Faculty of Health Profession

Nursing department
Case Study – Temporal Cyst SOL

Critical Care Nursing Clinical

Saja Jamal Jabarin

Clinical site: Al-Makassed hospital
Period of clinical practice: 18\12 – 23\1
The instructor: Ahmad salame
 Outline

o Biographic data
o Medical diagnosis
o Nursing Health History
o Chief complains
o History of present illness
o Other Current health problems
o Past medical Health History
o Past surgical history
o Psychosocial History
o Environmental History
o Family History
o Review of system: Physical assessment
o Intravenous therapy
o Lab test
o Pathophysiology of the disease- Multiple myeloma
o References
o Medications
o Care plan
o Teaching
o Summary
The reason for choosing this case is to know more about temporal cyst SOL and
craniectomy and how its related to critical care that we have been learned in the theoretical
course.

 Biographic Data:

o Name of penitent: A. H
o Age: 34 years old
o Hospital: Al-Makassed
o Ward: Neuro Intense care unit (ICU)
o Bed: 3
o Admission Date: .12.2024
o Type OF Admission: Elective – operation
o Allergies: Food: No allergies. Drug: No allergies. Not Known: No allergies
o Diet patient on: NPO
o Informant: The patient and the patient family and the patient’s file

 Medical Diagnosis:

Temporal cyst SOL

 Nursing Health History

 Chief complain:

“He admitted to the hospital for craniectomy.”

 History of present illness

The patient is diagnosed with temporal cyst SOL, admitted for craniectomy and
evaluation & management.

 Other Current health problems

No other current health problems.

 Past medical Health History

 The patient has no past medical history.

 Past surgical history

The patient had no surgeries

 Family History

The patient was working before her condition as a teacher. she is married and has 4
children. There is no inherited disease, and there is no contagious disease.

 Psychosocial History

The patient’s psychology was so bad during her illness, she was depressed and
anxious, but now she is in a good psychology, because she have her family supported
her during her illness.

 Environmental History

He lived in a relatively quiet area. According to her, the hospital environment

comfortable and the stuff also nice.

 Review of system: Physical assessment

 General Appearance

The patient skin and hair clean,50 WT, 170 HT, 37 years, she seems to be distress. he
is Conscious, oriented, he is using Foleys catheter, and cannula in his right hand. The
patient can’t move.

 Skin, Hair & Nails

Skin: Pale skin color, little dryness, lesions in skin tissues, no masses, no bad odors,
no purities, normal temperature 36.9, no scars. Texture: moisturized skin and clean
nails are cut and clean. Hair: short, light, unclean hair. Some gray hair. No swelling.

 Head and neck

 Head

S: The patient said there is no problems.

 O: The head is symmetry, a little dizziness, no pain, no trauma, syncope, there is no
unusual headache.

 Hair

S: The patient said there is no problems or masses.

O: tall, and light hair, clean hair, no alopecia.

 Eyes

S: The patient said there is no problems and she doesn’t use glasses.

O: The patient doesn’t use glasses, normal visual responses, no diplopia, no

glaucoma, No photophobia, normal white sclera, normal lashes and lids, equal,
regular rounded, normally reactive to light.

 Ears

S: The patient said there is no problems in hearing and she doesn’t use assistive
devices.

O: The patient does not use hearing aid, no presence of unusual discharge, no
infection, no tinnitus difficult to assess, no vertigo, and clean.

 Nose and sinus

S: The patient said there is no problems.

O: Normal olfactory ability, no frequent cold, no sneezing, no discharges, no pain no

epistaxis, no obstruction, no polyps and normal mucosa.

 Mouth and pharynx

S: The patient said there is no problems.

O: clean, no bleeding or swelling of gum, there is no abscesses, no dryness, no

salivation, no hoarseness, no lesions, no sore throat, no halitosis, normal voice-no
changes, does not use of dentures and no tonsillitis.

 Neck and nodes

S: The patient said there is no problems.

 O: No masses, no nodes enlargement, no pain, no swelling no tenderness.

 Respiratory system

S: The patient said there is no problems.

O: Respiratory: normal rate, rhythm, depth and saturation.

97% saturation, 15-20 respiratory rate.
No coughing, normal Chest movement, symmetrical, no retraction, not barrel chest.
Does not Uses accessory muscles. Lung sounds are clear, not diminished, no wheezes,
no crackles. The breathing pattern normal, no dyspnea, no orthopnea, no apnea, not
labored, no Gasping, not Cheyne-stokes. He is using Supportive device-face mask. No
respiratory disease.

 Cardiovascular system

S: The patient said there is no problems.

O: Pulses: normal rate 87, quality: regular, normal peripheral pulses.

Heart sounds: regular, no murmurs.
BP: 126/81, Normal capillary refill: <2 sec
No edema, no varicose veins, no chest pain.

 Abdomen

S: The patient said there is no problems.

O: No pain, no ascites, no bowel sounds, no flatulence, no hematemesis, no hernias,

no enlarged organs, normal umbilicus, no masses and no tenderness.

 General & Reproductive System

S: The patient said there is no problems. Menarche was at 15 years old. Regular
duration for 1 week, dysmenorrhea.

O: Normal developmental pattern, no lesions, no masses, no swelling, no discharge,

no prostate problems, impotence: normal, no venereal disease, fertility: normal.
 Rectum and anus

S: The patient said there is no problems.

O: No pain, no polyps, no inflammatory disease, no hemorrhoids.

 Eliminations

S: The patient said there is no problems.

O: The patient has normal bowel movement and doesn’t have any problem.

 Urinary

S: The patient said there is no problems.

O: Urine output is 2000-3000 ml per 24 hours, doesn’t use Foley’s catheter no anuria,
no polyuria, no dysuria, no urgency, no frequency, no hematuria, no nocturia, no
oliguria, no dribbling, no incontinence, no retention.

 Diet and Nutrient

S: The patient said there is no problems, and eat normally.

O: The patient on regular diet. Wt.: 50 kg. no anorexia, he sometimes has nausea and
vomiting, no heartburn. no anemia and no dysphagia.

 Musculoskeletal

S: The patient said there is no problems, and she independent doesn’t need help in
activity of daily living, and move normally

O: ROM: active movement in both upper limb, full PROM (passive).

Normal V\S, Weakness, fatigue. She walks normally. muscle tone: right: shoulder,
elbow, fingers 4/4. left: shoulder, elbow, fingers 4/4. Muscle power: left and right:
shoulder, elbow, fingers 4. Body alignment\ posture: normal, no kyphosis, no
lordosis, no scoliosis. She is on falling down precautions, use of restraints, bed in low
position, siderails up. Performance of ADLs: fully independent.

 Neurological
 S: The patient said there is no problems.

O: The patient is conscious, alert, oriented, she seems to comfortable.

Intravenous therapy

Type of IVF Amount Time started Time ended Reason for

IVF

Normal saline 1500 ml 8:00 am 8:00 pm Electrolyte

0.9% imbalance

:SPICAIL DIAGNOSTIC TEST DONE FOR THE PATIENT

.X-RAYS-CT SCAN-MRI…etc

.ULTRASOUNSD

.ECG&ECHO

.No data

Others: (CBC, KFT, LFT…ETC):

Test Normal values Patient values Interpretatio

n

WBC 3.60-10.60 2.29 Low

RBC 4.70-6.10 3.99 Low RBC

HGB 13.5-18 11.3 Low Hgb

HCT 40-54 34.9 Low

MCV 80-100 78.5 Normal

MCH 26-34 28.4 Normal

MCHC 32-36 32.5 Normal

RDW 11.50-14.50 12.9 Normal

PLT 150-450 120 Low

Neutrophil% 40-75 83.0 High

Neutrophil absolute count 2-7 1.90 Low

Lymphocyte % 20-45 15.2 Low

Lymphocyte absolute 1-3.50 0.347 Low

count

Monocyte% 2-10 1.30 Low

Monocyte absolute count 0.20-1 0.03 Low

Eosinophiles% 1-6 0.046 Low

Eosinophiles absolute 0.02-0.50 0.001 Low

count

Basophiles % 0-2 0.464 Normal

Basophiles absolute count 0.02-0.10 0.011 Normal

MPV 7.50-11.50 7.22 Low

Test Normal values Patient values Interpretatio

n

BUN 6-20 13.2 Normal

Serum creatinine 0.70-1.20 0.59 Normal

Serum electrolyte

Cl 98-107 98.5 Normal

K 3.50-5.30 4.26 Normal

Na 136-145 135 Low

 Pathophysiology of the disease-

o Definition

o Cause

o Symptoms

o Diagnosis

o Treatment

o References
 Medication

Generic name Dose- classification Side effect of Nursing

Frequenc medication prioritie
Trade name y-route s

Alloril 100 mg mg * 100 Xanthine oxidase Joint pain, joint stiffness Monitor
OD inhibitors or swelling. Rash signs of
Allopurinol hypersen
PO sitivity
reaction

Fluconazole cap 50 1 antifungals Skin rash, fast heartbeat,

mg *OD difficulty swelling
Diflucan PO

Solezol 40 anatomical Edema, depression,

mg*OD therapeutic insomnia
IV chemical
esomeprazole

Zovirax 400 antiviral Vomiting, nausea, rash,

mg*OD skin pain, headaches.
Acyclovir PO

Dexamethasone 10mg* corticosteroids Vision change, swelling,

STAT IV insomnia.
Decort

Zofran 8 Antiemetic Dizziness, headache,

mg*STAT constipation.
Ondansetron IV

Clexan 1 Anticoagulant Pain, bruising, bleeding,

SYR*OD swelling, itch, or rash at
Enoxaparin SC the injection site.
Prednisolone 100 Corticosteroids Sweating, weight gain,
mg*OD mood change.
Pediapred IV

Urosolit 300 gallstone Bladder pain, cloudy

mg*BID dissolution agents urine, dizziness.
ursodiol PO

Daunorubicin 50 anthracyclines Nausea, vomiting,

mg*STAT diarrhea, hair loss.
Cerubidine IV
 Main patient problem

1. Risk for falls

2. Risk for infection
3. Constipation
4. Fatigue
5. Pain
6. Headache
7. Risk for bedsores
8. Shortness of breath
9. Risk for bleeding
10. Nausea and vomiting
The patient problem: Risk for increased intracranial pressure related to increase brain
volume.

Nursing diagnosis:

Short goal: Patient verbalizes understanding of measures to prevent

Long goal: The client will exhibit

Nursing interventions Rational

Evaluation: The goal is

The patient problem: Risk for Infection.

The patient problem: increased stress

Nursing diagnosis: Risk for Infection related to presence of
Nursing diagnosis:

Short term goal: The patient will Identify actions to prevent/reduce risk of infection.

Short-term goal: The patient will

long-term
long-term goal:
goal: The patient
Patient and will remainwill
caregivers free of infectious processes, such as an elevated
temperature, or drainage from surgical sites or access sites

Nursing interventions Rational

Nursing interventions Rational

Require good hand washing protocol for all
personnel and visitors. Prevents cross-contamination and reduces
risk of infection.

Maintain strict asepsis for dressing changes,
wound care, intravenous therapy, and
catheter handling.
Evaluation: The goal is
Aseptic technique decreases the chances of
transmitting or spreading pathogens to or
between patients. Interrupting the chain of
infection (see image above) is an effective
way to prevent the spread of infection.

Evaluation: The goal is met, the patients is free from infection during hospitalization.

 Teaching

Teaching about daily care, prevention of bleeding, and prevention from falls are given
to the patient and to the caregiver.
 Summary

Male patient, 34 years old, has been admitted to the hospital in case of temporal cyst
SOL for craniectomy & evaluation after OP. he is on falling down precaution. Before
discharge he given teaching to minimize any complication in his condition.