St.

Paul University Manila

(St. Paul University System)
680 Pedro Gil St., Malate, 1004 Manila, Philippines
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
NURSING CARE STUDY
(Application of Nursing Process)
I. Patients Information
This is the case of a patient with initials of W.B. He is a 38 year old male. He had a chief complaint of gradual
progression of headache. His MRI showed a 2.5x2.5 cm suprasellar mass with obstructive HCP and was advised to undergo a surgery
at Philippine General Hospital.
The patient has no known allergies to any food or drugs and with medications of Dexamethasone 5mg IV q8,
Ranitidine 50mg IV q8, Cloxacillin 1g IV ANST(-) 1 hour prior to OR, Gentamycin 80mg IV 1 hour prior to OR, Tramadol 50 mg IV
q8, Mannitol 100cc IV q6. The clients final diagnosis is craniopharygioma.
II. Physical Assessment
Clients Initial: W.B.
Clients Admitting Diagnosis: Craniopharyngioma

AREAS TO BE
ASSESSED

Skull

Scalp
&
Hair

METHODS
OF
ASSESSMEN
T

NORMAL
FINDINGS

Rounded
(normocephal
ic and
symmetric,
Inspection
with frontal,
(Size, shape,
parietal, and
symmetry and
occipital
deformities)
prominences)
; smooth
skull contour;
no
deformities
White scalp,
no lice, no
Inspection
dandruff, no
(Color, lesions, lesions, hair
hair
evenly
distribution and distributed,
consistency)
thick, shiny,
free from
split ends

HEAD

Inspection
(Shape, texture,
symmetry of
movements,
facial
expressions,
edema and
hollowness)

Oval, square
or round in
shape,
symmetrical
facial
movements,
smooth, free
from
wrinkles, no
involuntary
movements,
and facial
expression
depends on
mood.
Symmetric
nasolobial
folds. No
signs of
edema and
hollowness.

Eyebrows

Inspection
(hair
distribution,
alignment, and
skin quality
and movement)

Hair evenly
distributed;
skin intact.
Eyebrows
symmetricall
y aligned;
equal
movement.

Eyelashes

Inspection
(Evenness of
distribution and
direction of
curl)

Equally
distributed;
curled
slightly
outward.

Inspection
(Surface
characteristics,
position in

Skin intact;
no discharge;
no

Face

ACTUAL
FINDINGS

Rounded and
smooth skull
contour. No
deformities.

White scalp,
no lice, no
dandruff, no
lesions, hair
evenly
distributed,
thick, shiny,
free from split
ends
Round in
shape,
symmetrical
facial
movements,
free from
wrinkles on
forehead and
outer canthus
of the eyes, no
involuntary
movements,
and facial
expression
depends on
mood and
situation.
Symmetric
nasolobial
folds. No
signs of edema
and
hollowness.
Evenly
distributed
hair; skin is
intact without
lesions.
Eyebrows
symmetrically
aligned;
moves equally
Eyelashes are
equally
distributed and
are curled
slightly
outward.
Eyelids have
intact skin; No
discoloration
and discharge

INTERPRETA
TION

Normal skull
on inspection

Normal
Findings

Normal
findings.

Normal
eyebrows.

Normal
eyelashes.

REVIEW OF RECORDS
1. Medical plan of care
To ensure and confirm diagnosis, series of diagnostic tests and laboratory exams
should be done to the patient that will verify the diagnosis:
A. Clients health history health history of the client may reveal past or recent illness
B. Physical examination to assess present health condition of the client as well as the
signs and symptoms present to him
C. Blood Chemistry- to measure different chemicals in the blood
D. Urinalysis- to assess the effects of CVD on renal function and the existence of
concurrent renal or systemic diseases
E. Tumor Markers- making a diagnosis of cancer or of a specific type of cancer
F. ECG- graphical recording of the electrical activities of the heart
To ensure condition, progress and response to treatment, continuous monitoring of
the patient is required:
Monitor vital signs and record every four hours. This is done to be able to evaluate
the bodys response to treatment.
Monitoring fluid intake and urinary output every shift and record to be able to
evaluate kidney function based on the amount of his daily intake of fluids, through
oral means and intravenous fluid administration and urinary output.
To maintain adequate nutrition and hydration:
IVF of PNSS 1L x 30 gtts/min- to replace fluid and electrolyte loss
Side drip of PNSS 1L x KVO and D5W 500 cc + 4 ampules of dopamine to replace
fluid and electrolyte loss
Diet as tolerated
Pharmacologic treatment:
Dexamethasone 5mg IV q8
Ranitidine 50mg IV q8
Cloxacillin 1g IV ANST(-) 1 hour prior to OR
Gentamycin 80mg IV 1 hour prior to OR
Tramadol 50 mg IV q8
Mannitol 100cc IV q6
To prevent spread of infection and further complications:
Wash hands before and after assessing the patient and after each procedure
Wear mask and gloves in every procedure that is needed to be done
Practice aseptic technique in every procedure to prevent infection
Encourage hygiene to prevent growth of microorganisms
To prevent recurrence of the disease:
Compliance of medications as prescribed by the physician
Always keep the clients back dry
To prevent further injury:

Observe safety precaution by raising side rails

Assist in activities of daily living

LABORATORY RESULTS
A. Blood Chemistry

Date
Examinatio Norma
Unit
Performe
n
l Value
Examinatio
Norma Unit
Result
d
n
l Value
4,
October 4,
BUN
2.60- October
mmol/
2010
2010
6.4
L

WBC
5L
19.76
9
10x10

Nursing
Responsibilitie
s
Significance
Nursing Responsibilities
6.2 N
It is measuring the nitrogen portion of the urea, is
Explain the
2
used as glomerular function and production and
need for this
It serves excretion
as a usual
guide
therate
severity
of BUN
the The
or the clients
of the
urea.toThe
at which
rises client
is procedure
to
disease. Thus
identifies
a
certain
person
with
significant
other
should
influenced by degree of tissue necrosis, protein
client.tell the
increase susceptibility
to the
infection.
be informed
of no the
catabolism and
rate at which the kidneys excrete
client that
reasons
the
specimen
urea nitrogen.
fasting is was
it is to be
needed.
Createnine 53-115 umol/L 102 N It signifies Impaired renal function. Creatinineordered,
is the how
collected,
the
equipment
Monocytesby-product
Monocyte
0.020%
0.109
have several
roles
in
the
immune
system
in the breakdown of muscle creatinine
thepressure
stinging
0.090
and this includes:
replenish
Apply
phosphate
resulting from energy metabolism.needed,
It is and
sensation
that
may
be felt.
resident macrophages
and
dendritic
cells
under
or a pressure
produced at a constant rate depending on muscle
There
no to the
fluid
normal states,
in response
to is
inflammation
dressing
mass and
of the
person and
removed from the body
by are
restrictions
before
signals, monocytes
can
move
quickly
(approx.
8-12
site to prevent
the kidneys. A disorder in kidney function reduces
collection
the
hours) to sites
of
infection
in
the
tissues
and
excretion of creatinine, resulting in increased levels furtherof
specimen.
divide/differentiate
into
macrophages
and
dendritic
of blood creatinine. It is a more specific and sensitive bleeding.
cells to elicit anindicator
immuneof
response..
kidney disease than the BUN
Label
the
obtained
Sodium
136mmol/ 140 N Sodium maintains the osmotic pressure and acid-base Observe the site
specimen for
and
secure
bleeding. it
145
L
balance and to transmit nerve impulses. Sodium
properly
concentration is under control of the kidneys and the
central nervous system acting through the endocrine
Apply pressure or a
system.
pressure dressing to the
Potassium
3.50mmol/ 3.5 N Potassium level evaluates changes in body potassium
venipuncture
site
to
5.10
L
and is helpful in diagnosing disorders of acid-base
prevent further bleeding.
and water balance in the body. It is not an absolute
Observe the site for
value and varies with the circulatory volume and
bleeding.
other factors such as taking diuretics.
In hypertension, the aldosterone level increases thus
Provide safety to the
resulting to water and sodium retention wherein the
client
potassium in our body is secreted that may result to
hypokalemia.
B. Metabolic profile
C. Urinalysis

Result

Significance

Date
Performe
d

Examinatio
n

Norma
l Value

Color

Pale
Yellow
to
Amber

Result

Interpretatio
n

Pale Normal Result

Yellow

Appearance

Clear

Clear

Normal Result

Ph

4 6.8

Normal Result

August 17,
2010

Significance

Nursing Responsibilities

The color of the urine ranges from

pale yellow to amber because of
the pigment chrome. It indicates
the concentration of the specific
gravity of urine. The color of the
urine is primarily due to the
urochrome( pigments that are
present in the diet or formed form
the metabolism of the bile). Due to
the present of the abnormal
pigments the color of urine changes
in many disease sates
The normal urine should be clear.
However, normal urine may also be
cloudy which provides a warning
abnormality such as pus, RBC, or
bacteria. However, excretion of
cloudy urine may not be abnormal
since the change in pH may cause
precipitation within the bladder of
normal urinary constituents.
Alkaline urine may appear cloudy
because of phosphates, acid urine
may appear cloudy because of
urates.
This is an indication of the renal
tubules ability to maintain normal
hydrogen ion concentration in the
plasma and extracellular fluid.

The client should be told

the type of specimen
needed and the best time of
day to collect it.
Explain the purpose and
specific method of urine
collection to the client.
Give the client the proper
specimen jars and
cleansing agents, if
necessary. The perianal
area should be washed if it
soiled with feces.
A small amount of fresh
urine is required, enough to
moisten a small strip of pH
paper.
A freshly avoided specimen
of at least 30ml is needed
for most urinometers. Food
and fluid restrictions are not
necessarily before
collection of the specimen.

Specific
Gravity

1.005
1.030

1.020

Normal Result

Specific gravity is a measurement

of the concentration of urine. It is a
means by which the kidneys
ability to concentrate urine is
measured. The range of urine
specific gravity depends on the
state of hydration varies with urine
volume and the loads of solid
excreted.

NURSING CARE PLAN

Assessment

With foleycatheter
With IV
Will be
undergoing an
invasive
procedure
(craniotomy)

NURSING CARE PLAN

(includes independent and dependent Nursing functions)
Nursing
Goal/Objectives
Nursing Intervention
Rationale
Diagnosis
Independent:
Risk for
After 8 hours of
Document and report
A complete
infection related
nursing
results of perioperative
nursing
to surgical
interventions the
nursing assessment
assessment
incision
patient will be
identify risk factors
allows
able to:
development of
a. Have normal
individualized
vital signs and
care plan
laboratory
Make sure all surgical
The human body
values
team members wear
is a major source
b. Have the
appropriate operating
of microbial
incision site
room attire
contamination
remain free
Inspect operating room
To provide safe
from signs and for cleanliness before
environment
symptoms of
opening supplies and
infection
instruments

Evaluation
Goals are met:
The vital signs
of the patient
remained on
normal
baseline
The incision
remain free
from signs
and symptoms
from infection
Dehiscence is
prevented

c. Avoid
dehiscence
from
occurring

Perform a surgical hand

scrub. Put on drapes on
patient, furniture and
equipment.

Check package integrity,

chemical indicator and if
appropriate expiration
date on all sterile items
before dispensing them
onto sterile field
Use proper techniques
when opening items onto
sterile field
Keep operating room
doors closed at all times
and minimize traffic in
and out

Surgical hand
scrub minimizes
number of
microorganisms
on skin. Sterile
gown and gloves
protect against
contamination
sterile drapes
create sterile
field
All items used
within field must
be sterile or field
will become
contaminated.
To avoid
contamination

Air turbulence
caused by
movement and
mixing of
corridor air with
room air can
sharply increase
bacterial counts
in operating
room

Maintain room
temperature and relative
humidity, unless
contraindicated
Wash hands following
contact with patient or
any object contaminated
with blood or body
fluids
Disinfect and sterilize all
instruments and
equipments before and
immediately after
surgical procedure

Promptly clean areas

outside sterile field that
become contaminated by
blood, tissues or body
fluids with an approved
disinfectants

Cooler air and

lower humidity
inhibit microbial
growth
Hand washing is
the most
effective means
for preventing
microbial
transmission
All instruments
and equipments
used during
surgery must be
free from
microorganisms
sterilizing
instruments and
equipment after
use prevents
growth and
spread of
microorganisms
during storage
To prevent
distribution of
microbes into
environment

Dependent
Perform preoperative
skin preparation of
surgical site (done by the
surgeon)

Classify surgical wound

according to degree of
contamination of wound
and surrounding tissue

Administer antibiotic as
ordered

Apply sterile dressing to

surgical wound before
remaining drapes

Skin preparation
reduces resident
microbial count
to subpathogenic
amounts and
inhibits rapid
rebound growth
of microbes
Classification
helps to assess
risk of wound
infection from an
endogenous
source and
determine need
for antibiotic
therapy
Intraoperative
administrations
of antibiotic can
decrease
incidence of
wound infection
and lessen its
severity
To avoid wound
contamination
and subsequent
infection

Cues

with copious
amount of
whitish
secretions
sedated
ineffective
cough
difficulty
vocalizing
nasal flaring
prolonged
expiration
phase
pursed lip
breathing
shortness of
breath

NURSING CARE PLAN

(includes independent and dependent Nursing functions)
Nursing
Goal/Objectives
Nursing Intervention
Rationale
Diagnosis
Ineffective airway After 4 hours of
Dependent
clearance related
nursing
Assess respiratory status
To detect early
to presence of
interventions the
at least every 4 hours
signs of
tracheobronchial
patient will be able
compromise
secretion
to:
Place the patient in semi
To aid breathing
a. cough
fowlers position and
and chest
effectively
support upper extremities expansion and to
b. expectorate
ventilate basilar
sputum
lung fields
c. absent
Help patient turn, cough
To help prevent
adventitious
and deep breathe
pooling of
breath sounds
secretions and to
d. produce normal
maintain airway
sputum
patency
e. have patent
Mobilize patient to full
To facilitate chest
airway
capabilities
expansion and
f. have ABG levels
ventilation
remain at
Provide tissues and paper To prevent
baseline
bags for hygienic sputum spreading
g. understand the
disposal
infection

Evaluation
Goals are met if
the patient will:
cough
effectively
expectorate
sputum
no
adventitious
breath
sounds
have patent
airway
have normal
ABG
understand
health
teaching
demonstrate
controlled

need for
adequate
hydration,
sputum monitor
and taking
medications as
ordered
h. demonstrate
controlled
coughing
technique

Teach patient about:

Maintaining adequate
hydration
Daily monitoring of
sputum
Controlled coughing
and postural drainage
The need to remain
active
Dependent

These steps
involve patient in
own health care

Suction as needed and

ordered

To stimulate
cough and clear
airways
To enhance
mobilization of
secretions that
interfere with
oxygenation

Perform postural drainage

percussion and vibration
every 4 hours as ordered

Cues

with copious
amount of
whitish
secretions
sedated
ineffective

NURSING CARE PLAN

(includes independent and dependent Nursing functions)
Nursing
Goal/Objectives
Nursing Intervention
Rationale
Diagnosis
Ineffective
After 4 hours of
Dependent
breathing pattern nursing interventions
Assess respiratory status To detect early
related to
the patient will be able at least every 4 hours
signs of
decreased energy to:
compromise
a. normal RR
Assess ABG levels
To monitor
b. normal ABG
according to facility
oxygenation and
levels
policy
ventilation status

coughing
technique

Evaluation
Goals are met if
the patient will:
normal RR
normal ABG
report
feeling

cough
difficulty
vocalizing
nasal flaring
prolonged
expiration
phase
pursed lip
breathing
shortness of
breath

c. report feeling
comfortable
when breathing
d. report feeling
rested
e. demonstrate
diaphragmatic
pursed-lip
breathing
f. achieve
maximum lung
expansion with
adequate
ventilation

Auscultate breath sounds

at least every 4 hours
Assist patient to
comfortable position

Teach patient about:

Pursed-lip breathing
Abdominal breathing
Performing
relaxation techniques

To detect
decreased or
adventitious
breath sounds

To promote
comfort, chest
expansion and

ventilation of
basilar lung fields
These measures
allow patient to
participate in

maintaining
health status and
improve
ventilation

comfortable
when
breathing
report
feeling
rested
demonstrate
d
diaphragmat
ic pursed-lip
breathing
achieved
maximum
lung
expansion
with
adequate
ventilation

DATA FROM TEXTBOOK

What is it?
Craniopharyngioma is a tumour that develops in the area of the brain called the hypothalamus,
which is close to the pituitary gland. It is usually found in children or young adults and accounts
for around 10% of all brain tumours in young people. It can however be diagnosed at any age.
How does it develop?
The pituitary gland starts growing early in a developing fetus from a small amount of tissue
called Rathke's pouch, that starts off in the throat area and moves upwards to the brain.
Craniopharyngiomas develop from the remains of Rathke's pouch. This explains their name
(cranio=skull, pharynx=throat, oma=tumor).
Is it dangerous?
Craniopharyngiomas are nearly always benign but can cause symptoms once they press upon
other parts of the brain around them. Therefore they are often quite large when they are detected
and may range in size from one, to more than four inches in diameter.
What are the common symptoms?
The symptoms produced by a craniopharyngioma are variable depending upon where the tumour
is and which area of the brain that it presses on.
1. Compression of the pituitary stalk or the pituitary gland itself can interrupt the
manufacture of part or all of the pituitary hormones. This may cause one or more of the
following symptoms

Loss of growth in children

Irregular periods

Delayed puberty

Reduction or loss of sexual drive

Fatigue

Low blood pressure

Dry skin

Increased sensitivity to cold and heat

Constipation

Unexplained weight gain

An increase in Prolactin levels, which can cause a milky discharge from the nipples (in
both men and women).

2. Pressure on the nerves that control vision can cause loss of peripheral (side) vision, which
may be noticed especially when driving
3. Involvement of the hypothalamus, an area at the base of the brain, may result in weight
gain, drowsiness, problems with temperature regulation, mood changes and depression or
passing large quantities of urine leading to problems with water balance (a condition
called Diabetes Insipidus).
4. Other symptoms can develop for a variety of reasons and may include personality
changes, headache, confusion, nausea and vomiting.
What happens if a craniopharyngioma is suspected?
Several specialists may need to be involved in planning investigations and supervising treatment.
1.

An Endocrinologist usually assesses the patient first and arranges tests to help make the
diagnosis.

2.

Most people will need an operation. This is done by a Neurosurgeon and can be
performed at Ninewells Hospital.

3.

Radiation is also sometimes used as treatment, usually in combination with surgery.

Radiation treatment is supervised by a specialist called an Oncologist.

What tests will the Endocrinologist do?

1. Blood tests can detect whether the pituitary gland is manufacturing enough hormones. If
any hormones are lacking, it is best to start treatment with hormone tablets as soon as
possible.
2. Complete Pituitary Function tests to assess all the major pituitary hormones.
3. Water deprivation test may be required if you are passing much urine and are thirsty.
4. An eye test (Visual field test) is used to determine whether there is any pressure on the
nerves controlling vision. This can usually be done on the same day as the Endocrine
Clinic appointment.

5. MRI scans are used to obtain a picture of the tumour and can tell the extent of the tumour
and whether it is invading or pressing on the surrounding brain. Most
craniopharyngiomas contain fluid and many also contain some calcium (like bones). This
means that they have a unique appearance on a scan that helps to distinguish them from
other pituitary tumours. There is often a waiting list for an MRI scan.
What type of operation is needed?
The surgeon will attempt to remove most or all of the tumour and preserve as much of the
normal tissue in the pituitary and surrounding brain. The type of operation that is needed will
depend on the exact location of the tumour.

If the tumour is mainly confined to the area of the pituitary gland, a trans-sphenoidal
operation (through the nose and sinuses) is often used.

If the tumor is not in this region, the surgeon may need to make an opening in the skull
(called a craniotomy) to allow access to the tumour.

Following surgery, tests are needed to determine if the pituitary gland is functioning normally. If
it is not, then hormones that are lacking need to be replaced in tablet form.
Why is radiation treatment necessary?
Sometimes it is not possible to completely remove the tumour. If this happens, radiation
treatment may be recommended. The aim of radiation treatment is similar to surgery i.e. to
destroy the tumour and preserve or improve pituitary function and vision. Radiation is also given
to prevent a tumour regrowing.
Hormone deficiencies can develop many years after radiation treatment has finished. For this
reason, all people who have undergone radiation treatment should be reassessed by an
Endocrinologist. Initially this will happen every few months but later once or twice a year can
suffice.

PATHOPHYSIOLOGY
Craniopharyngiomas are dysontogenic tumors with benign histology and malignant
behavior, as they have a tendency to invade surrounding structures and recur after what was
thought to be total resection. Craniopharyngioma usually presents as a single large cyst or
multiple cysts filled with a turbid, proteinaceous material of brownish-yellow color that glitters
and sparkles because of a high content of floating cholesterol crystals. Because of its appearance,
it has been compared to machinery oil. It most frequently arises in the pituitary stalk and projects
into the hypothalamus. It extends horizontally along the path of least resistance in various
directionsanteriorly into the prechiasmatic cistern and subfrontal spaces; posteriorly into the
prepontine and interpeduncular cisterns, cerebellopontine angle, third ventricle, posterior fossa,
and foramen magnum; and laterally toward the subtemporal spaces. It can even reach the sylvian
fissure.
Vascular supply is dependent on different sources, usually all from the anterior
circulation. The anterior portion of the tumor is supplied by small perforators coming off A1 (ie,
anterior cerebral artery); lateral portions receive perforators from the proximal portion of the
posterior communicating artery; and the intrasellar part is supplied by branches of the
intracavernous meningohypophyseal arteries. Craniopharyngioma rarely is supplied with blood
coming from the posterior circulation, unless the anterior blood supply for the anterior
hypothalamus and floor of the third ventricle is lacking.
Tumor adhesion to surrounding vascular structures represents the most common cause of
incomplete tumor removal. Fusiform dilatations of large surrounding vessels have been reported
after attempts at radical dissection of the tumor capsule; they injure vasa vasorum, thereby
weakening the adventitia. Tumor adhesion is the result of local inflammation. Several
inflammatory cytokines have been shown to be elevated in the craniopharyngioma cyst fluid
when compared with CSF. IL-1alpha and TNF-alpha were significantly elevated but lower than
10-fold. IL-6 was greater than 50,000 times more concentrated in the cystic fluid than CSF.1 This
supports the hypothesis that biomodulation of the cytokine profile could lead to long periods of
stability and even tumor regression. IFN-alpha exerts diverse influences mainly on cytokine
antagonists and soluble adhesion molecules and has been shown to play a role in the treatment of
craniopharyngioma in some limited trials, both after systemic use and local, direct intracystic
use.

DRUGS STUDY

Drugs

Tramadol

Mannitol

Dose,
Route
and
Freque
ncy
D:50mg
R: IV
F: q8

D: 100
ccc
R: IV
F: q6

Classific
ation

Action/
Indication

Side
Effects

Analgesic Tramadol is used similarly

to codeine, to treat
moderate to moderately
severe pain and most types
of neuralgia,

including trigeminal
neuralgia.

Nause
a and
vomiti
ng
Diarrh
ea

Mannitol is used clinically

to reduce acutely
raised intracranial

pressure until more

definitive treatment can be
applied, e.g., after head
trauma.

Bradyc
ardia
Hypot
ension
Cold
extrem
ities
Flushi
ng

Diuretic

Cloxacilli
n

Gentamyc
in

Cloxacillin is used
against staphylococci that
produce beta-lactamase,
due to its large R chain,
which does not allow
the beta-lactamases to
bind.

D: 1 g
R: IV
F: 1
hour
prior to
OR

Antibacte
rial

D: 80
mg
R: IV
F: 1
hour
prior to
OR

Antibacte
Gentamycin is

rial
an aminoglycoside antibiot
ic, used to treat many
types
of bacterial infections,

particularly those caused

by Gram-negative bacteria
.

Nause
a and
vomiti
ng
Abdo
minal
pain

Nause
a and
vomiti
ng
Consti
pation

Nursing
Responsibilitie
s
1. Docume
nt
indicati
on for
therapy,
characte
ristics
and
signs
and
sympto
ms
1. Docum
ent
indicati
ons for
therapy,
characte
ristic of
sympto
ms and
outcom
e
2. Note
ECG,
VS and
cardiop
ulmonar
y
assessm
ent
3. Monitor
intake
and
output
4. Keep
log of
BP and
pulse
for
provide
r review
1. Docum
ent
indicati
on for
therapy,
characte
ristics
and
signs
and
sympto
ms
1. Docume
nt
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ST. PAUL UNIVERSITY MANILA

ST.PAUL UNIVERSITY SYSTEM
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
NURSING CARE STUDY
(Application of Nursing Process)

CRANIOPHARYNGIOMA

Submitted by:
Ma, Christina B. Talosig
BSN 4D
Group 9

Submitted to:
Mr. Nick I. Alfaro
Clinical Instructor

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