Brain Tumors/Test 3 Flashcards
Brain Tumors: Types
- Primary
* Secondary
Primary brain tumor is:
arising from tissue within the brain and rarely metastasis
Secondary brain tumor is:
Metastasis from a malignant neoplasm elsewhere in the body (most common)
Characteristics of brain tumors:
- Arise from support cells of the brain tissue rather than the neurons
- Location impacts the choice of treatment
- One tumor can have multiple cell types
- Variable rate of growth, degree of malignancy: benign can progress to malignant
- No lypmphatic system in the brain to enhance metastasis outside the CNS
- Blood brain barrier prevents drugs from reaching the brain tumor
Brain tumors are classified by tissue from which they arise:
-gliomas: astrocytoma, glioblastoma multiforme, meningioma
Brain tumors: treatment goals
- Identify the tumor type and location
- Remove or decrease tumor mass
- Prevent/manage increased ICP
Brain Tumors: Surgical Therapy
*preferred treatment, complete surgical removal is not always possible because the tumor is not always accessible or has involved vital parts of the brain. Can reduce tumor mass to decrease ICP.
Brain Tumors/Radiation therapy
*common follow-up after surgery; radiation seeds implanted in brain
Stereotactic radiosurgery…
delivers a high concentration dose of radiation precisely directed at a location within the brain. When surgery is not an option due to location.
Chemotherapy:
limited by difficulty getting drugs across the blood-brain barrier, tumor cell heterogeneity and tumor cell drug resistance
Ivestigational therapy:
Hyperthermia and biologic
Altered spacial perception:
*Anosognosia
Anosognosia:
Apparent unawareness or denial of any loss or deficit in physical function
Loss of proprioceptive skills:
Lack of awareness of where various body parts are in relation to each other and the environment.
Agnosia
Inability to recognize a familiar object by use of the senses
Apraxia
Loss of ability to carry out a learned sequence of movements (dressing, brushing teeth, combing hair)
Spacial relationships:
Loss of ability to judge distance or size or localize objects in space
Brain tumors/bowel and bladder
*Frequency, urgency and urinary incontinence- potential for bladder retraining if cognitively intact
Neurogentic bladder:
frequency and urgency. Unilateral lesion: partial sensation and control of bladder.
*Brain stem: bilateral damage and the loss of control of urination
Motor:
Hemiparesis or hemiplegia on the opposite side of the ischemia site. Initially flaccid then progresses to spastic
Dysphagia:
- Swallowing reflex may be impaired
* Pt will pocket food on the effected side
Dysarthria:
Difficult and defective speech d/t impairment of the tongue or other muscles (parynx facial muscles) essential to speech.
- slurred speech/garbled
- Mental function intact
- May be unable to speak but no deficit in the ability to understand, read or write
Clinical manifestations: Dependent on location
- Pressure headache
- occurs at night or present when waking up
- n/v r/t food
- Symptoms of ICP
- s/s cranial nerve deficit
- Visual changes
- CIII, IV, VI: diplopia
- visual field: optic chiasm
- enlarged blind spot r/t papiledema
- Seizures
- Weakness or hemiparesis: motor cortex
- Speech difficulty: language area
- Alterations in LOC: midbrain
- Personality changes frontal lobe
Brain tumors: Complications
-Ventricle obstruction= hydrocephalus
Brain tumors: diagnostic studies:
- Extensive H&P
- Comprehensive neuro exam
- Similar for ICP
- V/S
- Neuro assessment
- ICP measurements
- skull, chest, spinal xray
- MRI, CT, PET, EEG, angiography
Brain Tumor: Labs
- CVC
- Coag profile
- lytes
- creatinine
- ABS’s
- Amonia level
- general drug and toxicology screen
- CSF tumor markers: analysis (for protein, cells, glucose)
- PET: distinguish recurrent tumors from radiatiion-induced necrosis neurosurgery
- ECG
- SPECT (single photon emission computed tomography).
- Other studies to rule out a primary lesion elsewhere in the body.
Brain tumor: Definitive diagnosis:
Histological exam
Treatment goals for brain tumors:
- Identify the tumor type and location
- Remove or decrease tumor mass
- Prevent/manage increased ICP
Surgical therapy: Preferred treatment
- Complete surgical removal is not always possible because the tumor is not always accessible or has involved vital parts of the brain. Can reduce tumor mass to decrease ICP
- Radiation therapy and radiotherapy:
- Stereotactic radiosurgery
- Chemotherapy
- Ivestigational
Radiation therapy and radiotherapty
Common follow-up after surgery; radiation seeds implanted in brain.
Stereotactic Radiosurgery:
Delivers a high concentration dose of radiation precisely directed at a location within the brain. When surgery is not an option due to location
Chemotherapy
Liimited by difficulty getting drugs across the blood-brain barrier, tumor cell heterogeneity and tumor cell drug resistance.
Investigational:
Hyperthermia, and biologic
Brain tumor: Assessment:
- objective-Rhomberg test
* Subjective
Rhomberg test:
Ask the patient to stand with teir feet together (touching each other). Then ask the patient to close their eyes. Remain close at hand in case the patient begins to sway or fall.
*What is being tested: Cranial nerve 8. With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense. (See s;ode 70)
Nursing diagnostics of brain tumors:
- Impaired tissue perfusion (cerebral r/t cerebral edema as evidence by
- Acute pain (HA) r/t cerebral edema and increased ICP aeb:
- Self care deficits d/t altered neumuscular function secondary to tumor growth and cerebral edema, aeb:
- Anxiety r/t diagnosis and treatment aeb
Potential complication of brain tumors:
- Seizure r/t abnormal electrical activity of the brain.
* Increased ICP r/t presence of tumor and failure or normal compansatory mechanisms
Implementation: Brain tumor
Confusion and behavioral instability: Protection from self-harm, self-protection, supervision of activity, use of side rails, judicious use of restraints, padding side rails, calm reassuring approach to care.
Motor and sensory dysfunctions : Brain tumors-
*Alteratiion in mobility, self image, language deficits; nutritional intake
Nursing management: Cranial surgery:
- Purpose-respiratory failure (especially posterior fossa surgery)
- Debulkling-
- Access for biopsy
- Chemotherapy
- Interstitial radiat
- Corneal abrasion
- Gastric ulceration or Cushing’s ulcer
- DI vs. SIADH (hydration status, I&O, Na and serum osmolarity)
Post-op (Cranial surgery) Medications:
- Corticosteroids
- Osmotic diuretics
- Anticonvulsants
- Dilantin (Phenytoin) drug of choice.
- Cerebyx (fosphenytoin)
- Benzodiazepines (larazepam, diazepam)
- Tegretol (carbamazepine)-causes bone marrow depression
- New antiepileptic drugs (AESs)
- Analgesics
- H2 blockers (famotidine-ranitidine if on steroids there is an increase in gastric secretions)
- bowel softeners
Dilantin CNS adverse reactions and side effects:
* ataxia *agitation *Cerebral edema *Coma *Dizziness *drowsiness *dysarthria *dyskinesia *EPS *HA *nervousness *weekness
Cranial Surgery types:
- Burr hole
- Craniotomy
- Craniectomy
- Cranioplasty
- Stereotactic procedure
- Shunt procedures
Burr hole-
Opening into the cranium with a drill; used to remove localized fluid and blood between the dura
Craniotomy
Opening into the cranium with removal of bone flap and opening the dura to remove a lesion, repair a damaged area, drain blood, or relieve ICP
Cranioectomy
Excision into the cranium to cut away bone flap
Cranioplasty
Repair cranial defect resulting from trauma, malformation, or previous surgical procedure, artificial material used to replace damaged or lost bone.
Stereotactic procedure:
Precise localization of a specific area of the brain using a frame or a frameless system based on three-dimesional coordinates, procedure used for biopsy, radiosurgery, or dissection
Shunt procedure-
Alternate pathway to redirect cerebrospinal fluid from one area to another using a tube or implanted device; examples include ventricular shunt and Ommaya reservoir
Cranial Surgery: Other complications:
- Respiratory failure:
- r/t posterior fossa surgery results in edema on brainstem and the inability to protect airway with cough or gag reflex
- Hydrocephalus
- r/t obstruction to normal flow of CSF
- Gas ulcerations
- cushings ulcers
- r/t stress response and or use of steroids
- steroids increase gastric secretions
Other cranial surgery complications:
*Diabetes insipidus
-surgery to pituitary gland effects ADH
-risk for severe dehydration
-vasopressin
-goal normal serum osmolarity <290
*SIADH- caused to much ADH to be secreted
TX fluid restriction, NS if use of IV fluids-problem usually self corrects
*Corneal abrasions r/t diminished cranial nerve 7 and temporary loss of the blink reflex on effective side.- intervention eye drops
PC of cranial surgery:
- Increased ICP r/t cerebral edema
- Aspiration r/t diminished reflexes
- CSF leakage/infection
- assess for CSF leakage which can lead to meningitis
- instruct patient not to blow his nose
Alteration in ADH: Too little
*Diabetes insipidus- surgery/swelling to pituitary gland effects ADH, risk for severe dehydration
Treatment- increase fluid intake, vasopressin, goal normal serum osmolarity <290
Too much ADH secretions:
*SIADH
Treatment- fluid restrictions, NS if using IV fluids, problem usually self corrected
Post Op meds:
- Corticosteroids
- Osmotic diuretics
- Anticonvulsants
Corticosteroids:
Decreases cerebral edema
Osmotic diuretics:
Decrease cerebral edema
Anticonvulsants:
prevent increase in oxygen comsumption
Dilantin (Phenytoin)
- Drug of choice
- CNS- adverse reactions and side effects: ataxia, nystamus, agitation, cerebral edema, coma, dizziness, drowsiness, dysarthria, dykinesia, EPS, HA, nervousness, weakness
- infiltration-purple glove
- skin integrity- skin irritations
- given too fast can cause cardiovascular collaps
- Cerebyx (fosphenytoin) can be given IV or IM
- Tegretol (carbamazepine)- cause bone marrow depression
Nursing management:cranial surgery-planning:
- Return to normal consciousness
- Be free from pain and discomfort
- rehabilitation to maximum ability
- Implementation- Pre op teaching
- Evaluation
Post Op care: cranial surgery:
- Neuro assessment and VS
- treat temp d/t increase metabolic demands
- prevent injury with least restrictive device
- incisional care (drainage should be minimal)
- assess for CSF drainage
- Assess protective reflexes and CNS fx
- Promote electrolyte balance
- Specific positioning
- supratentorial-HOB elevated
- infratentorial-place on side and flat
- if bone flat remove avoid pressure on site
- neutral position avoid neck flexion
- Mobility-early ambulation, observe for postural hypotension
- Comfort- medicate for comfort with codiene or non-analgesic
- Promote decreased intracranial pressure
- space activities, cough and vomiting should be avoided, suction only if necessary.
- Nutrition- assess for dysphagia, assess for gag reflex
- Elimination- keep accurate I&O, measure specific gravity, frequent blood glucose testing
