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Neurological disorder and neurosurgery
problems
Prepared by
Eman Mokhtar Mohamed
Hanaa farhate
2nd term of doctorate
Under supervision
Prof. Magda Abed Al aziz
Prof. of Medical Surgical Nursing
Faculty of Nursing
Ain Shims university
2009
Outlines
• Introduction
• Anatomy &physiology
• Assessment of neurological
disorder
• Neurosurgery
• Intra cranial hemorrhage
brain trauma
• Spinal trauma
• spinal tumor
• Brain tumor
• Application of nursing care
plane on patient with a Brain
Tumor
• Common
neurological disorder
Vascular disorders
(Cerbrovascular accident)
- Infectious disorders (Meningitis
and encephalitis)
- Autoimmune disease (Mythenia
gravis)
- Seizure disorders (Epilepsy)
General objectives
• At the end of this presentation the group
participant should be able to applied nursing care
plane for patient with neurological disorder
Specific objectives
• Discuss anatomy &physiology
• Explain assessment of neurological disorder
• Discuss Common neurosurgical disorder
• Discuss Common neurological disorder
• Apply of nursing care plane of patient with a
Brain Tumor
Introduction
• World Health Organization estimated in 2006 that
neurological disorders and their sequalae affect
as many as one billion people worldwide, and
identified health inequalities and social
stigma/discrimination as major factors
contributing to the associated disability and
suffering.
Introduction
• Assessment in either case requires knowledge of
the anatomy and physiology of the nervous
system and an understanding of the tests and
procedures used to diagnose neurologic
disorders. Knowledge about the nursing
implications and interventions related to
assessment and diagnostic testing is also
essential.
ANATOMY AND PHYSIOLOGY
NERVOUS SYSTEM
CENTRAL
BRAIN
PEREPHERAL
SPINAL CORD
CEREBRUM
CEREBELLUM
BRAIN STEM
Cells of the Nervous System
• The Neuron
• Functional unit of the nervous system; transmits impulses
• Cell Body: Controls metabolic activity
• Dendrite: Transmits impulses to the cell body
• Axon: Transmits impulse away from the cell body
Neuroglial Cells
• Provide support, nourishment, & protection to the neuron
Neurological Assessment
• Health History
• General Signs & Symptoms
• Physical Examination
• Diagnostic measures and Lab. investigation
Health history
• Past Medical & Surgical History
• Medications
• Allergies
• Habits / Lifestyle Changes
• Familial History of Neurologic Disorders
General Signs / Symptoms
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•
•
•
•
•
•
•
•
Memory Loss
•
Disorientation
•
Changes in level of consciousness •
Seizures
•
Speech or Swallowing Difficulties •
Vision & Pupillary Changes
•
Dizziness
Headache / Pain
Weakness
Loss of Coordination
Tremors
Numbness
Paralysis
Nausea / Vomiting
Bowel or Bladder Difficulties
Physical Examination
Considerations
• Level of Consciousness
• Consciousness:
• Arousal (Alertness) or Awareness (Content)
• Assessment: Orientation vs. Disorientation
• Person, Place & Time
• Varying sequence of questions is important !!
Physical examination
• Assessment Tools
• Glasgow Coma Scale (GCS)
• Three Categories:
• Eye opening
• Best motor response
• Best verbal response
• Scoring
• Highest or best possible score 15
• A score of < 8 indicates coma
• Lowest or worst possible score 3
Motor Assessment Cont.,
• Motor Movements & Strength
• Evaluate each extremity and compare with opposite side;
record each extremity separately.
• Graded: 0 to 5
(O = Paralysis → 3 = ROM / Gravity → 5 = ROM / Full Resistance)
• Deep Tendon Reflexes (DTR)
• Tap appropriate tendon with percussion or reflex hammer
• Achilles, quadriceps, brachioradialis, biceps and triceps
• Graded: 0 to +4
( 0= Absent→ +2 = Normal → +4= Hyperactive)
Diagnostic and lab investigation
Diagnostic Testing
• Imaging Studies of the Skull & Spine
• X-rays
• MRI
• CT Scans
• Position Emissions Tomography (PET) Scans
• A radioactive substance is either inhaled or injected to provide
images of the brain’s function.
• Used to assess blood flow, tissue composition & brain
metabolism, therefore it indirectly measures brain function.
Diagnostic Testing
• Electroencephalogram (EEG)
• Records the electrical activity of the brain through a
series of electrodes on the scalp.
• Used to diagnose and evaluate seizures disorders,
identify tumors, brain abscesses or infections and to
confirm of brain death.
• Evoked Potentials (EPs)
• A series of electrodes on the scalp and an external
stimulus is applied to the peripheral sensory receptors
to elicit change in brain waves.
• Stimulus maybe be visual, auditory or electrical.
Laboratory Testing
• Cerebrospinal Fluid (CSF) Analyses
• Normal Findings:
• pH 7.35-7.45
• Specific Gravity: 1.007
• Appearance: Clear, colorless and odorless
• Cells: minimal number of WBCs and no RBCs
• Positive Protein
• Positive Glucose (2/3 blood sugar value)
The goal of Management
• The goal in managing balance and mobility disorders
is to
• minimize disability
• improve functional performance.
Intracranial Pressures (ICP)
• Brain contained within the skull (closed container)
• Intracranial space is occupied by three components:
• Blood (10%)
• Cerebral Spinal Fluid (CSF) (10%)
• Brain Tissue (80%)
• Normal physiologic conditions ICP < 10 mmHg
• An ICP value of 20 mmHg (sustained) requires
immediate medical intervention.
Increased Intracranial Pressures
Causes of Increased ICP:
• Traumatic Brain Injuries
• Brain Tumors
• Other Causes:
• Meningitis or Encephalitis
• Brain Abscesses
• Hydrocephalus
Clinical Manifestations of
Increased ICP
• Deterioration in the level of conscious (confusion,
drowsiness).
• Changes in papillary response to light.
• Motor weakness on one side of the body (changes in
motor ability) hemiparesis or hemiplegia may be
seen. Decorticate (flexor) and decerebrate
(extensor).
• Headache, possible seizures and vomiting
Diagnostic studies
• Vital signs, neurologic assessments, ICP
measurements
• Skull, chest and spinal X-ray studies.
• MRI, CT scan, EEG, angiography, ECG.
• Transcranial Doppler studies.
• Laboratory studies, including CBC, coagulation
profile, electrolytes, ABGS, CSF analysis for (protein,
cells, glucose).
Complications of Increased ICP
• Diabetes Insipidus
• SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
• Herniation
• Brain Death
Management of ICP
Management of
ICP
• Medical therapy
• Surgical therapy
• Rehabilitation
Medical therapy
• Osmotic diuretics (mannitol) to reduce cerebral
edema.
• Loop diuretics e.g. lasix to decreasing circulating
blood volume and reducing edema.
• Corticosteroid se.g. decadron.
• Antiseizure drugs e.g. phenytocin
Surgical intervention
•
Aimed to removal of tumor, hematoma,
abscess or decompression of infracted or
necrotic cerebral tissue also helps to reduce
intracranial hypertension.
• Drainage of CSF through an intraventricular
catheter allows not only for control of ICP but also
for constant monitoring of the ICP.
Collaborative therapy
• Evaluation of head of bed to 30 degrees to improve
cerebral drainage.
• ICP monitoring by (intraventricular catheter).
• Another methods of ICP monitoring include the use of
ventriculostomy (where by a catheter is inserted into the
lateral ventricle and coupled to an external transducer).
• Intubation and mechanical ventilation
• Therapeutic hyperventilation and intubation to reduce
PaCo2 to 25-30 mmHg for better cerebral tissue
perfusion.
Nursing management
1. Nursing assessment
Increased ICP Nursing Diagnoses
• Ineffective cerebral tissue perfusion related to increased
ICP .
• impaired skin integrity related to bedrest or immobility.
• Knowledge deficit related to increased ICP or its
treatments.
• Decreased sensory perception related to neurological
impairment.
• Risk for injury related to altered level of consciousness or
seizures.
Increased ICP Nursing Diagnoses
• Ineffective airway clearance related to diminished
protective reflexes (i.e. cough or gag).
• Interrupted family processes related to health crisis.
• Risk for infection related to ICP monitoring device.
• Fluid volume deficit related to decreased level of
consciousness or hormonal imbalance.
• Imbalanced nutrition, less then body requirements related
to inadequate intake.
• Potential for sleep disturbances related to frequent
neurological status monitoring.
Planning
The over all goals are that the patient with ICP will
• Maintain a patient airway.
• Have ICP within normal limits
• Demonstrate normal fluid and electrolyte balance.
• have no complications secondary to immobility
and decreased LOC.
•
Increased ICP: Nursing
Considerations
• Respiratory / Ventilator Considerations
• Deep Suctioning
• Hyperoxygenate with each pass
• Limit the number of passes & < 10 seconds each pass
• Ensure tracheostomy ties are not too tight
• Limit / avoid unnecessary coughing or gagging
• Prevention of Infection:
• Ensure aseptic techniques with invasive line care
• Prevention of Injury
• Maintain seizure precautions (i.e. padded side-rails)
Increased ICP: Nursing
Considerations
• Nursing Activities Cont.,
• Administer medications as prescribed
• Maintain Nutritional Support
• High-protein & high-fiber diet
• Total Parenteral Nutrition (TPN)
• Dietary Supplements
• Maintain Therapeutic Environment
• Encourage contact from significant others
• Provide emotional support and education
Increased ICP: Surgical
Management
• Craniotomy
• Involves opening the skull to gain access to
intracranial structures.
• Indicated for relief of Increased ICP by tumor
removal, hematoma or abscess evacuation or
controlling hemorrhage.
Craniotomy Considerations
• Preoperative Nursing Care
• Assessment
• Frequent vital signs and neurological exams
• Documentation of neurological baseline
• Diagnostic / Laboratory Tests
• Blood tests / blood type and cross match
• Chest x-ray
• Education
• Avoid activities known to increase ICP
• Surgery specific instructions
• Provide Emotional Support
Craniotomy Considerations
• Postoperative Nursing Management
• Frequent Monitoring of Neurologic Status & Vital Signs
• Maintain ICP Monitoring Device
• Prevent Increased ICP
• Client positioning
• Prompt management of vomiting, fever & pain
• Administer anti-seizure medications as ordered
• Maintain Fluid / Electrolyte Balances
• Prevent / Monitor for Infection
• Aseptic technique for dressings & ICP monitoring device
• Pulmonary Care
Craniotomy Considerations
• Postoperative Nursing Management Cont.,
• Prevent Injury
• Seizure / Falls Precautions
• Eye Care / Skin Care
• Providing Emotional Support
• Patient Education
• Signs & symptoms of increased ICP
• Signs & symptoms of infection
• Incisional care
• Medications
• Neurologic Rehabilitation.
Craniotomy Considerations
• Post operative Complications
• Increased ICP
• Surgical Hemorrhage
• Fluid / Electrolyte Imbalance
• CSF Leak
• DVT
• Gastric Ulcers
• Pneumonia
• Seizures
Intracranial Hemorrhage (ICH)
• Trauma can cause bleeding within the brain tissue
or within the spaces surrounding the brain.
• The result is hematomas or collections of blood within
cranial vault; most serious of brain injuries
• Classified according to location:
• Epidural hematoma
• Subdural hematoma
• Intracerebral hematoma
Management Considerations
• Medical / Surgical Management
• Supportive Interventions
• Prevention or Management of Increased ICP
• Airway
• Ventilation
• Nutrition
• Pain and anxiety management
• Prevention of seizures & agitation
Head Injury
• Broad term to classify sudden trauma to head,
which includes injuries sustained to the scalp,
skull or brain.
• Most common causes:
• MVA: motor vehicle collisions (50%)
• Falls (21%)
• Violence (12%)
• Sports related-injuries (10%)
• The most serious type of head injury is traumatic
brain injury (TBI)
TBI: Clinical Manifestations
• Neurological Deficits
• Altered Level of
Consciousness
• Confusion
• Pupillary Abnormalities
• Vital sign Changes
• Altered Reflexes
• Headache
• Dizziness
• Impaired Hearing or
Vision
• Sensory or Motor
Dysfunction
• Seizures
Types of HEAD INJURY
Types of HEAD INJURY
Scalp laceration
Skull fracture
• Brain injury
• Minor
• As concussion
• Major
• As contusion
• Epidural hematoma
• Subdural hematom
• Intracerebral hemato
Types of HEAD INJURY
• 1-Scalp Injuries
• Isolated scalp injuries usually classified as minor
head injuries.
• The scalp is highly vascular with poor constrictive
abilities; bleeding is often profuse
• Infection is a major concern, which must be
prevented!!
2-Skull Fractures
• Types of Skull Fractures:
• Linear:
• Non-displaced fracture of the skull
• Depressed:
• Fracture involving the downward depression of bone into
brain tissue
• Comminuted:
• Fragmentation and downward displacement of bone into
brain tissue
• Basilar:
• Fracture occurring at the base of skull.
Manifestation of skull fracture
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Facial paralysis
Battle's sign (post auricular ecchymosis).
Conjugate deviation of gaze.
Rhinorrhea (CSF leakage from the nose)
Otorrhea (CSF leakage from the ear).
Raccoon eyes (periorbital edema and ecchymosis).
The major potential complication of
skull fractures
• Internal infections and hematoma
• Meningeal and tissue damage.
3-brain Injury
• A-Cerebral Concussion
• Head injury with temporary loss of neurological function with no
structural damage.
• Cause: jarring of the brain results in temporary disruption of
synaptic activity;
• Clinical Manifestations:
• Loss of consciousness; usually brief
• Amnesia regarding events immediately prior to injury
• Postconcussion Syndrome
• Usually occurs within 24 to 48 hours after injury and may present up
to several months later, but will subside in time.
• S/Sx: lethargy, irritability, memory deficits, dizziness & insomnia
3-brain Injury
• B-Cerebral Contusion Bruising of the brain tissue;
actual structural damage visible on diagnostic testing
(i.e. CT scan).
• Clinical Manifestations
• Loss of consciousness (more than brief)
• Vary depending on the location & size of contusion
• Secondary injury is possible (i.e. hemorrhage or
cerebral edema) the client must be monitored closely
for increased ICP.
Epidural Hematoma (EDH)
• Blood collects between the dura mater & the skull
• Most often arise from arterial hemorrhage
• Cause usually is injury of middle meningeal artery; resulting in
rapid accumulation of blood.
• Clinical Manifestations:
• + LOC after initial trauma; usually at the location of injury
• Lucid interval (30-50% experience)
• Rapid deterioration in neurologic status; S/Sx of ↑ ICP
• Management
• Medical emergency requiring immediate medical and surgical
intervention (i.e. craniotomy).
Subdural Hematoma (SDH)
• Blood collects between the dura mater & the
arachnoid mater
• Often originating from venous hemorrhage
• Cause is usually injury to bridging veins; venous blood tends to
accumulate more slowly than arterial blood, therefore
signs/symptoms of ↑ ICP tend not occur as quickly.
• Two Main Types of SDH
• Acute (less than 48 hours after injury)
• Requires immediate medical and /or surgical intervention
• Chronic (over 2 weeks after injury)
• Often forget actual injury; common in elderly
• S/Sx of ↑ ICP fluctuate or “come and go”
• Management: Burr hole clot evacuation or craniotomy
Intracerebral Hematoma (ICH)
• Blood collects within the brain tissue (parenchyma)
• Bleeding causes displacement of brain tissue; even small
bleeds can cause significant neurological alterations.
• Destroys brain tissue
• Causes cerebral edema
• Increases ICP
• S/Sx of ↑ ICP maybe be immediate or develop overtime
• Management:
• Depends on location of the bleed and size of the bleed
• Small ICH will be absorbed overtime
• Surgical management only if anatomically appropriate; if
not will be managed medically.
TBI: Management Considerations
• Medical / Surgical Management
• Supportive Interventions
• Prevention or Management of Increased ICP
• Airway
• Ventilation
• Nutrition
• Pain and anxiety management
• Prevention of seizures & agitation
• See previous discussion of medical / surgical
management of increased ICP
Nursing process
• 1. Assessment:
• 1. Assess for developing  ICP
• 2. GCS score
• 3. Assessing and monitoring the neurologic
status.
• 4. Determining whether a CSF leak has occur
Nursing Diagnosis
Ineffective tissue perfusion (cerebral) related to interruption of
CBF associated with cerebral hemorrhage, hematoma, and
edema.
Hyperthermia related to increased metabolism, infection, and loss
of cerebral integrative function secondary to possible
hypothalamic injury.
Acute pain (headache) related to trauma and cerebral edema.
Impaired physical mobility related to decreased LOC and
treatment imposed bed rest.
Anxiety related to abrupt change in health status, hospital
environment, and uncertain future.
Potential complication: increased ICP related to cerebral edema
and hemorrhage.
Planning
The overall goals are that the patient with an acute head
injury will
(1) maintain adequate cerebral perfusion;
(2) remain normothermic;
(3) be free from pain, discomfort, and infection; and
(4) attain maximal cognitive, motor, and sensory
function.
TBI: Management Considerations
• Nursing Considerations
• Frequent neurologic assessments / vital signs
• Fluid and electrolyte balances
• I & O and daily weights
• Increased ICP
• Client positioning & Care
• Nursing Activities
• Maintain skin integrity
• Protection from injury
• Prevent infection
• Provide rest
• Provide support & education to client and/or significant others
Evaluation
• The expected outcomes are that the patient with
a head injury will:
• Maintain normal cerebral perfusion pressure.
• Achieve maximal cognitive, motor, and sensory
function.
• Experience no infection, hyperthermia, or pain.
SPINAL CORD INJURIES
• Definition
• Injuries to the spinal cord resulting in loss of motor and
sensory function are by far one of the most devastating
traumatic injuries that health care providers encounter.
• Recent studies indicate that traumatic spinal cord injury
occur most often between (16-30 ages).
• 82% of all victims are male.
SPINAL CORD INJURIES
Causes
• Motor vehicle accidents.
• Falls and violence.
• Sports injuries and gunshot.
• An injury in the cervical or high thoracic region
may result in quadriplegia, whereas an injury in
the thoracic or lumbar region results in
paraplegia.
Diagnostic studies
• Complete spine films to assess for vertebral fracture
• X-ray include C1-T1 to document the presence of vertebral
injury.
• CT scan to assess the stability of the injury, location and
degree of bony injury).
• MRI, vertebral angiography to rule out vertebral artery
damage.
• A comprehensive neurologic examination is performed along
with assessment of head, chest and abdomen for additional
injuries or trauma.
Surgical therapy
•
•
•
•
•
•
Criteria used in the decision for early surgery include:
Evidence of cord compression
Progressive neurologic deficit
Compound fracture of the vertebrae.
Bony fragments (may dislogye and penetrate the cord).
Penetrating wounds of the spinal cord or surrounding
structures.
• The more common surgical producers include:
• Decompression laminectomy by anterior cervical and the
approaches with fusion, posterior laminectomy with the use of
acrylic wire mesh and fusion, and insertion of stabilizing rodes
Rehabilitation and home care
• Rehabilitation focus on refined retraining of
physiologic processes and extensive patient and
family teaching about how to manage the physiologic
and life changes resulting from injury.
• The process of rehabilitation begins immediately and
the primary objective of care is to assist the patient in
achieving an optimum level of physical and mental
function within the limits of the disability.
• The patient can learn to use remaining functional
muscles and adaptive devices to achieve
independence in daily activities.
• Ambulation with or without bracing may be attempted
in select patients with lumbar or sacral injures.
• Teaching the patient and family aspects of self care.
• Bladder and bowel reconditioning are considered
Spinal tumor
• A spinal tumor is a cancerous (malignant) or
noncancerous (benign) growth that develops within or
near spinal cord or within the bones of spine.
• Although back pain is the most common indication of a
spinal tumor, most back pain is associated with stress,
strain and aging not with a tumor.
•
Signs and symptoms
• may include:
• Back pain, often radiating to other parts of body and worse at
night
• Loss of sensation or muscle weakness, especially in legs
• Difficulty walking, sometimes leading to falls
• Decreased sensitivity to pain, heat and cold
• Loss of bowel or bladder function
• Paralysis that may occur in varying degrees and in different parts
of body, depending on which nerves are compressed
• Scoliosis or other spinal deformity resulting from a large, but
noncancerous tumor
Types of spinal tumors
• Spinal tumors are classified according to their
location in the spine.
• Extradural
• Vertebral tumors.
Vertebral tumors
• Intradural-extramedullary tumors.
• These tumors develop in the spinal cord's
arachnoid membrane (meningiomas), in the
nerve roots that extend out from the spinal cord
or at the spinal cord base
• Intramedullary tumors. These tumors begin in
the supporting cells within the spinal cord.
Diagnostic Measures
• Spinal magnetic resonance imaging (MRI).
• Computerized tomography (CT).
• Myelogram.
• Biopsy.
Complications
• Both noncancerous and cancerous spinal tumors can
compress spinal nerves, leading to
• loss of movement or sensation below the level of the
tumor
• sometimes to changes in bowel and bladder function.
Nerve damage is often permanent, and disabilities are
likely to continue even after the tumor is removed.
Depending on its location, a tumor that impinges on the
spinal cord itself may be life-threatening.
Management of spinal cord tumor
• Surgery.
•
This is often the first step in treating tumors that can be
removed with an acceptable risk of nerve damage.
• Even with advances in treatment,
• The goals of surgery to treat spinal tumors include:
• Remove the spinal tumor, or as much of it as possible
• Stabilize the spine
• Reduce pain
• Improve function and quality of life
• Complications of post operative
• bleeding
• damage to nerve tissue
•
Radio therpy
• Types of Radiation Therapy
External Radiation Therapy: External radiation therapy is the most common and is
delivered to the patient from the outside of the body. In other words, radiation is
directed at a specific area of the body or target. This type of therapy is often provided
on an outpatient basis.
• Internal Radiation Therapy (or Interstitial Radiation Therapy): This kind of
radiation therapy delivers radiation by means of sealed implants inserted near the
tumor. This type of therapy is more common in cases of neck cancer. This therapy
usually requires hospitalization because the patient is radioactive. Special
precautions are taken to protect hospital staff and visitors.
• Palliative Radiation Therapy: This is delivered to help reduce pain and symptoms
from metastatic cancer (cancer that has spread).
• Prophylactic Radiation Therapy: This is delivered to cancer-free areas to help
prevent the spread (metastasis) of cancer cells. This type of radiation is not suitable
for all patients or types of cancerous spinal tumors.
Chemotherapy
• . A standard treatment for many types of cancer,
chemotherapy hasn't proved beneficial for most
spinal tumors. However, there may be
exceptions. either alone or in combination with
radiation therapy.
• Nursing Care Plan as similar of nursing care
plane of spinal injury
Brain Tumors
• Space-occupying intracranial lesions
• Benign or malignant.
• Clinical manifestations differ according to area of lesion
and rate of growth
• Common Signs / Symptoms:
• Alterations in consciousness
• Neurologic deficits
• Motor & Visual Disturbances
• Headaches
• Seizures
• Vomiting (maybe sudden and projectile)
Types of Brain Tumors Cont.,
• Brain tumors arising from supporting structures
• Meningiomas
• Encapsulated, non-invasive; usually benign
• Slow growing; well defined
• Compresses rather than invades
• Acoustic Neuromas
• Non- malignant ; slow growing
• CN VIII affected: tinnitus, hearing loss, impaired balance,
unsteady gait & facial pain / numbness on the side of tumor
• Developmental Tumors
• Angiomas
• A benign mass of abnormal blood vessels with thin walls; prone
to rupture
Brain Tumor: Management
Considerations
• Increased Intracranial Pressure
• Pharmacologic Agents
• Corticosteroids (dexamethasone and prednisone)
• Osmotic Diuretics
• Antiseizure, antiemetic & analgesic medications
• See previous discussion of ↑ ICP management &
nursing considerations
• Tumor Removal / Destruction
• Surgical Interventions
• Craniotomy
• ICP monitoring
Brain Tumor: Management
Considerations
• Tumor Removal / Destruction Cont.,
• Medical Interventions
• Chemotherapy (often a combination of agents utilized)
• Routes of Administration
Intracranial Route
• Disk-shaped drug wafers (Gliadel wafers) maybe implanted
for some tumors (i.e. glioblastomas multiforme or recurrent
tumors) during a craniotomy.
• Systemic / Venous Route
• Most agents poorly penetrate the blood-brain barrier
• Temodar (temozolomide) can penetrate; widely used today
Brain Tumor: Management
Considerations
• Radiation Therapy
• External radiation therapy
• Gamma Knife (stereotactic radiosurgery)
• Single dose of high ionized radiation
to selectively destroy the tumor.
• Requires the use of a helmet device;
therapy usually takes about a hour
• The client usually will stay over-night
at the hospital for observation.
• Internal radiation therapy (Brachytherapy)
• A catheter is inserted in or just next to a tumor to deliver
radiation by means of radioactive capsules “seeds”
• The radioactive source will then be left in place from several hours to
several days to kill the tumor cells; Client hospitalized during treatment.
Nursing process
• 1. Nursing assessment
• Assess neurologic status (LOC, motor ability, sensory perception,
integrated function (include bowel and bladder function).
• Watching a patient perform activities of daily living and listening to
the patient's conversation.
• Interview data are as important as the actual physical
assessment.
• Questions concerning medical history, intellectual abilities, and
educational level and history of nervous system infection and
trauma should be asked.
• Determination of the presence of seizures, syncope, nausea and
vomiting, pain and headache
Nursing diagnoses
• Impaired tissue perfusion (cerebral), related to cerebral
edema.
• Acute pain (headache) related to cerebral edema and
increased ICP.
• Self care deficits related to altered neuromuscular function
secondary to tumor growth and cerebral edema.
• Anxiety related to diagnosis and treatment.
• Potential complication: seizures related to abnormal electrical
activity of the brain.
• Potential complication: increased ICP related to presence
tumor and failure of normal compensatory mechanisms
Planning
•
The overall goals are the patient with a brain
tumor were
• (1) maintain normal ICP,
• (2) maximize neurologic functioning
• (3) be free from pain and discomfort,
• (4) be a ware of the long term implications with
respect to prognosis and cognitive and physical
functioning.
Nursing implantation
• Assisting the family in understanding the behavioral
changes can be affected on the patient.
• Protecting the patient from self harm is an important part
of nursing care due to behavioral instability
• Minimization of environmental stimuli, creation of a
routine and use of reality orientation can be incorporated
into the care plan for the confused patient.
• Seizures often occur with tumors. There are managed
with antiseizure drugs.
Nursing implantation
•
•
•
•
Alternations in mobility managed by encouraged the patient to
provide as much self care as physically possible.
Self image often depends on the patient's ability to participate
in care within the limitations of the physical deficits.
Language deficits (e.g., dysphasia), so the disturbance in
communication can be frustrating for the patient and may
interfere with the nurse's ability to meet the patient's needs.
Attempts should be made to establish a communication
system that can be used by both the patient and the staff.
Assessing the nutritional status of the patient and ensuring
adequate nutritional intake are important aspects of care, may
have to be fed (orally,NGT, TPN).
Evaluation
• The expected outcomes are that the patient with a brain tumor
will:
• Be free of pain, vomiting, and other discomforts.
• Maintain ICP within normal limits.
• Demonstrate maximal neurologic function (cognitive, motor,
sensory) with regard to the location and extent of the tumor.
• Maintain optimal nutritional status.
• Accept the long term consequences of the tumor and its
treatment.
Application of nursing care plane on patient
with a Brain Tumor
• Claire Lange is a 44-year-old television announcer. During one night’s
broadcast, she confuses several major news items so badly that her coanchor tries to correct her. Ms. Lange responds angrily that she does not
need any help and then rises and storms off the set. As she leaves the
camera area, she limps noticeably and appears to drag her left leg. The
show’s producer asks her what is wrong; she screams that nothing is wrong,
she simply has another headache.
• He follows her to her dressing room and inquires about her headaches. She
tells him that they come and go but have been getting worse lately. He then
asks her if she has injured her left leg; she responds that the leg was weak
because she was tired. As the producer leaves the dressing room, Ms. Lange
begins to shake and collapses on the floor. The producer recognizes that she
is having a seizure and calls for an ambulance.
• Ms. Lange is admitted to the neurology floor of the local hospital for
evaluation. A CT scan, MRI study, and EEG are completed and identify an
intracranial mass. A biopsy of the mass is positive for malignant cells. A
glioma in the frontal lobe is identified, and surgery is scheduled for that
week.
DIAGNOSES
• • Acute pain (headache), related to tumor and increase in
intracranial pressure
• • Disturbed body image, related to upcoming hair loss and cranial
incision
• • Anxiety, related to unknown future following surgery
• EXPECTED OUTCOMES
• • Verbalize the causes of pain.
• • Verbalize an understanding of the changes in body appearance
that are associated with the scheduled intracranial surgery (e.g.,
shaving of the head prior to surgery, cranial incision, facial ,
swelling postoperatively).
• • Identify measures that will help minimize the effect of the hair
loss.
• Verbalize a reduction in anxiety.
PLANNING AND IMPLEMENTATION
• • Assess level of discomfort using a rating scale of 0 to 10.
• • Provide a quiet, non stimulating environment.
• • Position the client for comfort, keeping the head of the bed
elevated to promote venous drainage.
• • Assess level of consciousness for potential increases in ICP.
• • Encourage to verbalize feelings about the surgery.
• • Suggest measures that may help minimize the hair loss, such as
the use of turbans, scarves, hats, and wigs.
• • Suggest relaxation techniques to decrease anxiety.
EVALUATION
• By the time of surgery, Ms. Lange has recognized the relationship
between the brain tumor and the headache. She states that lying
in a flat position and coughing increase the headache. The head
of the bed is kept at a 30- to 45-degree angle. Daily activities are
spaced to provide periods of rest.
• Ms. Lange demonstrates no significant changes in level of
consciousness. She has talked about the effect of the hair loss
and her television responsibilities.
• Ms. Lange has learned that the hair preparation would be done in
surgery and that the hair would be saved for her. She states she
has already consulted her hair stylist and that “scarves and
turbans are on the way.”