SAFETY:

Violations of medical asepsis: ________________________________________________

Violations of safety measures: ________________________________________________

ACTIVITIES OF DAILY LIVING:

Can/Cannot perform

Feeding Brushing teeth Bathing Transferring

Dressing Combing Others: __________________________________

PHYSICAL EXAMINATION FINDINGS

HEAD/SKULL:

EYES/VISION:

EARS/HEARING:

NOSE, MOUTH AND THROAT:

NECK AND LYMPH NODES:

THORAX (CHEST AND LUNGS):Anterior:

Posterior:

HEART AND CARDIOVASCULAR SYSTEM:

ABDOMEN:

NEUROLOGICAL:

MUSCULOSKELETAL:

GENITALIA:

EXTREMETIES:

(Follow IPPA format when documenting Physical Examination findings)

LIST OF IDENTIFIED NURSING PROBLEMS

PRIORITIZATION OF NURSING PROBLEM

1. Oxygenation2. Nutrition3. Elimination4. Activity and Exercise5. Comfort and Safety6. Sexual- Reproductive7. Psychological8. Psychosocial

LABORATORY FINDINGS

Review of anatomy and physiology

Pathophysiology (highlight patient manifestation)

NCP

ASSESSMENT INTERVENTIONEVALUATION

CUES NURSINGDIAGNOSIS

SCIENTIFICEXPLANATION

PROBLEM STATEMENT

(GOAL)

NURSINGINTERVENTION RATIONALE

Drug Study

DRUG NAME/

GENERIC

CLASSI-FICATION

DOSAGE/STOCKDOSE

ACTION INDICATION CONTRAINDICATION

SIDEEFFECTS

ARVERSEREACTION

NURSING RESPONSIBILITIES

Medical Management (

Nursing Management

Discharge Planning

METHOD (Example)

M (Medications):Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset.Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.

E (Exercise/Environment):Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allow you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.

T (Treatments):Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.)

H (Health knowledge of disease):Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is

important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.

O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.

D: (Diet):Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.

Evaluationa. Narrative evaluation of the objectivesb. Patient status after discharge

Recommendation

References/Bibliography

How to Write a Case Study Paper for NursingA well-written case study paper for a nursing program requires some planning and consideration. All too often students begin writing before they complete appropriate, preliminary steps. Ideally, before you begin a paper, you should already have determined the focus and format of it. You will then follow this up with a fact-gathering step in which you will gather and collate the content of your paper. Finally, there is the construction/execution step in which you will write the paper in a standard format (such as the APA style) and edit it.A nursing case study paper contains several sections that fall into three categories:1. The status of the patient Demographic data Medical History Current diagnosis and treatment

2. The nursing assessment of the patient Vital signs and test results Nursing observations (i.e., range of motion, mental state)

3. Current Care Plan and Recommendations Details of the nursing care plan (including nursing goals and interventions) Evaluation of the current care plan Recommendations for changes of the current care plan

Patient StatusThe first portion of the case study paper will talk about the patient — who they are, why they are being included in the study, their demographic data (i.e., age, race), the reason(s) they sought medical attention and the subsequent diagnosis. It will also discuss the role that nursing plays in the care of this patient.Next, fully discuss any disease process. Make sure you outline causes, symptoms, observations and how preferred treatments can affect nursing care. Also describe the history and progression of the disease. Some important questions for you to answer are: 1) What were the first indications that there was something wrong, and 2) What symptoms convinced the patient to seek help?Nursing AssessmentWhen you are discussing the nursing assessment of the patient describe the patient’s problems in terms of nursing diagnoses. Be specific as to why you have identified a particular diagnosis. For example, is frequent urination causing an alteration in the patient’s sleep patterns? The nursing diagnoses you identify in your assessment will help form the nursing care plan.Current Care Plan and Recommendations for ImprovementDescribe the nursing care plan and goals, and explain how the nursing care plan improves the quality of the patient’s life. What positive changes does the nursing care plan hope to achieve in the patient’s life? How will the care plan be executed? Who will be responsible for the delivery of the care plan? What measurable goals will they track to determine the success of the plan?The final discussion should be your personal recommendations. Based on the current status of the patient, the diagnosis, prognosis and the nursing care plan, what other actions do you recommend can be taken to improve the patient’s chances of recovery? It is important that you support your recommendations with authoritative sources and cited appropriately per APA style guidelines.Creating a well-written nursing case study paper doesn’t need to be a grueling challenge. It can actually be very rewarding, and it’s good practice for assessing patients while out in the field, too. Keep in mind that your instructor will not only grade you on the quality of the content of your paper, but by how you apply the APA style, as well. If you find that you are spending too much time formatting your paper, consider using formatting software as a helpful tool to ensure accuracy so you don’t lose points on a well written paper because of some formatting errors.David PlautDavid Plaut is the founder of Reference Point Software (RPS). RPS offers a complete suite of easy-to-use formatting template products featuring MLA and APA style templates, freeing up time to focus on substance while ensuring formatting accuracy. For more information, log

ontohttp://www.referencepointsoftware.com/ or write to:info @ referencepointsoftware.comReference Point Software is not associated with, endorsed by, or affiliated with the American Psychological Association (APA) or with the Modern Language Association (MLA).

INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also called Pneumonitis or

Bronchopneumonia. Pneumonia can be a serious threat to our health. Although pneumonia is a special concern for

older adults and those with chronic illnesses, it can also strike young, healthy people as well.  It is a common illness

that affects thousands of people each year in the Philippines, thus, it remains an important cause of morbidity and

mortality in the country.

There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia,

bacteria, viruses, fungi or other organisms attack your lungs, leading to inflammation that makes it hard to breathe.

Pneumonia can affect one or both lungs. In the young and healthy, early treatment with antibiotics can cure bacterial

pneumonia. The drugs used to fight pneumonia are determined by the germ causing the pneumonia and the

judgment of the doctor. It’s best to do everything we can to prevent pneumonia, but if one do get sick, recognizing

and treating the disease early offers the best chance for a full recovery.

A case with a diagnosis of Pneumonia may catch one’s attention, though the disease is just like an ordinary cough

and fever, it can lead to death especially when no intervention or care is done. Since the case is a toddler, an

appropriate care has to be done to make the patient’s recovery faster. Treating patients with pneumonia is necessary

to prevent its spread to others and make them as another victim of this illness.

ANATOMY AND PHYSIOLOGY

The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the

process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20

times per minute taking in and disposing of those gases.

Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each

bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each

lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs

are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways

that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called

alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated

blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled

from the body.

Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of

those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances

has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each

other during breathing.

PATHOPHYSIOLOGY

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid.

Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells can’t work properly.

Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs

in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects

patches throughout both lungs.

Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common.

Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia

pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella

pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses:

respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher

bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical

strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus

neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever).

The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions

from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from

contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization,

cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as

in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to

transmissible agents.

Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes

accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles

with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H.

influenzae.

NURSING PROFILE

a. Patient’s Profile

Name: R.C.S.B.

Age: 1 yr,1 mo.

Weight:10 kgs

Religion: Roman Catholic

Mother: C.B.

Address: Valenzuela City

b.  Chief Complaint: Fever

Date of Admission: 1st admission

Hospital Number: 060000086199

c. History of Present Illness

2 days PTA – (+) cough

(+) nasal congestion, watery to greenish

(+) nasal discharge

Tx: Disudrin OD

Loviscol OD

Few hrs PTA - (+) fever, Tmax= 39.3 C

(+) difficulty of breathing

(+) vomiting, 1 episode

Tx: Paracetamol

Sought consultation at ER: Rx=BPN, Salbutamol neb.

IE: T = 38.3C, CR= 122’s, RR= 30’s

(+) TPC

SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema

d. Past Illness

(-) asthma

(-) allergies

e. Family History

PMHx: (+) asthma (mother)

f. Activities of Daily Living

Sleeping mostly at night and during afternoon

Usually wakes up early in the morning (5AM) to be milkfed.

Eats a lot (hotdogs, chicken, crackers, any food given to her)

Active, responsive

BM (1-2 times a day)

Urinates in her diaper (more than 4 times a day)

Likes to play with those around her

g. Review of Systems

Neuromuscular: weakness of muscles

Integumentary: (-) cyanosis

Respiratory: tavhypnea; (+) DOB; (+) coarse crackles, (+) wheezes,

Digestive: food aversion, vomits ingested milk

DRUG STUDY

View NCP

NURSING ACTIONS

INDEPENDENT

positioning of the patient with head on mid line, with slight flexion

rationale: to provide patent, unobstructed airway , maximum lung excursion

auscultating patient’s chest

rationale: to monitor for the presence of abnormal breath sounds

provide chest and back clapping with vibration

rationale: chest physiotheraphy facilitates the loosening of secretions

considering that the patient is an infant, and has developed a strong stranger anxiety

as manifested by “white coat syndrome” ,  it is a nursing action to play with the patient.

rationale: to establish rapport, and gain the patients trust

DEPENDENT

administer due medications as ordered by the physician, bronchodilators, anti pyretics and anti biotics

rationale:  bronchodilators decrease airway resistance, secondary to bronchoconstriction,

anti pyretics alleviate fever, antibiotics fight infection

placing patient on TPN  prn

rationale:  to compensate for fluid and nutritional losses during vomiting

COLLABORATIVE

assist respiratory therapist in performing nebulization of the patient

rationale:  nebulization is a favourable route of administering bronchodilators

and aid in expectorating secretions, hence patient’s breathing

PHYSICIAN’S ORDER SHEET

11/19/06          

Admit patient to ROC under the service of Dr. Vitan secure consent for  admission and management, TPR every shift

then record. May have diet for age with strict aspiration precaution, IVF D5 0.3NaCl 500cc to run at

62-63mgtts/min.May give paracetamol 125mg 1supp/rectum if oral paracetamol is not tolerated.

11/20/06         

For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use zinacef brand of cefuroxine 750mg- given ½

vial 375mg every 8hours, nebulize    (Ventolin 1 nebule) every 6 hours, paracetamol drugs prn every 4hours (Temp

37.8).

11/21/06         

Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF, revise Cefuroxine IV to Cefuroxine 500mg via

deep Intramuscular BID,continue  management.

11/22/06          

Continue management and refer.

DISCHARGE PLANNING

Take the entire course of any prescribed medications. After a patient’s temperature returns to normal,

medication must be continued according to the doctor’s instructions, otherwise the pneumonia may recur.

Relapses can be far more serious than the first attack.

Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid

relapse.

Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen

mucus in the lungs.

Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be infected.

It’s important to have the doctor monitor his progress.

Encourage the guardians to wash patient’s hands. The hands come in daily contact with germs that can

cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands

thoroughly and often can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g.

smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.

Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.

Protect others from infection. Try to stay away from anyone with a compromised immune system. When

that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.

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ESTHER FUNMILAYO AFOLALU

06370934

NUI Galway

Bachelor of Nursing Science 3NG1

NU324 CLINICAL PRACTICE 6

Title of assignment: Case study (Brain tumour).

Module Leader: Toni Ui Chiardha

Assignment due date: 08 May 2009

Actual date of submission: 08 May 2009

Word limit for assignment: 2500 words

Actual word count: 2768 words

Brain tumours are relatively uncommon yet this particularly cancer

has a significant effect on the affected individual; low survival rates and dire

prognosis in many cases are a sad reality for most patients. These cancers

occur most frequently in older populations and are also a common cancer

seen in children. (Baumann & Zumwalt, 1989, Pelletier et al., 2002, Grant,

2004, McKinney, 2004). Smeltzer & Bare (2004 pg. 1970) described a brain

tumour as ‘a localized intracranial lesion that occupies space within the

skull...with effects occurring from compression and infiltration’. A benign

or malignant lesion can arise from anywhere in the complex brain structure

thus there are many distinct forms of primary brain tumours. The most

common and aggressive types are gliomas which arise from the glial cells of

the brain itself, different forms of gliomas include astrcoytomas,

glioblastomas, and oligodendroblastomas (Franges, 2006). Other main

types of tumours include meningiomas which are slow-growing benign

masses arising from the meninges, acoustic neuromas, pituitary adenomas

and angiomas (Smeltzer & Bare, 2004, Franges, 2006). McKinney (2004)

identified several risk factors known to be associated with developing brain

tumours, including previous head injury, disruption of the functioning of the

immunes system by viruses, allergies, infections and gradual development

of changes to the individual’s genetics, and exposure to certain chemicals,

extremely low frequency magnetic fields, and radiofrequency signals from

mobile phones.

Clinical manifestations of brain tumours are often due to the effects of

the tumour whether it is compressive as in the case of meningiomas or

related to specific effects on the area of the brain where the tumour occurs,

for example an individual with a pituitary adenoma might present with

hormonal disorders as well as generalised tumour effects (Hickey, 2003a).

General effects are mostly related to abnormalities in brain volume caused

by the tumour itself and cranial nerves impairment, these include seizures

due to disturbances of brain electrical activities, cerebral oedema,

obstruction to normal cerebrospinal fluid flow, raised intracranial

pressure(ICP), headaches and vomiting, cognitive deficits, fatigue, changes

in level of consciousness, and other focal deficits relating to specific areas

of the brain and resulting in specific symptoms such as visual, speech and

language disturbances, personality changes and coordination

problems(Belford, 2000, Hickey, 2003a, Bohan & Glass – Macenka, 2004,

Lovely, 2004). Initial diagnosis of brain tumour is based on neurological

examination and assessment of presenting symptoms; diagnosis is

confirmed by identifying the location of a tumour through computer

topography (CT scan) and magnetic resonance imagery (MRI) (Rampling et

al., 2004, Franges, 2006). Further diagnosis to evaluate tumour histology

and extensiveness are usually done through CT or MRI guided biopsy

(Hickey, 2003a, Bohan & Glass – Macenka, 2004). Treatment of the cancer

is usually aimed at precise surgery to remove or lessen the tumour so as to

relive tension effects and symptoms of raised ICP. Curative or palliative

chemotherapy many also be used, but radiotherapy remains the prevailing

treatment for most brain tumours (Hickey, 2003a, Rampling et al., 2004,

Whittle, 2004).

A diagnosis of brain tumour is worrisome for patients and their

families, the cancer affects individuals intensely in a lots of different ways;

damage to the intricate workings of the brain may result in symptoms that

not only hamper the individual physically but also pose a great threat to

whole personality and sense of self, thus holistic nursing care of the patient

is paramount (Barker, 1990, Mogensen, 2008). There are certain nursing

priorities and interventions that are distinctive for brain tumour patients;

three of which include management of seizures, management of increased

intracranial pressure and cerebral oedema and management of fatigue and

activity intolerance.

Management of seizures: Seizures commonly occur in patients with

brain tumours with up to 30% of patients presenting with seizures at

diagnosis and between 50 – 70% presenting with seizure activities as the

disease progresses (Rabbitt & Page, 1998). Seizure occurrence may be

related to the histology and location of the tumour; it’s been investigated

that slow-growing temporal and frontal lobe tumours accounts more for the

occurrence of seizures (Kilpatrick et al., 1994, Krouwer et al., 2000, Hickey,

2003a, van Breemen et al., 2007). Seizure activity in brain tumour patients

are said to be caused by tumour’s irritation of and interference with the

cells and electrochemical activity of the brain (Belford, 2000, Rabbitt &

Page, 1998, Hickey, 2003a). Managing seizures is a significant aspect of the

nursing care for these patients as seizures further complicates a diagnosis

of brain tumour by limiting quality of life, ability to perform daily activities,

independence and coping (Lovely, 2004, van Breemen et al., 2007, Tremont

– Lukats et al., 2008). Nursing interventions during a seizure are to promote

patient dignity and safety by clearing the environment, keep the bed in a

low position with side rails up and padded, it’s also important not to put

anything in patient’s mouth while teeth is clenched during a grand-mal

seizure, it’s essential to monitor airway and ventilation during a seizure and

to guide but not restrict patient movement. Following a seizure it’s

important to ensure the patient is comfortable and positioned on side, note

any resultant weakness or paralysis and the specifics of seizure

activity( duration, movements of involved body parts, papillary reaction,

level of consciousness and behavioural and psychical conditions post-

seizure) should be documented accurately (Hickey, 2003b, Carpenito –

Moyet, 2008). It’s also important to administer prescribed anticonvulsants,

paying particular attention to medication interactions, serum levels and

potential side effects (Belford, 2000). Brain tumour complications such as

increased intracranial pressure and post neurosurgical complications such

as decreased cerebral perfusion, pyrexia, hypotension, hypoxia, and

electrolyte imbalance could potentially aggravate seizures and should thus

be managed as appropriate (Barker, 1990, Hickey 2003c). Seizures can be

very upsetting for the patient and family, thus nursing interventions are also

aimed at educating patients and family members regarding coping with the

impact of seizures, recognising auras preceding seizures and taking safety

measures in the event of a seizure (Rabbitt & Page, 1998).

Management of increased intracranial pressure and cerebral

oedema: Within the confined space of the skull, three main components;

brain, cerebrospinal fluid and blood are needed to maintain adequate

intracranial pressure (0 – 15mmHg), any abnormal volume shift relating to

any one of these components would result in a compression of the

remaining two which would consequently increase intracranial

pressure(Allan, 2006). Brain tumours intervene with this complex

intracranial relationship between volume and pressure by initiating cerebral

oedema, disrupting the flow of cerebrospinal fluid and leading to collection

of fluid in the cellular space in brain (Smeltzer & Bare, 2004, National Brain

Tumor Association, 2007, Mogensen, 2008). Increased intracranial pressure

prompts further cerebral oedema which results in movement of brain tissue

though the small opening of the rigid dura, this is a particularly morbid

complication of neurological malignancies resulting in death from brain

herniation (Hickey, 2003d, Smeltzer & Bare, 2004).

Observing for signs of increased intracranial pressure are thus a vital

nursing priority in relation to care of the brain tumour patient in all stages

of the diseases, even postoperatively as complications from curative

surgical intervention may aggravate brain swelling and intracranial

pressure (Barker, 1990, Hickey, 2003c). Tension headaches with associated

nausea and vomiting are often experienced in connection with increased

intracranial pressure and are caused by stress on the pain receptive areas

in the brain (Cohen, 1995, Lovely, 2004). Other signs and symptoms include

deteriorating level of consciousness, impaired papillary function,

papilledema, abnormal motor responses, sudden onset of one-sided

weakness, respiratory difficulties, and late changes in the vital signs termed

as Cushing’s triad (hypertension, bradycardia and irregular respirations)

(Barker, 1990, Belford, 2000, Hickey, 2003d, Smeltzer & Bare, 2004, Allan,

2006). Nursing interventions include carrying out frequent neurological

examinations to monitor for the aggravation of symptoms. Head of bed

should be elevated to 30 – 45 degrees in order to optimise jugular venous

drainage which would contribute to lowering intracranial pressure (Hickey,

2003d, Carpenito – Moyet, 2008). Extreme flexion and extension of the head

and neck, straining, coughing or any other process that could illicit the

valsalva manoeuvre should be avoided as this impede jugular veins,

obstructs venous return and increases intracranial pressure. Likewise in

this regard, a relaxed stress –free environment should be provided for the

patient. Furthermore, nursing activities that could increase intracranial

pressure such as suctioning, giving a bed bath, and repositioning should not

be carried out consecutively (Belford, 2000, Hickey, 2003d, Smeltzer &

Bare, 2004, Carpenito – Moyet, 2008). During episodes of increased

intracranial pressure, oxygenation may be indicated in order to maintain

sufficient blood flow to the compromised brain, steroids(dexamethasone)

and osmotic diuretics( mannitol )are usually prescribed to reduce brain

oedema and draw out excess fluids from the brain and reduce pressure

(Hickey, 2003d).

Management of fatigue and activity intolerance: Fatigue is a

major and recurrent issue in patients with brain tumours and has wide-

ranging and crippling effect on daily living activities and functioning. It may

be a chronic symptom, a result of many factors relating to the cancer itself,

pain, the effect of treatment such as chemotherapy, radiotherapy or

anticonvulsant medications or related to depression, anaemia, infection or

impaired functional ability (Lovely, 2004, Palmieri, 2007). It is described by

Lovely (2004, p. 278) as a ‘symptom depicting weakness, exhaustion,

lethargy, inability to concentrate, malaise, sleepiness and lack of

motivation’. Activity intolerance is decreased performance in and inability

to fulfil activities of daily living due to fatigue (McFarland & McFarlane,

1997, Straight, 2002). According to National brain tumor foundation (2007)

fatigue and resultant activity intolerance is regarded as one of the worst

incapacitating effect of having a brain tumour. It could potentially lead to

worse problems concerning quality of life, ineffective coping and serious

neuropsychiatry complications such as chronic depression if not addressed

promptly (Eriksson, 1994, Lovely, 1998, Pelletier et al., 2002, Smeltzer &

Bare, 2004).

It’s thus a clinically relevant nursing priority to acknowledge and

evaluate the impact of fatigue on quality of life when caring for these

groups of patients. Nursing interventions are directed towards identifying

causes of fatigue and helping patients achieve increased activity intolerance

by attaining a balance between rests and carrying out activities within

capabilities, decreasing level of fatigue and consequently achieving more

independence in performing activities of daily living (Straight, 2002). If

fatigue is related to anaemia, it’s vital to transfuse and monitor effects of

red blood cells as prescribed to raise haemoglobin levels, also if depression

is evaluated as a cause for fatigue and activity intolerance, anti-depressants

may be prescribed and patient should be informed sufficiently regarding

this (Lovely, 2004). Other nursing interventions aimed at managing fatigue

incorporate assisting with activities as appropriate and encouraging

exercises in order to maintain muscle strength. Referring the patient to and

liaising with physiotherapy and occupational therapy would be beneficial in

assessing patient’s specific ability and developing ways to enhance activity

tolerance. During periods of non – hospitalisation, the nurse should provide

information to the patient and family regarding developing methods of

energy preservation by recognising causes of fatigue, arranging activities

around energy levels and aiming to exercise for at least 30 minutes thrice

weekly(Lovely, 2004, Palmieri, 2007). Moreover, it’s essential to encourage

the patient and reassure of appropriate means of achieving an optimal level

of activity through proper hydration, eating a nutritionally balanced diet ,

getting adequate levels of sleep, rest, and exercise and managing stress

through breathing exercises, relaxation techniques and mental stimulation

(Straight, 2002, Smeltzer & Bare, 2004).

As Graham & Cloughesy (2004) explained the histological and

pathological distinctiveness of the different classification of brain

malignancies means that pharmacological treatments and interventions

would inevitably vary. However there are two main classes of pharmacology

agents that are routinely prescribed for use in patients with brain tumour,

due to the fact that they manage symptoms that manifest fairly consistently

in patients with all types of brain tumour.

Corticosteroids are a group of pharmacological agents that behave

in the same ways as the steroid hormones produced by the adrenal glands,

they are effectively used to reduce cerebral swelling and production of

cerebrospinal fluid and relieve signs and symptoms associated with brain

tumours such as motor deficits, headaches and impaired mental states in up

to as much as two-thirds of brain tumour patients (Graham & Cloughesy,

2004, Grant, 2004, Nahaczewski et al., 2004). The main type of

corticosteroids used are glucocorticoids, which works as an inflammatory

agent and also by binding to intracellular glucocorticoids receptors and

initiating effects that stops the use of glucose by fatty tissues and

muscles(Janning & Lassiter, 2003, Nahaczewski et al., 2004).

Dexamethasone is the most commonly prescribed corticosteroid; initial dose

of 10mg is given intravenously, subsequent dosage is normally 16mg/day

and may be given either orally or intravenously, both ways acting equally

effectively in the swift and total absorption of the drug (Gerrard & Franks,

2004, Nahaczewski et al., 2004). Whilst proving to be an effective aspect of

the pharmacological treatment of brain tumour patients, dexamethasone

presents with many side effects and significant drug interactions. At least

half of patient receiving dexamethasone therapy will experience at least one

side effects, which include gastritis, endocrine hormonal imbalances giving

rise to hyperglycaemia, appetite stimulation and subsequent weight gain,

fluid and sodium retention, steroid characterised ‘moon face’ appearance,

steroid induced psychosis and other drastic neuropsychological changes,

thromboembolism, severe musculoskeletal defects due to osteoporosis and

proximal myopathy and most severely immunosuppression in the long term

resulting in profound neutopenia and increased susceptibility to infections

especially PCP(pneumocystis carinii pneumonia) (Rabbitt & Page, 1998,

Janning & Lassiter, 2003, Graham & Cloughesy, 2004, Gerrard & Franks,

2004, Mogensen, 2008).

Nursing management of side effects are related to providing

emotional support for altered body image and psychological disturbances,

monitoring for risks of infections, preventing gastrointestinal complications

by administering dexamethasone with meals and administering prescribed

histamine-2 receptor blocker or proton pump inhibitor, and educating

patients regarding blood glucose monitoring and eating a low sodium diet

(Rabbitt & Page, 1998, Nahaczewski et al. 2004, Franges, 2006). Drug

interactions induced toxicity by phenytoin and perpetuation of side effects

in patients receiving chemotherapy makes dosage monitoring a vital issue

(Graham & Cloughesy, 2004, Nahaczewski et al., 2004). If side effects

worsen, dexamethasone may need to be discontinued, gradual dose

reduction is essential as abrupt withdrawal of steroid hormones may

complicate neurological symptoms and also induce life-threatening

cardiovascular complications (Rabbitt & Page, 1998, Janning & Lessiter,

2003).

Anticonvulsants are pharmacological agents commonly prescribed

to manage seizure activity which are common occurrences in brain tumour

patients; however several studies have shown no proven benefit of

prophylactic use of anticonvulsants in the absence of seizure activity

(Rabbitt & Page, 1998, Gerrard & Franks, 2004, van Breemen et al., 2007).

There are different classes of anticonvulsants that may be used to control

seizures but phenytoin is one often prescribed. Phenytoin is part of a class

of anticonvulsants known as hydratonins and acts by inhibiting sodium

reception and movement in the brain and thus regulating brain cell’s

sensitivity to electrical discharges that causes epileptic muscle contractions

(Janning & Lassiter, 2003, Lovely, 2004).

Initial dose of phenytoin is 20mg/kg given intravenously at 50 mg/min

and subsequent dosage of 4 – 7mg/kg/d (qd – tid) is maintained , however,

due to the well-known side effects and drug interactions of phenytoin with

dexamethasone and certain chemotherapy drugs(such as nitroureas,

etoposide, and methotrexate) that occurs because all pharmacological

agents are competing for the same important metabolic P450 enzyme

pathway, it’s often a challenge to maintain therapeutic levels(10 – 20 mg/l)

of phenytoin and avoid drug toxicities in brain tumour patients (Rabbitt &

Page,1998, Krouwer et al., 2000, Graham & Cloughesy, 2004, Lovely, 2004

Tremont – Lukats et al.,2008). It is thus essential to monitor serum drug

level and signs of toxicities and other side effects which can often present

like and be mistaken for tumour dysfunction. Phenytoin’s side effects which

are perpetuated by drug toxicities especially in chemotherapy receiving

patients include neuro-cognitive deficits(ataxia, dizziness, headaches,

encephalopathy), gingival hyperplasia, suppression of the bone marrow,

liver impairment, and severe skin rashes known as Stevens Johnson

syndrome which can occur in the first few weeks following drug

commencement (Krouwer et al., 2000, van Breemen et al., 2007).

This case study reveals the complex and diverse needs of patient

presenting with a brain tumour. Diagnosis of brain tumours presents many

challenges for patients, family and health professionals. Clinical

manifestations of the illness may be subtle or associated with drastic

changes in patient’s ability to function. Successful disease management is

dependent on nurses’ knowledge of the disease and accompanying clinical

manifestations and acknowledgment of how the cancer diagnosis is

affecting patient’s functioning, coping and relationship. This is achieved by

identifying key nursing priorities, managing symptoms, observing closely

for complications and carrying out appropriate therapeutic clinical and

psychosocial nursing interventions.

REFERENCE LIST

Allan, D. (2006) ‘Disorders of the nervous system’, in Alexander, M. F.,

Fawcett, J. N., & Runciman, P. J. (eds.) Nursing practice, hospital and home:

the adult. 3rd edn. Edinburgh: Churchill Livingstone, pp. 395 – 442.

Barker, E. (1990) ‘Brain tumour: frightening diagnosis, nursing challenge’,

RN, 53 (9), pp. 46 – 52

Baumann, C. K. & Zumwalt, C. B. (1989) ‘Intracranial neoplasms. An

overview’, AORN journal, 50 (20), pp. 240 – 257.

Belford, K. (2000) ‘Central nervous system cancers’ in Yarbro, C. H.,

Frogge, M. H., Goodman, M., & Groenward, S. L. (eds.) Cancer nursing:

principles and practice’. 5th edn. London: Jones & Bartlett, pp. 1048 – 1096.

Bohan, E. & Glass – Macenka, D. (2004) ‘Surgical management of patients

with primary brain tumours’, Seminars in oncology nursing, 20 (4), pp. 240

– 252.

Carpenito – Moyet, L. J. (2008) Nursing diagnosis: application to clinical

practice.12th edn. Philadelphia: Lippincott, Williams & Wilkins.

Cohen, B. H. (1995) ‘Headaches as a symptom of neurological disease’,

Seminars in pediatric neurology, 2 (2), pp. 144 – 150.

Eriksson, J. H. (1994) Oncologic nursing. 2nd edn. Springhouse PA:

Springhouse Publishing Co.

Franges, E. Z. (2006) ‘When a headache is really a brain tumor’, The nurse

practitioner, 31 (4), pp. 47 – 51.

Gerrard, G. E. & Franks, K. N. (2004) ‘Overview of the diagnosis and

management of brain, spine, and meningeal metastases’, Journal of

neurology neurosurgery and psychiatry, 75 (supplement II), pp. ii37 – ii42

BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009).

Graham, C. A. & Cloughesy, T. F. (2004) ‘Brain tumor treatment:

chemotherapy and other new developments’, Seminars in oncology nursing,

20 (4), pp. 260 – 272.

Grant, R. (2004) ‘Overview: brain tumour diagnosis and management /Royal

college of physicians guidelines’, Journal of neurology neurosurgery and

psychiatry, 75 (supplement II), pp. ii18 – ii23 BMJ [Online]. Available at:

http://jnnp.bmj.com (Accessed 23 March 2009).

Hickey, J. V. (2003a) ‘Brain tumors’ in Hickey, J. V. (ed.) The clinical

practice of neurological and neurosurgical nursing. 5th edn. Philadelphia:

Lippincott, Williams & Wilkins, pp. 483 – 508.

Hickey, J. V. (2003b) ‘Seizures and epilepsy’ in Hickey, J. V. (ed.) The

clinical practice of neurological and neurosurgical nursing. 5th edn.

Philadelphia: Lippincott, Williams & Wilkins, pp. 501 – 526.

Hickey, J. V. (2003c) ‘Management of patients undergoing neurosurgical

procedures’ in Hickey, J. V. (ed.) The clinical practice of neurological and

neurosurgical nursing. 5th edn. Philadelphia: Lippincott, Williams & Wilkins,

pp. 319 – 344.

Hickey, J. V. (2003d) ‘Intracranial hypertension – theory and management of

increased intracranial pressure’ in Hickey, J. V. (ed.) The clinical practice of

neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott,

Williams & Wilkins, pp. 285 – 318.

Janning, S. W. & Lassiter, T. F. (2003) ‘Pharmacological management of

neuroscience patients’ in Hickey, J. V. (ed.) The clinical practice of

neurological and neurosurgical nursing. 5th edn. Philadelphia: Lippincott,

Williams & Wilkins, pp. 215 – 237.

Kilpatrick, C., Kaye, A., Dohrmann, P., Gonzales, M., & Hopper, J. (1994)

‘Epilepsy and primary cerebral tumours’, Journal of clinical neuroscience, 1

(3), pp. 178 – 181.

Krouwer, H. G. J., Pallagi, J. L., & Graves, N. M. (2000) ‘Management of

seizures in brain tumour patients at the end of life’, Journal of palliative

medicine, 3(4), pp. 465 – 475.

Lovely, M. P. (1998) ‘Quality of life of brain tumor patients’, Seminars in

oncology nursing, 14 (1), pp. 73 – 80.

Lovely, M. P. (2004) ‘Symptom management of brain tumor patients’,

Seminars in oncology nursing, 20 (4), pp. 273 – 283.

McFarland, G. K. & McFarlane, E. A. (1997) Nursing diagnosis and

intervention: planning for patient care. 3rd edn. St. Louis: Mosby.

McKinney, P. A. (2004) ‘Brain tumours: incidence, survival, and aetiology’,

Journal of neurology neurosurgery and psychiatry, 75 (supplement II), pp.

ii12 – ii17 BMJ [Online]. Available at: http://jnnp.bmj.com (Accessed 23

March 2009).

Mogensen, K. (2008) ‘The whole picture: addressing the diverse needs of

the patient treated for a brain tumor’, Clinical journal of oncology nursing,

12 (5), pp. 817 – 819.

Nahaczewski, A. E., Fowler, S. B., & Hariharan, F. S. (2004)

‘Dexamethasone therapy on patients with brain tumors – a focus on

tapering’, Journal of neuroscience nursing, 36 (6), pp. 340 – 343.

National brain tumor foundation (2007) The essential guide to brain tumors.

Available at:

http://www.braintumor.org/upload/contents/330/GuideFINAL2007.pdf.

(Accessed 15 April 2009).

Palmieri, R. L. (2007) ‘Responding to primary brain tumor’, Nursing, 37 (1),

pp. 36 – 41.

Pelletier, G., Verhoef, M. J., Khatri, N., & Hagen, N. (2002) ‘Quality of life in

brain tumor patients: the relative contribution of depression, fatigue,

emotional distress and existential issues’, Journal of neuro-oncology, 57 (1),

pp. 41 – 49.

Rabbitt, J. E. & Page, M. S. (1998) ‘Selected complications in neuro-

oncology patients’, Seminars in oncology nursing, 14 (1), pp. 53 – 60.

Rampling, R., James, A., & Papanastassiou, V. (2004) ‘The present and

future management of malignant brain tumours: surgery, radiotherapy,

chemotherapy’, Journal of neurology neurosurgery and psychiatry, 75

(supplement II), pp. ii24 – ii30 BMJ [Online]. Available at:

http://jnnp.bmj.com (Accessed 23 March 2009).

Smeltzer, S. C. & Bare, B. (2004) Brunner & Suddarth’s Textbook of

medical-surgical nursing. 10th edn. Philadelphia: Lippincott, Williams &

Wilkins.

Straight, L. (2002) ‘Activity intolerance’ in Ackley, B. J. & Ladwig, G. B.

(eds.) Nursing diagnosis handbook. A guide to planning care. 5th edn. St

Louis: Mosby, pp. 120 – 125.

Tremont – Lukats, I.W., Ratilal, B.O., Armstrong, T., & Gilbert, M.R. (2008)

‘Antiepileptic drugs for preventing seizures in people with brain tumors’,

Cochrane database of systematic review, Issue 2 Art. No.: CD004424. DOI:

10.1002/14651858.CD004424.pub2.

van Breemen, M. S. M, Wilms. E. B., & Vecht, C. J. (2007) ‘Epilepsy in

patients with brain tumours: epidemiology, mechanisms, and management’,

Lancet. Neurology, 6 (5), pp. 421 – 430.

Whittle, I. R. ‘The dilemma of low grade glioma’, Journal of neurology

neurosurgery and psychiatry, 75 (supplement II), pp. ii31 – ii36 BMJ

[Online]. Available at: http://jnnp.bmj.com (Accessed 23 March 2009).