STATEMENT OF THE PROBLEM Primary brain tumors compose a heterogeneous group of neoplasms that vary widely by site of origin,

morphologic features, growth potential, extent of potential invasiveness and tendency for progression, and recurrence and treatment response. In some cases, craniotomy with maximal surgical excision of a brain tumor provides the best treatment for prolonging survival and improving neurological status of patients with brain tumors (Sawaya, 1998). In the case of some benign brain tumors, surgery may be curative. Although craniotomy for surgical resection of a brain tumor may not be curative in other cases, it does offer more accurate diagnosis than needle biopsy, improvement in symptoms with decreased intracranial pressure (ICP), and theoretically an increased response to other treatments such as chemotherapy and radiation. Caring for a patient with a craniotomy post brain tumor resection requires a multidisciplinary approach with the bedside nurse playing a vital role. Postoperative complications can often lead to permanent neurologic injury if gone unrecognized. Prompt recognition of postoperative neurologic decline by the bedside nurse and timely diagnosis and intervention by the multidisciplinary team improves patient outcome and subsequent quality of life.

INTRODUCTION Brain tumors are masses of abnormal cells that have grown out of control. In most other parts of the body, it is important to distinguish between benign (non-cancerous) and malignant (cancerous) ones. Benign tumors in other parts of the body are almost never life- threatening. The main reason cancer are so dangerous is because they can spread throughout the body and interrupt the way the normal organs function. Most brain cancers can spread through the brain tissue but rarely spread to other areas of the body. Even so-called benign tumors can, as they grow, press on or invade normal brain tissues, causing damage that is often disabling and sometimes fatal. For this reason, doctors usually speak of "brain tumors" rather than "brain cancers." The major differences are how readily they spread through the rest of the central nervous system and whether they can be removed and not come back. Brain and spinal cord tumors are different in adults and children. They often form in different places, develop from different cell types, and may have a different treatment and prognosis (outlook).

WHAT ARE BRAIN TUMORS? BRAIN TUMOR localized intracranial lesion that occupies space within the skull usually grows as a spherical mass but can also grow diffusely and infiltrate tissue

PHYSIOLOGIC CHANGES RESULTS TO THE FF. PATHOPHYSIOLOGIC EVENTS increased ICP and cerebral edema seizure activity and focal neurologic signs Hydrocephalus Altered pituitary function

PRIMARY BRAIN TUMORS- originate from cells and structures within the brain SECONDARY BRAIN TUMORS- develop from structures outside the brain and occur in 10% to 20% of patients with cancer; more common

TUMOR GRADING/STAGING Grade I-cells differ slightly from normal cells and are well differentiated (mild dysplasia) Grade II-cells are more abnormal and are moderately differentiated (moderate dysplasia) Grade III-cells are very abnormal and are poorly differentiated(severe dysplasia) Grade IV-cells are very immature (anaplasia) and undifferentiated; cell of origin is difficult to determine

Characteristics of Primary Brain Tumors A. Benign brain tumor Slow-growing cells Distinct borders Rarely spreads to other parts of brain or spine May be considered life threatening secondary to vital location in the brain Often requires only craniotomy for tumor resection B. Malignant brain tumor Rapidly growing cells Invasive of surrounding tissues Tends to spread to other locations of brain and spinal cord but rarely outside the central nervous system (CNS) Life threatening Often requires multiple modality treatments with craniotomy for tumor resection as well as chemotherapy, radiation, and other treatments

Risk Factors: Most brain tumors are not associated with any known risk factors and have no obvious cause, but there are a few factors that may raise the risk of brain tumors. For Adults and Children: Radiation Exposure - The best established environmental risk factor for brain tumors is radiation exposure, most commonly from some type of radiation therapy. Today, most radiation-induced brain tumors are caused by radiation to the head given for the treatment of other cancers. This is most common in people who received radiation to the brain as children as part of their treatment for leukemia. These brain tumors usually develop around 10 to 15 years after the radiation. Family History - Most people with brain tumors do not have a family history of the disease, but in rare cases brain cancers run in families. o Neurofibromatosis type 1 (NF1): People with this inherited condition have higher risks of schwannomas, meningiomas, and certain types of gliomas, as well as neurofibromas (benign tumors of peripheral nerves). Changes in the NF1 gene cause this disorder. o Neurofibromatosis type 2 (NF2): This inherited condition, which is much less common than NF1, is associated with vestibular schwannomas (acoustic neuromas) and, in some patients, meningiomas or spinal cord ependymomas. Changes in the NF2 gene are responsible for neurofibromatosis type 2. o Tuberous sclerosis: People with this inherited condition may have subependymal giant cell astrocytomas (low-grade astrocytomas that develop beneath the ependymal cells of the ventricles), in addition to benign tumors of the skin, heart, or kidneys. It is caused by changes in either the TSC1 or the TSC2 gene. o Von Hippel-Lindau disease: This condition is associated with an inherited tendency to develop hemangioblastomas (blood vessel tumors) of the cerebellum or retina as well as tumors of the kidney, adrenal glands, and pancreas. It is caused by changes in the VHL gene. o Li-Fraumeni syndrome: People with this condition are at higher risk for developing gliomas, along with certain other types of cancer. It is caused by changes in the p53 gene. Immune System Disorder - People with impaired immune systems have an increased risk of developing lymphomas of the brain or spinal cord.

Additional Possible Causes Use of cellular telephone Exposure to increase tension wires Use of hair dyes Head trauma Dietary exposure to such factors as nitrates 5th, 6th, 7th decades Slightly in male

Highest Incidence

Most brain tumors originate Glial cells (cells that make up the structure & support system of the brain and spinal cord. Supratentorial (above the covering of cerebellum)

CLASSIFICATION OF PRIMARY BRAIN TUMORS IN ADULT I. INTRACEREBRAL TUMORS A. Glioma 1. 2. 3. 4. 5. Astrocytomas (Grade I and II) Glioblastoma multiforme(Astrocytoma grade III and IV) Oligodendrocytoma (low &high grades) Ependymoma (Grade I and IV) Medulloblastoma

II. TUMORS ARISING FROM SUPPORTING STRUCTURES A. Meningiomas B. Neuromas (acoustic) C. Pituitary Adenomas III.DEVELOPMENTAL TUMORS A. Angiomas B. Dermoid, Epidermoid, teroma. Craniopharyngioma IV. METASTATIC LESIONS

CLINICAL MANIFESTATIONS: Increased ICP Headache Vomiting Visual disturbances

LOCALIZED SYMPTOMS: Hemiparesis Seizures

Mental status changes

MOTOR CORTEX TUMOR Jacksonian seizures

OCCIPITAL LOBE TUMOR Contralateral homonymous hemianopsia Visual disturbances

CEREBELLAR TUMOR Dizziness Ataxic or staggering gait Marked muscle incoordination nystagmus

FRONTAL LOBE TUMOR Personality disorders Changes in emotional state and behavior Apathetic mental attitude

CEREBELLOPONTINE ANGEL TUMOR Tinnitus and vertigo Progressive ear deafness Numbness and tingling of the face and tongue Weakness or paralysis of face Abnormalities in motor function

PATHOPHYSIOLOGY Risk Factors: Radiation Exposure Family History Immune System Disorder

Mutation of normal cells to abnormal cells that the immune system fails to recognize or respond to

Compression

Invasion

Infiltration

Cerebral Edema ICP

Seizure Activity
Compression

Focal Neurological Deficits

Alteration in normal pituitary function

Clinical manifestation depends on the location and size of the tumor General Manifestation: Headache Nausea and vomiting Papilledema Changes in level of consciousness

TUMOR INCREASES ICP

ASSESSMENT OF THE PATIENT

NAME: AGE: 61

PATIENT L

OCCUPATION: TEACHER (RETIRED) RELIGION: ROMAN CATHOLIC BIRTH DATE: APRIL 3, 1951

SEX: FEMALE CIVIL STATUS: MARRIED ADDRESS: TISA, CEBUCITY, PHILIPPINES

PAST HISTORY: Client experienced frequent headaches and blurred vision. Also experiences light headedness in some occasions. Has been admitted due to reasons stated but was discharged shortly after because of invaluability of findings. PRESENT HISTORY: Client experienced a loss of consciousness prior to admission. Shortly after gaining consciousness, she then noticed dizziness, progressive muscle weakness and wasnt able to move her hands. FAMILY HISTORY: On her mothers side, there were incidences that point to high blood pressure, cancer and blindness. On fathers side, diabetes and increased blood pressure was also evident.

PHYSICAL ASSESSMENT

NEUROLOGICAL

I *

SKIN

HEAD

EYES

EARS

RESULT >responsive >conscious >oriented in date >with GCS of 15 >positive abrasions in both arms >sagging skin >positive bruises in left arm >pale colored skin >positive freckles >positive sutures >negative dandruff >head is symmetrical >coordinated extra ocular movement >shiny white and moist >pinkish conjunctiva >negative hearing disorder >negative tinnitus

SIGNIFICANCE NORMAL

INDICATION

ABNORMAL

INDICATES TISSUE TRAUMA

NORMAL

NORMAL

NORMAL

NOSE

>negative nasal discharges >negative sinusitis

NORMAL

MOUTH

NECK

>negative stomatitis NORMAL >positive halitosis >22 teeth noted >moist >positive tastes with good swallowing reflex NORMAL >negative vein

UPPER EXTREMITIES

CHEST

BREAST

ABDOMEN

distention >negative goiter >positive bruises in both extremities >unclean nails >negative fracture noted >negative mass noted >negative abnormal breath sound >with 72 beats per minute >negative mass noted >brown colored nipple >negative inversion of nipple >negative abdominal distention >negative

Abnormal

Normal
NORMAL NORMAL

NORMAL NORMAL

NORMAL

NORMAL

GENITOURINARY *

LOWER EXTREMITIES

gastroenteritis >negative abrasions >negative swelling >negative dysuria >negative hematuria >negative pain on suprapubic >negative burning sensation when urinating >positive abrasion >positive bruises in both extremities >unclean nails >negative fracture noted

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

NORMAL NORMAL NORMAL NORMAL

Indicates tissue trauma Indicates tissue trauma

Laboratory Results A. CBC Typing - Identifies the total number of blood cells (leukocytes, erythrocytes and platelets) as well as the hemoglobin, hematocrit and RBC indices. Because cellular morphology is particularly important in most Hematologic disorders. In this test, a drop of blood is spread on the glass slide, stained and examined under a microscope. The shape and size of the erythrocytes and platelets, as well as the actual appearance of Leukocytes, provide useful information in identifying hemotologic conditions.

Result Normal Value Significance RESULT 12. 59 NORMAL VALUE 5.00-10.00 SIGNIFICANCE High. Acute Infection *The WBC is an indicator of Immune function of the body. Elevation is seen during the ongoing infection of inflammation. High. Stress and Acute Infection * Neutrophils are recruited to the site of injury within the minutes following

White BloodCell

Neutrophils

85.0

50.00-70.00

trauma and are the hallmark at acute inflammation Low. Chronic Infection; Viral Infection * A lymphocyte count Lymphocytes 9.3 20.00-44.00 is usually a pary of a peripheral complete blood cell count and is expressed as percentage of lymphocytes to total white blood cells counted. Low. Anemia * Erythrocytes also play a part in the bodys immune system: when lysed bypathogens such as bacteria, their hemoglobin release free radicals that break down the pathogens cell wall and membrane, killing it. Low. Chronic Blood loss * This is used to evaluate the hemoglobin content of erythrocytes. Low. Hemorhage; hemorrhage *This test is useful in the diagnosis of anemia.

Red blood cell

4. 04 4.

20-5.40

Hemoglobin

118

125-160

Hematocrit

35.6

37.0-47.0

B. CT Scan -provides cross-sectional images of soft tissue and visualizes the area of volume changes to an extremity and the compartment where changes takes place. CT Scan has a high degree of sensitivity for detecting lesions. Results: First CT Scan: There is a 27 x 23 x 19mm (CC x AP x Tr), acute hemorrhage extravasations in the Right basal ganglia with minimal surrounding edema. The ensuing mass effect compresses the Rightlateral ventricle. In addition, there is a subarachnoid hemorrhagic

accumulation predominantly in the left temporal lobe along the Slyvian Cisterm and adjacent sulci There is no localized tumor or dystrophic calcification. The rest of the ventricles are enlarged, the midline structure are undisplaced. The corpus callosum, centrum semi ovale, thalani, brainstem, cerebellum, cranial base and calvarium show no findings of note. Second CT: scan revealed there is no reduction in the attention with unchanged size of the right Basal Ganglionic-hemorrhage. The Subarachnoid hemorrhage in the Left Slyvian cistern has diminished in size and density. The rest of the findings have remained the same. Impression: Acute Right basal Ganglionic hemorrhage with minimal mass effect as described. Acute subarachnoid hemorrhage predominantly in the Left temporal region, as described. C. T Cage - which revealed no definite fracture, dislocation, lytic nor blastic lesion is demonstrated and bones and joints are intact.

DIAGNOSTIC EXAMINATION CT SCAN (COMPUTERIZED TOMOGRAPHY) - creates detailed images of various crosssections of tissues and bony structures, which can help identify the tumors location and can sometimes help determine the tumors type. CT scans can also detect swelling, bleeding, or other conditions associated with the tumor. MAGNETIC RESONANCE IMAGING (MRI) - produces highly detailed images from different angles and often make it easier to identify abnormal tissue, especially when tumors are located near bone. PET - measures the consumption rate of the sugar substance in different parts of the brain. This is helpful in detecting recurrent tumor growth, and may help distinguish the grade of malignancy in an existing tumor. X-RAYS- may be used to determine the condition of the skull and the effect of the tumor on bony structures. BONE SCAN-also known as nuclear imaging, are used to detect areas of unusual activity in the bones using low levels of radioactive elements. LUMBAR PUNCTURE A lumbar puncture, or spinal tap, may be used to obtain a sample of cerebrospinal fluid to look for substances that indicate the presence of a tumor. EVOKED POTENTIAL STUDIES Evoked potential testing involves stimulating the nerves using an electrical impulse. The

transmission of that impulse along the spinal cord to the brain is then monitored via electrodes on the scalp. ENDOCRINE EVALUATION Samples of blood and urine may be taken during the diagnostic process to measure hormone levels. This can help in diagnosing pituitary tumors. EEG An electroencephalogram (EEG) is a test that measures the electrical activity of the brain and looks for abnormalities. BRAIN TUMOR BIOPSY After preliminary diagnostic tests are done, the exact diagnosis for a brain tumor is usually obtained through a biopsy, a surgical procedure in which the surgeon gathers a sample of the tumor. The tumor tissue and cells are then examined under a microscope.

Laboratory studies i. Comprehensive hematological, chemistry, and coagulation profiles ii. Culturesblood, sputum, CSF, and rash aspirate Computed tomography (CT) of the head (must always precede lumbar puncture [LP]) Diabetes Insipidus(DI) Cerebral Salt Wasting (CSW) Syndrome of Inappropriate Diuretic Hormone(SIADH) Signs Serum NA level >145 mEq/L Serum NA <135 mEq/L Serum NA level <135 mEq/L Serum Osmolality >300m Osmo/L Serum osmolality WNL or increased >290 mOsm/L Serum osmolality <280 mOsm/L Urine output > 200 cc/hr x 2 consecutive hours High urine sodium High urine sodium Urine specific gravity <1.005 Decreased plasma volume Increased plasma volume Decreased extracellular volume Increased extracellular volume Treatment Replace excess urine output Volume replacement Fluid restriction Vasopressin or DDAVP Administration of exogenous sodium (i.e., hypertonic saline) Administration of exogenous sodium (i.e., hypertonic saline infusion)

LP and CSF studies

Normal cell counts of <5 cells/ml in CSF versus elevated count in all types of meningitis Elevated protein levels Glucose levelselevated, viral meningitis; decreased, fungal and bacterial meningitis Gram stain and culturesdetermine the causative organism

MEDICAL MANAGEMENT - Chemotherapy

- External-brain radiation therapy - RADIATION THERAPY cornerstone of treatment decreases the incidence of recurrence of incompletely resected tumors. - BRACHYTHERAPY surgical implantation of radiation sources to deliver high doses at a short distance -has had promising results for primary malignancies usually used as an adjunct to conventional radiation therapy or as a rescue measure for recurrent disease.

- INTRAVENOUS AUTOLOGOUS BONE MARROW TRANSPLANTATION -used in some patients who will receive chemotherapy or radiation therapy, because it can rescue the patient from the bone marrow toxicity associated with high dosage of chemotherapy and radiation. -A fraction of patients bone marrow is aspirated, usually from the iliac crest, and stored. The patient receives large doses of chemotherapy or radiation therapy to destroy large numbers of malignant cells. The marrow is then reinfused intravenously after treatment is completed.

- CORTICOSTEROIDS - may be used before and after treatment to reduce cerebral edema and promote smoother and more rapid recovery.

- GENE TRANSFER THERAPY - uses retroviral vectors to carry genes to the tumor, reprogramming the tumor tissue for susceptibility for treatment.

- PHOTODYNAMIC THERAPY - treatment of primary malignant brain tumors that delivers targeted photodynamic therapy while conserving healthy brain tissue.

Treatment for Primary Brain Tumors I. Biopsy Biopsy of the tumor tissue is performed to provide a definitive diagnosis. Tissue is obtained by stereotactic biopsy or open craniotomy. Tumor histology guides the treatment plan for the patient. II. Stereotactic Biopsy This is a closed procedure that allows the neurosurgeon to navigate a biopsy needle to the precise location of the lesion with minimal disruption to normal brain tissue (Figure 2). A. Advantages a. Provides access to deep-seated tumors and tumors in eloquent areas 2. that are surgically inaccessible with significant neurologic risk 3. Creates smaller incision 4. Can be performed under local anesthesia and conscious sedation, which 5. provides a safer option for patients who have a contraindication to general anesthesia 6. Involves decreased operative time 7. Requires shorter hospital stay 8. Allows precise placement of burr hole 9. Yields accurate diagnosis in 95% of cases 10. Serves as a more cost-efective option compared with open craniotomy B. Disadvantages 1. Does not provide the direct visualization of an open procedure 2. Can not address lesions causing mass effect, which must be addressed with craniotomy 3. May cause bleeding from vascular tumors (i.e., metastatic renal cell carcinoma, choriocarcinoma, and metastatic melanoma), which can be catastrophic 4. Only provides tumor pathology of small samples, which may not be representative of large tumor6 AANN Reference Series for Clinical Practice

III. Craniotomy A. Surgical procedureopening of the bones of the skull in order to access a tumor for resection B. Shape of incision (determined by lesion size, lesion site, or both) 1. Straight 2. Curved 3. Coronalear to ear 4. Pterionalslightly curved in front of the ear 5. Question mark 6. Horseshoe shaped C. Advantages 1. Provides direct visualization of brain tissue and tumor borders 2. Enables total tumor removal, if possible 3. Creates opportunity to obtain tumor tissue for pathology and definitive diagnosis 4. Decompresses intracranial contents, reduces ICP 5. Requires only local anesthesia and permits monitoring of conscious sedation for tumors involving the eloquent cortex 6. Allows placement of local therapies (i.e., gliadel wafers, other chemotherapy, brachytherapy) 7. Relieves symptoms 8. Improves neurological status and quality of life D. Disadvantages 1. Involves inherent risks due to the invasive nature of the procedure 2. May result in increased swelling due to trauma from surgery 3. Usually requires intensive care unit (ICU) stay 4. Results in higher total hospitalization costs compared with stereotactic surgery IV. Other Surgical Options A. Awake craniotomies with brain mapping a) Procedure is useful when the tumor involves the eloquent cortex (motor strip, sensory areas, and speech). b) Medical team can interact with the patient during surgery and monitor for complications. B. Functional magnetic resonance imaging (fMRI) a) This allows for noninvasive brain mapping by using an fMRI scanner. b) Patient is asked to perform repetitive tasks such as reading a list of words, finger tapping, or thinking of certain types of objects. c) The areas that control these functions within the brain show increased activity, which can be translated into an image that shows the anatomical area of interest.

d) The fMRI scan is then combined with a conventional MRI scan in which a contrast medium is given that outlines the tumor. e) The combination of these scans is transferred to a surgical computer that guides the neurosurgeon on the appropriate navigational path to preserve these areas. C. Neuroendoscopy a) Surgery is performed by making one or more incisions (or small burr holes) and using an endoscope to visualize the tumor. b) This is applicable only to tumors within the ventricular system. c) It is a minimally invasive surgery due to small burr holes and potentially less traumatic to normal tissue. d) Surgeon has increased ability to perform microsurgical procedures. e) MRI is performed after surgery to assess the extent of tumor removal and to assist with the planning of further treatments. D. Stereotactic surgery a) Similar to stereotactic biopsy; however, instead of obtaining a sample of the tumor, the goal is to remove as much of the tumor as possible.8 AANN Reference Series for Clinical Practice b) Surgery utilizes computer equipment and MRI scan to coordinate the location of the tumor and navigational path to remove it. V. Chemotherapy a) Chemotherapy is an important treatment option for many types of brain tumors. b) It is used in conjunction with other modalities such as surgery and radiation. c) Due to its toxic nature, chemotherapy precautions should be followed at all times. d) Its use has been limited in some tumors due to the bodys natural defense mechanism called the blood-brain barrier. 1. Commonly used chemotherapy agents a) b) c) d) e) f) g) Carmustine (BCNU) Lomustine (CCNU) Procarbazine (PCV) Vincristine Thiotepa Methotrexate Temozolomide (Temodar)

2. Chemotherapy drugs that can cross the blood-brain barrier a) b) c) d) e) BCNU CCNU Procarbazine Thiotepa High dose Methotrexate

f)

Temozolomide (Temodar)

3. Common side effects a. b. c. d. e. f. g. h. Nausea, vomiting, or both Hair loss Neutropenia Fatigue Diarrhea Weight loss Mucositis Sterility

4. Combination therapy (where 2 or more chemotherapy agents are utilized together) also common.

VI. Radiation Therapy A. Damages cellulas DNA 1. Tumor cellsrapidly dividing nature susceptible to radiation 2. Normal cellsalso affected B. Allows for maximum recovery of normal cells (in divided doses)Guide to the Care of the Patient with craniotomy PostBrain Tumor Resection 9 C. Varies according to tumor location and pathology, which affects type and efficacy

D. Types 1. External beam radiation therapy a. Involves directing a beam of radiation to a tumor b. Affects the tumor, operative cavity, and a 2-cm margin 2. Three-dimensional conformal radiation therapy a. Serves as a focal method of radiation b. Involves shaping multiple beams of radiation to the exact contour of the treatment area c. Spares most sourrounding area from exposure to radiation

3. Intensity modulated radiation therapy (IMRT) a. Allows variations of shape and intensity of radiation to be delivered to different parts of treatment area b. Enables precise treatment of tumor according to thickness 4. Hyperfractionated radiation therapy a. Provided in two fractions per day b. Delivers a higher total dose of radiation per day c. Used in brain stem tumors only generally d. Under investigation in tumors of other locations 5. Gamma-knife therapy and stereotactic radiosurgery therapy a. Do not affect all of the surroding tissue, unlike conventional radiation therapy that does b. Involve immobilizing a patients head in a frame c. Provide concentrated radiation to tumors by focusing many ultra low-dose beams from multiple angles onto the tumor bed d. Vary from single dose to fractionated doses based on the tumor and its location e. Vary according to tumor location and pathology, which affects therapy type and efficacy f. Treat small areas of residual tumor or recurring tumors 6. Brachytherapy a. Places radioactive isotopes in close contact with the tumor or directly in the tumor bed after tumor resection b. Provides precise doses of radiation to the treatment area F. Possible side effects 1. Hair loss 2. Fatigue 3. Redness of the skin (similar to sun burn) 4. Headache 5. Swelling 6. Visual and neurological disturbances 7. Hearing loss

8. Facial numbness10 AANN Reference Series for Clinical Practice VII. Investigational Treatment A. Monoclonal antibody therapy B. Gene therapy C. Immunotherapy D. Vaccines E. Radiation sensitizers F. Combination therapies Introduce radiation, intracavitary local chemotherapy, or both in combination with systemic chemotherapy.Guide to the Care of the Patient with Craniotomy PostBrain Tumor Resection Associated Nursing Diagnosis

Common nursing diagnosis related to physical condition: Alteration in Comfort Alteration in Nutrition Altered Oral Mucous Membrane (r/t stomatitis) Fatigue Alteration in Cerebral Perfusion Risk of Infection Risk of Impaired Skin Integrity Knowledge Deficit (diagnosis, treatment, discharge and follow-up) Common nursing diagnosis related to emotional needs: Fear/Anxiety Personal Identity Disturbance Body Image Disturbance Anticipatory Grieving Dysfunctional Grieving Altered Role Performance Social Isolation Impaired Social Interaction Altered Family Processes Impaired Adjustment Ineffective Individual/Family Coping Ineffective Denial

Nursing Care/Interventions: During Diagnosis The main goal during the diagnosis phase is to provide the patient with information about the tests that are being conducted and the information that is being attained from the results. Many patients have suffered short term memory loss and impaired or altered mental status, so patient education must be geared to the level of patient cognition. For patients who can understand the diagnosis, a level of denial, anger, hostility and sometimes refusal to consider treatment will be present. Before and After Surgery Pre-op management of the patient undergoing brain tumor surgery is similar to other pre-op surgical procedures. The following should be completed prior to the patient going to surgery:

Informed consent. Clarify and reinforce information provided by physician. Describe preparatory events. Discuss with patients family length of surgery and where they are to wait. Pre/post op patient education (deep breathing exercises for example). Review with patient and family what to expect during hospitalization. Routine labs/NPO DVT prophylaxis (thigh high support stockings pre and sequential stockings post).

Post-op Management: Attain complete report on the patient status during the intraoperative phase. This should include:

Overview of the surgery (anatomical approach, length, specific area of brain involved).

History of preoperative neurological deficits. Pre-existing medical problems (Co-morbidities). Current and baseline neurological status. Information provided to family (location of family). Review of post-operative orders.

Nursing Assessment/Interventions: Assess and monitor ABCs Monitor routine vital signs Monitor O2 saturation Monitor I&O (to prevent Foley related UTI, remove Foley when patient is stable). HOB 30 degrees/Side rails up Initially NPO (most orders allow for progression of diet as patient tolerates). Initially bed rest (as with NPO, most orders allow for the progression of activity as the patient tolerates).

 Monitor Neuro exam to include: o LOC o Pupillary reaction o Eye movement o Motor function o Sensory function Review of laboratory data to include: o Hemoglobin/Hematocrit o BUN/Creatinine o Electrolytes (Potassium, Calcium, Sodium, Glucose) o Serum Osmolarity Pain and sedation control Basic hygiene Turning Q 2 hours (note: do not combine nursing activities that are known to increase intracranial pressure) Range of motion Inspection of incision and dressing for drainage Nursing Management During Radiation the nurses primary role during radiation therapy is to provide emotional support to the patient and family and assess and manage the side effects that come with radiation treatment. These specific interventions include:

Prior to starting radiation, inform patient and family of the various activities that will occur during the administration of radiation.

Provide proper skin care to radiation site. Administer antiemetics (antidiarrheal agents may also be necessary). To manage anorexia, offer small portions of food that are easily digested. For fatigue and malaise; schedule activities that allow for rest periods in between.

Note results of CBC with special attention to WBC and platelet counts. (Bone marrow depression decreases platelets and increases risk of hemorrhage).

Monitor neurological status and for signs of increased ICP. Provide emotional support that includes the prompt attention to resolution of side effects.

Nursing Management During Chemotherapy the most important nursing intervention during chemotherapy is for the nurse to be well educated regarding the medication(s) the patient is to receive. Control and management of side effects is crucial during the administration of chemotherapy agents. As described in the above chemotherapy agent table; control of nausea, vomiting, diarrhea, stomatitis, anorexia, alopecia and bone marrow depression are the most commonly seen side effects of chemotherapy.

Comprehensive Drug Study A. DEXAMETHASONE Brand name: Decadron, Deronil, Dexone, Hexadrol Drug Classification: Steroid Mechanism of action: Decreases the inflammation, mainly by stabilizing leukocyte lysosomal membranes. Also suppresses the immune response, stimulates bone marrow and influences protein, fat and carbohydrate metabolism. Indications Cerebral Edema Inflammatory Conditions Shock 11 Adverse Reaction CNS: Psychotic Behavior, Euphoria CV: Congestive hart failure, Hypertension, Edema Skin: Delayed wound healing, various skin eruptions Other: Muscle weakness, susceptibility to infections. Nursing Considerations Gradually reduce drug dosage after long term therapy. Tell patient not to discontinue drug abruptly or without doctors consent. Monitor patients weight, blood pressure and serum electrolytes. Watch for depression or psychotic episodes, especially in highdose therapy. Inspect patients skin for petechiae Not used for alternate day therapy B. CAPTOPRIL Brand Name: Capoten Drug Classification: ACE inhibitors Mechanism of Action: By inhibiting Angiotensin- converting enzyme, prevents pulmonary conversion of Angiotensin I to Angiotensin II Indications Hypertension Congestive heart Failure Adverse Reactions Blood: Leukopenia, Agranulocytosis CNS: Fainting CV: Tachycardia, Congestive heart failure Skin: Pruritis Other: Angioedema on the face and Extremities Nursing Consideration Monitor Patients Blood Pressure and Pulse rate frequently Perform WBC and differential counts before starting treatment every 2weeks for the first 3 months of therapy and periodically thereafter Advice patient to report any sign of infection Should be taken 1 hour before meal since food in the G.I tract may reduce absorption. C. CHLORAMPHENICOL Brand name: Chloromycetin, Mychel Drug Classification: Antibiotic 12 Mechanism of Action: Inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome. Indications Severe infections caused by sensitive salmonella species Various sensitive gram- negative organisms causing meningitis Adverse Reactions CNS: Headache, confusion, mild depression, delirium, GI: Nausea, vomiting Other: Infections by nonsusceptible organisms, hypersensitivity reaction

Nursing Considerations Culture and Sensitivity test may be done before first dose and p.r.n Monitor CBC, platelets, serum iron and reticulocytes before and every 2 days during therapy. Stop drug immediately if anemia, leukopenia develops Instruct patient to report adverse reactions to the doctor, especially nausea and vomiting and confusion. Give IV slowly over 1minute Monitor for evidence of super infection by nonsusceptible organisms D. PENICILLIN G Na Brand Name: Crystapen Drug Classification: Anti infective Mechanism of Action: Bactericidal against microorganisms by inhibiting cell-wall synthesis during active multiplication. Bacteria resist penicillin by producing penicillinases-enzyme that converts penicillin to inactivate penicillin acid. Adverse Reactions CNS: Convulsion Local: Vein irritation Others: Hypersensitivity (edema), overgrowth of nonsusceptible organisms. Nursing Considerations Obtain cultures for sensitivity tests before first dose. Unnecessary to wait for test results before beginning therapy. Before giving penicillin, ask patient if she had any allergic reactions to this drug. If patient has High blood level of this dug, she may have convulsions. Be prepared by keeping side rails up on bed. Give IV intermittently to prevent vein irritation. Change site every 48 hours. 13 Give penicillin at least 1 hour before bacteriostatic antibiotics. With prolonged therapy bacterial or fungal super infections may occur especially patients who are elderly, debilitated or who have low resistance. E. Ranitidine Hydrochloride Brand Name: Zantac Drug Classification: Anti ulcer Mechanism of Action: Competi Adverse Reactions CNS: Convulsion Local: Vein irritation Others: Hypersensitivity (edema), overgrowth of nonsusceptible organisms. Nursing Considerations Assess patient for abdominal pain. Note the presence of blood in the emesis, stool, or gastric aspirate. Ranitidine may be added to total parenteral nutrition solutions Dont confuse Ranitidine with Ramantidine; Dont confuse Zantac with Xanax or Zyrtec.

Conclusion of Case Study:

This client did suffer mild neurologic damage as a result of surgery. She was discharged to a rehabilitation facility, and eventually recovered most of her lost function. She continues to enjoy an active life and has become involved in helping others facing similar experiences.

References: Brunner and Suddarths Textbook of Medical-Surgical Nursing, 11 Ed. http://www.brain-surgery.us/brain_tumor.html#module1 http://emedicine.medscape.com/article/779664-overview http://www.cancer.org/Cancer/BrainCNSTumorsinAdults/DetailedGuide /index http://www.cancer.org/Cancer/BrainCNSTumorsinChildren/DetailedGui de/index http://www.scribd.com/doc/23193235/BRAIN-TUMORS http://dynamicnursingeducation.com/class_more.php?class_id=112&m ore=31 http://www.surgeryencyclopedia.com/Ce-Fi/Craniotomy.html

END