OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING

VALENZUELA CAMPUS

Pineal region tumor with obstructive hydrocephalus s/p VPS

s/p Radiotheraphy with VP Shunt malfunction
In Partial Fulfillment of requirements of NCM 107B RLE leading to the degree
of Science in Nursing

Presented to:

Mr. Francis M. Culala

Presented by:

Bungay, Maria Paula M.

BSN 4Y 1-1

Group 1B

August 1, 201

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 TABLE OF CONTENTS

I. Introduction

II. Objectives

III. Patients Profile

IV. Anatomy and Physiology

V. Pathophysiology

VI. Laboratory Examination Results

VII. Gordons Assessment

VIII. Nursing Care Plans

IX. Drug Study

X. Health Teachings

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I. Introduction

The pineal gland, which is a tiny gland located in the back of the base of the
brain, creates the neurotransmitters melatonin and serotonin, although its purpose is
not entirely clear. Tumors in this region can be of a wide variety of types; the most
common are germ cell tumors, which arise from developmental abnormalities, and
pineal cell tumors, which come from the cells of the pineal gland itself.

Regardless of the type of tumor involved, tumors in the pineal region usually
cause symptoms through one of three mechanisms. They can increase pressure in
the skull by blocking the flow of cerebrospinal fluid (hydrocephalus), they can
compress part of the brain, or they can cause disruptions in the endocrine system,
the system that controls hormones and includes the pineal gland. Hydrocephalus is a
common result of tumors in this region, and will lead first to headaches, and then
perhaps to nausea, vomiting, and altered mental status. The brainstem and the
cerebellum are the most common sites of compression from a pineal region tumor;
compression in these regions can cause abnormal eye movements (including
Parinauds syndrome, the inability to look up), double vision, uncoordinated body
movements, or unsteady gait. Endocrine dysfunction is less common and usually is
caused when the tumor involves the hypothalamus, a nearby brain region that is
involved in growth and metabolism.

The first line of treatment for pineal region tumors is surgery. The extent of
the surgical removal is a significant factor in outcome. In addition, the surgical
removal of the tumor will provide tissue samples, which are analyzed under a
microscope to provide an accurate diagnosis. If hydrocephalus is present, a shunt (a
tube that allows cerebrospinal fluid to flow out) may be placed prior to surgery. In the
case of benign tumors, complete resection usually provides a cure. For malignant
tumors, the removal of as much of the tumor as possible is thought to improve
outcome and response to adjuvant therapy. Some germ cell tumors respond very well
to radiation therapy, and chemotherapy may have a role in the treatment of some
tumor types. Stereotactic radiosurgery, which involves the use of a highly focused
beam of radiation to target the cancer cells and leave the surrounding brain
unaffected, also may be used in the case of small tumors.

Germ Cell Tumors

Intracranial germ cells tumors constitute a wide range of tumors that arise
from germ cells, including sex cells, present during the development process. Germ
cell tumors commonly are associated with the reproductive system, but there are
several types that occur in and around the brain.

Benign germ cell tumors include teratomas, dermoid tumors, and epidermoid
tumors. Endodermal sinus tumors, embryonal cell tumors, and choriocarcinomas are
at the malignant end of the spectrum, while germinomas and immature teratomas
fall somewhere in between. The pineal region is one of two areas in the brain where
germ cell tumors can occur. Germ cell tumors are very rare; they make up 0.4 to 3.4
percent of all intracranial tumors. In general, these tumors manifest in patients by
adolescence.

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 Germ cells tumors may arise from different types of cells, and they are
differentiated by biochemical markers in the blood and cerebrospinal fluid. Lab tests
for these markers will be used in addition to imaging tests (MRI and CT) and biopsies
to provide a diagnosis.

Treatment for germ cells tumors vary based on the tumor type and usually
consists of some combination of surgery, radiation therapy, and chemotherapy. In the
case of benign tumors, for example, complete surgical resection usually provides a
cure. Malignant germ cell tumors, on the other hand, require some kind of adjuvant
therapy. Germinomas, for example, are particularly sensitive to radiation therapy.
Germinomas and other malignant germ cell tumors also respond to chemotherapy as
an adjuvant treatment.

Pineal Cell Tumors

Unlike germ cell tumors, which arise in the pineal region despite being
unrelated to the pineal gland itself, pineal cells tumors arise directly from the
functional cells of the gland, called pineal parenchymal cells. These cells are
unrelated to the neurons and glial cells (supporting cells) in the brain. However, there
are glial cells present in the gland, and these cells may give rise to tumors called
gliomas.

Tumors that arise from pineal parenchymal cells are categorized according to
their malignancy. Pineocytomas are the more benign version, while pineoblastomas
are malignant. Even rarer than germ cell tumors, they make up just 0.4 to 1.0
percent of intracranial tumors. Approximately 50 percent of these are the malignant
pineoblastomas, 30 percent are pineocytomas, and 20 percent are mixed. These
tumors tend to occur from adolescence through middle age.

As with other brain tumors, imaging tests and surgical biopsy are used to
provide diagnosis and assess the malignancy of these tumors.

Surgery usually is the initial treatment. Complete surgical resection of discrete

benign pineocytomas is associated with an excellent prognosis and perhaps a cure.
For the more malignant pineoblastomas, surgical removal of as much of the tumor as
possible may improve the response to other forms of therapy. Radiation therapy has
shown some efficacy in treating pineoblastomas, but the role of chemotherapy is
unclear because it has not been studied extensively.

Masses in the pineal region have a relatively broad differential because of the
variety of cell types found in the region.

If large enough, the mass may compress the tectal plate which may cause a
defect in up-gaze (Parinaud syndrome) or, obstructive hydrocephalus if the cerebral
aqueduct is compressed.

Hydrocephalus

Is the buildup of too much cerebrospinal fluid in the brain. Normally, this fluid
cushions your brain. When you have too much, though, it puts harmful pressure on
your brain. Hydrocephalus can be congenital, or present at birth. Causes include
genetic problems and problems with how the fetus develops. An unusually large head
is the main sign of congenital hydrocephalus. Hydrocephalus can also happen after
birth. This is called acquired hydrocephalus. It can occur at any age. Causes can

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include head injuries, strokes, infections, tumors, and bleeding in the
brain. Hydrocephalus can permanently damage the brain, causing problems with
physical and mental development. If untreated, it is usually fatal. With treatment,
many people lead normal lives with few limitations. Treatment usually involves
surgery to insert a shunt. A shunt is a flexible but sturdy plastic tube. The shunt
moves the cerebrospinal fluid to another area of the body where it can be absorbed.
Medicine and rehabilitation therapy can also help.

Overview

The pineal gland is a small gland in the mid-brain shaped like a pinecone. It
produces melatonin, a serotonin derivative and hormone that control sleep/waking
patterns, circadian rhythms and the bodys ability to regulate to the seasons. Pineal
tumors are rare in adults, representing 1% of all brain tumors overall. However,
pineal tumors make up 3-8% of intracranial tumors in children and the average age
of patients at time of diagnosis is 13 years old. The most common types of pineal
tumors are germ cell tumors (germinoma, teratoma); glial cell tumors (astrocytoma,
ependymoma); pineal cell tumors (pineocytoma, pineoblastoma) and miscellaneous
tumors (pineal cyst, meningioma). 10% of pineal tumors are benign, another 10% are
relatively benign (low grade), while the remaining 80% are highly malignant. In
children younger than 10, certain germ cell tumors may secrete hormones that can
create an endocrinologic disturbance and lead to precocious puberty. In this instance,
the pineal tumor affects the hypothalamus, which in turn can compromise or over
stimulate pituitary function.

Objectives:

Nurse Centered

1. Describe factually, the personal and pertinent family history of the patient and
relate it to the present condition.
2. Perform comprehensive physical assessment.
3. Trace the book-based and client-centered pathophysiology
4. Determine the predisposing and precipitating factors and the signs and
symptoms and relate to the disease process.
5. Enumerate and describe the diagnostic and laboratory procedures as well as the
nursing responsibilities in relation to the disease condition
6. Enumerate the different treatment modalities and their indication specifically for
the patients condition.
7. Identify the pharmacologic treatment provided to the patient, relate the actions
of each drug with the disease process and evaluate the patients response to the
medications given.
8. Identify nursing diagnoses, formulate short-term goals, carry out appropriate
interventions and evaluate the plan.
9. Appraise the effectiveness of medical and surgical nursing management in
treating the patient.
10. List the preventive measure for the occurrence of Pineal region tumor.

Patient Centered

1. Report understanding of the disease process.

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2. Understand the indications of the different diagnostic procedures and medical
management involved in her care.
3. Cooperate with the necessary medical and nursing interventions.
4. Adhere with the health teachings provided.
5. Understand the different ways of health promotion and prevention in relation to
the disease condition.
6. Demonstrate improved conditions as evidenced by absence of further
complications.

III. Patients Profile

Name: Mr. ARD

Age: 18 years old
Nationality: Filipino
Religion: Roman Catholic
Civil Status: single
Date Admission: July 27, 2015
Time of Admission: 8:15 AM
Ward: SICU bed 3
Initial Diagnosis: Pineal region tumor with obstructive hydrocephalos s/p radiotherapy
Diagnosis: Shunt Malfunction

HISTORY OF PAST ILLNESS

No information was obtained from the patient and the S.O. due to
unavailability.

Pre-operative Diagnosis
Pineal region tumor with obstructive hydrocephalos s/p radiotherapy s/p VPS
s/p VP shunt resiting with intraventricular hemorrhage.

PHYSICAL ASSESSMENT
Physicians Physical Assessment done by the Resident on Duty (July 27, 2015,
lifted from the patient's chart)
Height: 56
Weight: 81 kg

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Vital Signs as follows:
T: 36.9 C PR: 116 bpm RR: 18cpm BP: 150/90 mmHg SAO2: 97%

GENERAL SURVEY

Mr. ARD, Assessed/received patient lying on bed, sleeping, conscious with GCS
15. With the following vital signs:

Temperature: 36.7 C

Heart rate: 70 bpm

Respiratory rate: 20 bpm

Blood Pressure: 140/90 mmHg

SAO2: 96%

NUTRITIONAL STATUS

SKIN

> skin is brown smooth, warm, moist, with poor turgor and elasticity

HAIR

> Hair was shaved for the operation.

> Silky and smooth skin.

> No areas of hair loss noted.

NAILS

> Trimmed clean nails.

> Concave shaped; with a nail plate angle of about 160 degrees.

> Smooth in texture.

> Intact epidermal lining around the nails.

EYES AND VISION

> Anicteric sclera

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> Pink palpebral conjunctiva

NECK

> No tonsillopharyngeal discharge

RESPIRATORY SYSTEM

> Symmetric chest expansion

> - tagging

> - retraction

> vesicular breath sound on both lung field

ABDOMEN

> Direct tenderness at epigastric area.

> Abdominal skin is intact.

> Distended abdomen noted.

> Audible bowel sound upon auscultation.

> Abdominal dullness upon percussion.

MUSCULOSKELETAL

> Posture is good

> Scar at the right upper quadrant of the abdomen.

NEUROLOGIC

>With a GCS of 15

> Patient was conscious but unable to respond.

URINARY SYSTEM

> Patient has indwelling Foley Catheter

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REVIEW OF SYSTEM

Integumentary System

The patient has no history of bruises in both upper and lower extremities.

Head

The patient had no history of any form of head injuries.

Eyes

Patient had no history of any eye problems.

Ears and Hearing

Patient had no history of smelly discharges on both ears, and no complaints of

hearing impairment.

Breast and Axillae

The patient had no history of breast nodules, no enlargement, no tenderness, no

pain and unusual discharges.

Respiratory System

The patient has no history of asthma or other respiratory problems.

Cardiovascular System

The patient has a history of hypertension.

Genitourinary System

The patient had no history of any genital problems. Usually urinates at least 30cc
per hour.

Gastrointestinal System

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 The patient had no experience of abdominal pain.

Musculoskeletal System

Patient has no history of joint pain.

Neurologic System

Patient had no history of any major mental problems.

IV. Anatomy and Physiology

CENTRAL NERVOUS SYSTEM

Nervous System

The nervous system is broken down into two major parts: the central nervous
system, which includes the brain and spinal cord, and the peripheral nervous system,
which includes all nerves, which carry impulses to and from the brain and spinal cord.
These include our sense organs, the eyes, the ears, our sense of taste, smell and
touch, as well as our ability to feel pain.

Spinal Cord

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 The spinal cord is a long bundle of neural tissue continuous with the brain that
occupies the interior canal of the spinal column and functions as the primary
communication link between the brain and the rest of the body. The spinal cord
receives signals from the peripheral senses and relays them to the brain.

Brain

The brain is the largest and most complex part of the nervous system. It is
compose of more than 100 billion neurons and associated fibers. The brain tissues
have a gelatin like consistency. The semi-solid organ weighs about 1400g
(approximately 3 pounds) in the adult human.

1. The frontal lobes (motor complex) controls voluntary motor activity.

2. The parietal areas these same areas are thought to contribute to reasoning,
problem solving activities and emotional stability.
3. The occipital lobe contains a primary visual receptive (interpretation) area
and visual association areas.
4. The temporal lobe is located under (inferior to) the lateral sulcus. It contains
primary auditory receptive area and secondary auditory association areas.

Brain Stem

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 The brain stem is the part of the brain that connects the cerebrum and
diencephalons with the spinal cord.

Medulla Oblongata

The medulla oblongata is located just above the spinal cord. This part of the
brain is responsible for several vital autonomic centers including

The respiratory center, which regulates breathing.

The cardiac center that regulates the rate and force of the heartbeat.
The vasomotor center, which regulates the contraction of smooth muscle in
the blood vessel, thus controlling blood pressure.

The medulla also controls other reflex actions including vomiting, sneezing, coughing
and swallowing.

Pons

Continuing up the brain stem, it reaches the Pons. The pons lay just above
the medulla and acts as a link between various parts of the brain. The pons connects
the two halves of the cerebellum with the brainstem, as well as the cerebrum with
the spinal cord. The pons, like the medulla oblongata, contains certain reflex actions,
such as some of the respiratory responses.

Midbrain

The midbrain extends from the pons to the diencephalon. The midbrain acts
as a relay center for certain head and eye reflexes in response to visual stimuli. The
midbrain is also a major relay center for auditory information.

Diencephalon

The diencephalons are located between the cerebrum and the mid brain. The
diencephalons houses important structures including the thalamus, the
hypothalamus and the pineal gland.

Thalamus

The thalamus is responsible for "sorting out" sensory impulses and directing
them to a particular area of the brain. Nearly all sensory impulses travel through the
thalamus.

Hypothalamus

The hypothalamus is the great controller of body regulation and plays an

important role in the connection between mind and body, where it serves as the
primary link between the nervous and endocrine systems. The hypothalamus
produces hormones that regulate the secretion of specific hormones from the
pituitary. The hypothalamus also maintains water balance, appetite, sexual behavior,
and some emotions, including fear, pleasure and pain.

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Limbic System

The limbic system, often referred to as the "emotional brain", is found buried
within the cerebrum. Like the cerebellum, evolutionarily the structure is rather old.

Cerebellum (little brain)

The functions of the cerebellum include the coordination of voluntary muscles,

the maintenance of balance when standing, walking and sitting, and the maintenance
of muscle tone ensuring that the body can adapt to changes in position quickly.

Cerebrum

The largest and most prominent part of the brain, the cerebrum governs
higher mental processes including intellect, reason, memory and language skills. The
cerebrum can be divided into 3 major functions:

Sensory Functions - the cerebrum receives information from a sense organ;

i.e., eyes, ears, taste, smell, feelings, and translates this information into a
form that can be understood.
Motor Functions - all voluntary movement and some involuntary movement.
Intellectual Functions - responsible for learning, memory and recall.

Meninges

The meninges are made up of three layers of connective tissue that surround
and protect both the brain and spinal cord. The layers include the Dura mater, the
arachnoid and the pia matter.

Pia mater is a vascular layer of connective tissue that is so closely connected

to the brain and spinal cord that is follows every sulcus and fissures.
Dura mater is a tough non-stretchable vascular membrane with 2 layers the
outer and inner layer.

Reflex Mechanism

Our conscious autonomic responses to internal and external stimuli known as

reflex responses provide many homeostatic functions. Although the spinal cord is
often thought of as the reflex center, it is not the only site for regulation .Many of the
complex reflexes controlling the heart rate, breathing, blood pressure, swallowing,
coughing, and vomiting are found in the brain stem.

Cerebrospinal Fluid

The cerebrospinal fluid is a clear liquid that circulates in and around the brain
and spinal cord. Its function is to cushion the brain and spinal cord, carry nutrients to
the cells and remove waste products from these tissues.

Neurons:

A neuronal cell body (soma) is like other cell in that it contains most of the
organelles seen in other cells.

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There are several types of neurons - anaxonic neurons: small neurons where the
dendrites and axons are indistinguishable.

Bipolar neurons: small neurons with two distinct processes; a dendritic

process and an axon extending from the cell body.
Unipolar neurons: large neurons with the cell body lying to one side of the
continuous dendritic process and axon.
Multipolar neurons: large neurons with several dendrites and a single axon
extending from the cell body.

Bipolar neurons: Bipolar neurons are CNS neurons specific for transmitting
information from specialized sensory systems: sight, smell and hearing.

Grey and white matter: Grey matter consisting of unmyelinated neurons is the
processing area of the CNS. White matter located in the inner cortex and
surrounding grey matter in the spinal cord - provide pathways of communication
between grey matters.

Glial Cells

CNS Glial Cell Types: There are 4 types of glial cells:

1. astrocytes - Regulates the chemical microenvironment surrounding neurons.

2. Oligodendrocytes - Myelinate central nervous system axons.
3. Microglia - Migrating phagocytic cells resembling immune cells that remove
waste, debris, and pathogens.
4. Ependymal cells - Columnar cells that line the ventricles of the brain and the
spinal canal in the spinal cord.

Peripheral Nervous System

The PNS includes all neurons other than those in the brain and spinal cord. It
consists of pathways of nerve fibers between the CNS and all outlying structures in
the body. Included in the PNS are 12 pairs of cranial nerves and 31 pairs of spinal
nerves.

Nerves

Nerves are made up of specialized cells, which act as little wires, transmitting
information to and from the central nervous system and brain. Nerves form the
network of connections that receive signals (known as sensory input) from the
environment and within the body, and transmit the body's responses, or instructions
for action, to the muscles, organs, and glands. Nerve cells are located outside the
central nervous system or spinal cord.

Cranial Nerve

12 pairs of cranial nerves arise from the brain. Most of the cranial nerves are
composed of both motor and sensory neurons although a few cranial nerves carry

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only sensory impulses. Except for the olfactory and optic nerves, whose nuclei lie just
below the cerebrum, all other cranial nerve nuclei lie within the brain stem

The Cranial Nerves

Nerves Type Function

I sensor
olfaction (smell)
Olfactory y

vision
II sensor
(Contain 38% of all the axons connecting to
Optic y
the brain.)

III motor
eyelid and eyeball muscles
Oculomotor *

IV motor
eyeball muscles
Trochlear *

V Sensory: facial and mouth sensation

mixed
Trigeminal Motor: chewing

VI motor
eyeball movement
Abducens *

Sensory: taste
VII
mixed Motor: facial muscles and
Facial
salivary glands

VIII sensor
hearing and balance
Auditory y

IX
Sensory: taste
Glossopharyng mixed
Motor: swallowing
eal

X main nerve of the

mixed
Vagus parasympathetic nervous system (PNS)

XI
motor swallowing; moving head and shoulder
Accessory

XII motor
tongue muscles
Hypoglossal *

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 Pineal Region Tumor

These tumors originate from normal cells in the pineal gland. The pineal gland
is located in the center of the brain and is involved in the secretion of specific
hormones.

Tumor types occurring in the pineal region may or may not involve the pineal
gland. True pineal cell tumorspineocytoma, pineoblastoma, and mixed pineal
tumorsare covered on this page.

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 Tumors that may occur in this region but are not necessarily pineal tumors
include: germinoma, non-germinoma (eg, teratoma, endodermal sinus tumor,
embryonal cell tumor, choriocarcinoma, and mixed tumors), meningioma,
astrocytoma, ganglioglioma, and dermoid cysts. Information on these particular
tumors can be found elsewhere on this site.

Location

The pineal gland is located at the rear of the third ventricle, which is one of
the fluid-filled cavities of the brain. Pineal tumors come from the normal cells of the
pineal gland.

Description

There are three types of pineal tumors:

Pineocytoma: Slow-growing, grade II tumor.

Pineoblastoma: More aggressive, grade IV, malignant tumor. A grade III

intermediate form has also been described.

Mixed Pineal Tumor: Contains a combination of cell types.

Symptoms

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 Symptoms are most often caused by blockage of the cerebrospinal fluid flow
and problems with the eye movement pathways. Headache, nausea and vomiting,
and double vision are common.

Incidence

Pineal region tumors represent less than 1% of all primary brain tumors;
however, 3% to 8% of childhood brain tumors occur in this area. These tumors tend
to occur in young adults between 20 and 40 years old. About 10% to 20% of the
tumors, particularly pineoblastoma, have the potential to spread through the
cerebrospinal fluid. This usually occurs late in the disease. The tumors, however,
rarely spread elsewhere in the body.

Cause

Like many tumor types, the exact cause of pineal cell tumors is not known. However,
scientists have identified chromosomal abnormalities, which may play a role in the
development of these tumors.

Treatment

Standard treatment for these kinds of tumors is radiation therapy. Radiation of

the entire brain and spinal cord is recommended in patients with pineoblastoma.
Chemotherapy may also be considered, particularly if the tumor has spread or if it
regrows.

Surgery may be possible in some individuals to determine the tumor type and
remove part of the tumor. In some cases, placement of a shunt (similar to a drain) is
used to relieve pressure caused by buildup of cerebrospinal fluid.

Obstructive Hydrocephalus

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 Hydrocephalus is a condition in which an abnormal amount of cerebrospinal
fluid accumulates in the brain. It is sometimes referred to as water on the brain,
and indeed the name hydrocephalus comes from the Greek words for water (hydro)
and head (kephale). Cerebrospinal fluid, or CSF, is a clear, watery fluid that surrounds
the brain and spinal cord. CSF serves many important functions. It cushions and
protects the brain from injury; it delivers nutrients to nourish the brain; it removes
waste from tissues; and it regulates pressure within the brain.

Normally, CSF is produced and continuously circulates in cavities called

ventricles before being absorbed into the bloodstream. Obstructive hydrocephalus
occurs when the passage of CSF is blocked. When this occurs, the fluid builds up
inside the ventricle and causes pressure on adjacent brain tissue. Another kind of
hydrocephalus, called non-obstructive or communicating hydrocephalus, occurs when
the brain has trouble re-absorbing CSF or produces too much CSF. This article will
review the common symptoms and treatment of obstructive hydrocephalus.

Causes

Hydrocephalus can occur at any age, but it is most common in infants and
young children or in adults over the age of 60. According to the National Institute of
Neurological Disorders and Stroke, hydrocephalus affects approximately one in every
500 children. Obstructive hydrocephalus can be a congenital condition, meaning it is
present at birth. In these cases, it typically results from a genetic disorder such as
spina bifida (a malformation of the spine), or as a complication of premature birth
with brain hemorrhage. In other cases, the hydrocephalus is an acquired condition
that develops later in life due to a brain tumor or cyst, head injury, or an infection
such as meningitis.

Symptoms

The symptoms of hydrocephalus vary according to age and individual.

Hydrocephalus can be more obvious in infants and toddlers because the bones of the
skull are not yet closed, and the build-up of fluid can cause an enlarged head, a tense
or bulging soft spot, a thin scalp, prominent veins in the scalp, or separated bones in

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the head. In addition, infants may suffer from symptoms such as vomiting,
drowsiness, irritability, constant downward gaze, poor appetite, or seizures. The same
symptoms may be present for toddlers and young children, along with headache,
nausea, fever, delayed progress in walking or talking, poor coordination, inability to
concentrate, or loss of sensory or motor functions.

In older children and adults, the bones of the skill are closed together and the
head cannot enlarge. Therefore, the symptoms of hydrocephalus reflect increased
pressure on the brain. These symptoms may include headache, loss of coordination
or balance, nausea, vomiting, bladder control problems, impaired vision, and changes
in concentration or memory.

Diagnosis

The diagnosis of hydrocephalus usually includes a physical and neurological

exam as well as imaging tests. The neurological exam checks eye movement and
vision, hearing, sensation, reflexes, balance and coordination, motor skills, thinking
and memory. Imaging tests such as MRI, CT scan, and ultrasound (for infants) can
help to determine the severity and cause of the hydrocephalus.

Treatment

The treatment of obstructive hydrocephalus depends on the cause of the

obstruction and the severity of the condition. If the hydrocephalus is not creating
symptoms, or if it is due to a temporary obstruction, intervention may not be
required. In most cases, though, it is necessary to have surgery. If the hydrocephalus
is due to a tumor or cyst that can be surgically removed, this is usually the best
option. However, sometimes the obstruction cannot be removed, so instead surgery
is required to divert the flow of CSF and avoid accumulation and pressure on the
brain. This approach does not cure the hydrocephalus, but it does address the
symptoms of the disease and allows for satisfactory long-term management.

There are two methods for diverting CSF. The first option is the surgical
insertion of a shunt. This is a small, flexible plastic tube that sends the excess CSF
into another area of the body where it can be safely absorbed, usually in cavities
near the abdomen or the heart. The shunt has a valve that controls the flow of CSF
and maintains normal pressure levels within the ventricle. All of the components of
the shunt system are enclosed in the body. The surgery to insert a shunt is a
relatively short and uncomplicated procedure. However, shunts have several
drawbacks. They can malfunction or become infected or clogged. Children tend to
outgrow the shunts and need later surgery to replace them.

The second method for diverting CSF is a relatively new, minimally invasive
procedure called ventriculoscopy (sometimes called endoscopic third
ventriculostomy, or ETV). In this treatment, the neurosurgeon uses an endoscope,
which is a tiny telescopic camera that can be inserted into the ventricle to view the

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fluid and the obstruction. The surgeon can then create a hole in the membrane at the
bottom of the ventricle to allow the CSF to detour around the obstruction and flow
freely into the rest of the brain for re-absorption. Ventriculoscopy has many
advantages. When successful, it avoids the need for a shunt and it has a lower long-
term complication rate than shunts. However, ventriculoscopy is not usually
recommended for children under two years of age, due to a higher rate of failure. In
addition, sometimes the first hole in the membrane closes up over time and the
procedure must be repeated. The procedure is also more complicated than a
traditional shunt surgery, so it is important that you have a neurosurgeon who is
trained in endoscopic techniques.

Surgery

Pineal region tumours

The pineal gland is just below the area where the two cerebral hemispheres
join. Tumours in this part of the brain are extremely rare. They can be made up of
different types of cells.

The most common tumours found in the pineal gland are germinomas; others
include teratomas, pineocytomas and pineoblastomas.

Symptoms of brain tumours

A brain tumour may cause symptoms because the space it takes up in the
skull puts pressure on the brain or because it is disturbing the function of the part of
the brain it's growing in.

Symptoms of brain tumour may occur due to following reasons:

Symptoms due to increased pressure in the skull

Seizures

Symptoms connected with the tumour's position

Personality changes

Symptoms due to increased pressure in the skull. The brain is

contained within the skull and has a fixed amount of space. If a tumour grows in the
brain it will often cause an increase in pressure, which can cause symptoms to
develop. An increase of pressure in the skull is called raised intracranial pressure
(ICP). The most common symptoms of a rise in the pressure within the brain are
headaches, feeling sick (nausea) and vomiting. Of course, many other things can
cause headaches or feelings of sickness, but if you have either of these for over a
week with no sign of getting better, it's important to see your doctor. A pressure
headache may be most severe in the mornings, and can occasionally wake you.
Usually this type of headache gets better during the day. However, it may get worse
when you cough, sneeze, bend down or do any hard physical work. All of these tend
to raise pressure in the brain. If the raised pressure makes you sick, it may be worse
in the morning than during the day. Another possible symptom of a brain tumour is

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drowsiness. This can happen as the pressure in the brain increases. You may find
that you sleep more or that you drop off during the day when you wouldnt normally.
As well as the symptoms described here, raised intracranial pressure can also cause
changes to your sight, such as blurred vision, 'floating objects' and tunnel vision. It
may also make you confused or affect your balance. Seizures Seizures (fits) are
another common symptom caused by brain tumours. Some people can may
experience muscle spasms which could be twitching or jerking of an arm or leg or
sometimes the whole body. Occasionally they can cause moments of
unconsciousness.

It's important to remember that a seizure can be caused by medical

conditions other than a brain tumour. A seizure can be a frightening experience. if
you have one you should seek medical help so that the cause can be diagnosed and
treated.

Symptoms connected with the tumour's position

Some symptoms may be caused by tumours in particular parts of the brain.

Sometimes a headache can feel worse on the same side of the tumour. In general,
each area of the brain controls particular functions. A tumour in a particular part of
the brain may prevent that area of the brain from working normally.

Some of these symptoms are listed below, grouped under the different parts of the
brain. They are included only as a guide. Exact diagnosis can only be made by a
doctor and confirmed by tests.

The diagram showing the lobes and functions of the brain shows the different
functions of each area of the brain.

Frontal lobe tumours Changes in personality and intellect. Uncoordinated walking

or weakness of one side of the body, loss of smell, occasional speech difficulties.

Parietal lobe Difficulty speaking or understanding words. Problems with writing,

reading or doing simple calculations. Difficulty in coordinating certain movements,
and finding your way around. Numbness or weakness on one side of the body.

Occipital lobe Loss of vision on one side. The person may not notice this at first and
it may sometimes be discovered during routine eye tests.

Temporal lobe Fits, which may cause strange sensations: a feeling of fear or
intense familiarity (dj vu), strange smells or blackouts. Speech difficulties and
memory problems.

Cerebellum Lack of coordination which affects walking and speech (dysarthria),

unsteadiness, flickering involuntary movement of the eyes (nystagmus). Vomiting
and neck stiffness.

Brain stem Unsteadiness and an uncoordinated walk. Facial weakness, a one- sided
smile or drooping eyelid. Double vision. Vomiting or headache just after waking (this
is rare). Difficulty speaking and swallowing. Symptoms may appear gradually.

22
All the above symptoms may be caused by conditions other than a brain tumour. If
you have any of the symptoms described it is important that you go to see your GP.

Personality changes

Sometimes brain tumours may cause changes in personality or behaviour. These

symptoms usually occur when the tumour is in the brains cerebral hemispheres. This
situation can be very unsettling for the person and their family. Sometimes a referral
to a psychologist for assessment and support can help.

Driving

As brain tumours can cause changes in the way that your brain works, it may be
dangerous to drive. In the UK, there are laws which restrict some people with brain
tumours from driving for a time. The restrictions vary with the type of tumour you
have, and the type of driving license you hold.

However, you will not usually be allowed to drive for at least a year after the
condition has been diagnosed and in some circumstances you may not be able to
drive again. With some types of benign tumours you may be able to drive again once
you have recovered from your treatment.

It is your legal responsibility, not your doctor's, to tell the Drivers and Vehicle
Licensing Authority (DVLA) about your illness. The DVLA will advise of you of any
restrictions on your right to drive. You should also inform your car insurance
company.

How brain tumours are diagnosed

Usually, if you have slowly developing symptoms you'll see your GP, who will
examine you. If a brain tumour is suspected, they will refer you to a specialist doctor,
either:

a neurologist (a specialist in brain and nerve disorders) or

an oncologist (a doctor who specialises in cancer treatment). Sometimes

people with brain tumours have a sudden seizure (fit) or sudden onset of
problems associated with the position of the tumour, and may be taken
straight to hospital, where tests are carried out to diagnose the tumour. Brain
tumours are often treated in specialist centres, so you may have to travel to
your nearest centre. At the hospital At the hospital the doctor will ask you
about your general health and any previous medical problems. You will then
have a general physical examination. The doctor may listen to your chest and
feel your abdomen to check your general health, and you will have a detailed
examination to test your nervous system. The examination of your nervous
system may include:

Mental exercises, eg basic arithmetic and simple questions.

An eye examination using an instrument that shines a light at the back of the
eye (ophthalmoscope). This test is done to see if the optic disc at the back of

23
 your eye is swollen. This swelling is known as papilloedema and is a sign of
raised pressure in your skull. Your eyesight will also be tested.

Hearing tests.

Facial muscle tests smiling, grimacing etc.

Tongue movement, checking your swallow (gag) reflex.

Checking the strength of your arms and legs, and your reflexes.

A test of your ability to feel pinpricks on areas of skin, to tell the difference
between hot and cold, and possibly to recognize the feeling and shape of
familiar objects like coins.

Checking your balance and coordination, for example by asking you to walk a
few steps or perform repeated movements.

Further tests for diagnosing brain tumours

At the hospital you may have to have some of the following tests. Your doctor
will select the most suitable ones for your particular situation and symptoms.

Following tests are routinely used for diagnosing brain tumours:

Brain MRI (magnetic resonance imaging) scan

Brain CT (computerised tomography) scan

Biopsy

Skull x-ray

PET (positron emission tomography) scan

SPECT (single photon emission computerised tomography) scan

Blood tests and chest x-rays

Brain MRI (magnetic resonance imaging) scan

This test uses magnetic fields to build up a detailed picture of the inside of
your head. Before the scan you may be asked to complete and sign a checklist. This
is to make sure that its safe for you to have an MRI scan, because the scanner is a
powerful magnet. The checklist asks about any metal implants you may have, for
example a pacemaker, surgical clips, bone pins etc. You should also tell your doctor if
you have ever worked with metal or in the metal industry as very tiny fragments of
metal can sometimes lodge in the body. If you do have any metal in your body its
likely that you wont be able to have an MRI scan. In this situation another type of
scan can be used. Before having the scan, youll be asked to remove any metal
belongings including jewellery. You are usually given an injection of dye into a vein in
the arm, which doesnt usually cause discomfort. This is called a contrast medium

24
and can help the images from the scan to show up more clearly. During the test
youll be asked to lie very still on a couch inside a long cylinder (tube) that is open at
both ends. The whole test can take up to an hour. Its painless but can be slightly
uncomfortable, and some people feel a bit claustrophobic during the scan. Its also
noisy, but youll be given earplugs or headphones. You will be able to hear, and
speak to, the person operating the scanner. Brain CT (computerised tomography)
scan This is a series of x-rays, which builds up a three-dimensional picture of the
inside of your head. During the test you will be asked to lie with your head inside an
opening in the scanner. The scan is painless but takes longer than a normal x-ray
(from 5 to 10 minutes). It may be used to identify the exact area and size of the
tumour. Most people who have a CT scan are given an injection of a liquid into a vein,
to allow particular areas of the brain to be seen more clearly. The injection may make
you feel hot all over for a few minutes. Before having the injection, it is important to
tell your doctor and the person doing the scan if you are allergic to iodine or have
asthma or diabetes. You'll probably be able to go home as soon as the scan is over.

Biopsy

A patient having a CT scan

It's often necessary for the doctor to take a small part of the tumour (a biopsy) to find
out exactly what type of tumour you have (see Surgery for more information).

Skull x-ray

Very rarely, brain tumours may show up on an x-ray picture. The test is simple and
painless. You will have to lie on a couch in the hospitals x-ray department and you
will be asked to keep your head still for a few seconds.

PET (positron emission tomography) scan

A PET scan uses low-dose radioactive glucose (a type of sugar) to measure the
activity of cells in different parts of the body. A very small amount of the mildly
radioactive substance is injected into a vein, usually in your arm. Tumours normally
absorb more of the glucose and the radioactivity shows up on the scan.

25
 After the injection you may be asked to lie in a dark room with your eyes
closed. You'll then be taken to the scanning room and asked to lie on a couch with the
scanning ring around you. The dose of radiation you receive is no more than a normal
x-ray.

A PET scan is not routinely used to diagnose a brain tumour but it may help to
tell whether a tumour is growing and whether it is cancerous (malignant) or benign.
PET scans arent available in all hospitals, and you may have to travel to a hospital
some distance away from your home to have one.

SPECT (single photon emission computerised tomography) scan

This test is similar to a PET scan. It can help to detect abnormalities in the
blood brain barrier as it looks at blood flow through the brain.

You are given an injection of a very mild radioactive substance, usually in your
arm. This susbstance travels in the blood to the brain. Then, in the scanning room,
pictures (scans) of the brain are taken.

Blood tests and chest x-rays

There isn't a specific blood test that can detect brain tumours, but you may
have blood tests to check your general health. A chest x-ray may also be done as
part of a general health check.

Treating brain tumours

26
Treatments such as surgery, radiotherapy or chemotherapy may be used alone or in
combination to treat brain tumours. The choice of treatment will depend on a number
of factors, including the type of brain tumour and its size, the grade of the tumour, its
position and your general health.

Mutlidisciplinary team

A team of doctors and other health professionals will plan your care. This is known as
a multidisciplinary team (MDT) and may include:

a neurosurgeon a doctor who specializes in operating on the brain or

nervous system

a neurologist a doctor who specializes in treating illnesses of the brain and

nervous system

a clinical oncologist a doctor who treats cancer with radiotherapy and

chemotherapy

a specialist nurse who gives information and support to people with brain
tumours. The MDT may also include other health care professionals, including
a:

dietitians

physiotherapists

occupational therapists

psychologists or counsellors.

Giving your consent

Before you have any treatment, your doctor will explain its aims. They will
usually ask you to sign a form saying that you give your permission (consent) for the
hospital staff to give you the treatment. No medical treatment can be given without
your consent, and before you are asked to sign the form you should be given full
information about:

the type and extent of the treatment you are advised to have

the advantages and disadvantages of the treatment

any other types of treatments that may be appropriate

any significant risks or side effects of the treatment.

If you do not understand what you've been told, let the staff know
straight away so that they can explain again. Some cancer treatments can be very
complex, so it's not unusual for people to need repeated explanations. It is often a
good idea to have a friend or relative with you when the treatment is explained, to

27
help you remember the discussion more fully. You may also find it useful to write
down a list of questions before you go to your appointment. Patients often feel that
the hospital staff are too busy to answer their questions, but it's important for you to
be aware of how the treatment is likely to affect you. The staff should be willing to
make time for you to ask questions. You can always ask for more time to decide
about the treatment if you feel that you cant make a decision when it is first
explained to you. You are also free to choose not to have the treatment. The staff
can explain what may happen if you do not have it. It is essential to tell a doctor or
the nurse in charge, so that they can record your decision in your medical notes. You
do not have to give a reason for not wanting to have treatment, but it can be helpful
to let the staff know your concerns so that they can give you the best advice.
Second opinion Your MDT use national treatment guidelines to decide on the most
suitable treatment for you. Even so, you may want another medical opinion. Either
your specialist, or your GP, will be willing to refer you to another specialist for a
second opinion, if you feel it will help. Getting a second opinion may cause a delay in
the start of your treatment, so you and your doctor need to be confident that it will
give you useful information. If you do go for a second opinion, it may be a good idea
to take a friend or relative with you, and have a list of questions ready; so that you
can make sure your concerns are covered during the discussion. The benefits and
disadvantages of treatment Often, people are concerned about the possible side
effects associated with treatment. Many of the treatments for brain tumours can
cause side effects.

However, improved ways of reducing or avoiding many of these problems

have made most of the treatments much easier to cope with.

Treatment can be given for different reasons and the potential benefits will
vary depending upon the individual situation. Surgery can be done with the aim of
curing some types of brain tumour. Occasionally additional treatments are also given
to reduce the risk of it coming back.

If the tumour is at a more advanced stage or in a part of the brain thats

difficult to reach without risk of damage, the treatment may only be able to control it.
This can lead to an improvement in symptoms and a better quality of life. However,
for some people in this situation the treatment will have little effect on the tumour
and they may get the side effects without any of the benefit.

If youve been offered treatment that aims to cure your brain tumour,
deciding whether to accept the treatment may not be difficult. However, if a cure is
not possible and the treatment is to control the tumour for a period of time, it may be
more difficult to decide whether to go ahead with treatment.

Making decisions about treatment in these circumstances is always difficult,

and you may need to discuss in detail with your doctor whether you wish to have
treatment. If you choose not to, you can still be given supportive (palliative) care,
with medicines to control any symptoms.

Treatment overview

With most primary brain tumours, surgery is often the first treatment if the
tumour can be removed without causing harm to the surrounding brain tissue.
However, certain tumours may not need to be operated on immediately, or at all.

28
Some low-grade gliomas, for example, may be carefully monitored if they are not
causing problems, and others may be treated with radiotherapy alone. Rare tumours
of the brain, such as germinomas or lymphomas, are sometimes treated without an
operation, using radiotherapy and chemotherapy.

Surgery can range from having a biopsy (see Surgery for more information) to
find out which type of tumour it is, to a major operation where the tumour is
completely removed.

Radiotherapy is often used after surgery. It may be given if a tumour has not
been completely removed, or if there is a chance that abnormal cells may be left
behind following surgery. Or, in the case of high-grade tumours, radiotherapy may be
recommended even if all of the tumour has been surgically removed.

When surgery is not possible, or not necessary, radiotherapy, with or without

chemotherapy, is used as the main treatment.

Symptom control treatment

In both primary and secondary brain tumours, treatment for particular symptoms
may be necessary. For example, anticonvulsant medicines to prevent seizures (fits)
and steroids to reduce any inflammation and swelling around the tumour.

Surgery for brain tumours

Very often a biopsy is used to find out exactly what type of brain tumour you have.
The biopsy may also be done as part of an operation to remove the tumour.

o Biopsy

o Craniotomy

Biopsy

A biopsy is the removal of a small piece (sample) of the tumour.

The sample is sent to a laboratory where it is examined by a pathologist (a doctor
who specialises in how disease affects the body's tissue) who can tell what kind of
cells are present. Having a biopsy may mean a few days in hospital as it usually
involves an operation under a general anaesthetic. An MRI brain scan or CT scan is
done to find the position of the tumour to the nearest millimetre. During the
operation a small hole, called a burr hole, is made in the skull. A fine needle is then
passed down through the burr hole to remove a small piece of the tumour to be
examined by the pathologist. Guided biopsy Sometimes, especially if the tumour is
deep within the brain, you may have a specialist type of biopsy called a guided
biopsy. This can be done either by stereotactic biopsy or by neuronavigation. With
stereotactic biopsy you will be fitted with a head frame either before or after you
have been scanned. This helps the doctors to guide the biopsy needle to exactly the
right part of the brain. Once the frame is in place the doctors will drill a small hole in
the skull in much the same way as a normal biopsy. The frame will then guide the
needle to the right place. A stereotactic biopsy is usually done under a local
anaesthetic, but may involve a general anaesthetic. With neuronaviagtion a frame is
not needed. The biopsy is taken with a fine needle (in a similar way to a stereotactic

29
biopsy). The surgeon uses the scan to help guide the needle to the right place.
Before the scan you may have markers stuck to parts of your head (called fiduciary
markers). These markers show up on the scan and help the surgeon guide the
needle to the affected area. Craniotomy Once the type of brain tumour is known, a
more extensive operation can be done to remove all or part of it. A craniotomy is an
operation that involves opening the skull. For this operation, you will be given a
general anaesthetic. However, you may be awake for at least part of the operation
(with the surgical area numbed) if doctors need to check your brain function during
surgery. This is called an awake craniotomy.

Some of your hair may need to be shaved off in the anaesthetic room before
the operation (doctors try to shave only as much as is necessary). The surgeon will
cut the scalp and the piece of skull over the tumour, remove the tumour itself, and
replace the piece of skull. The flap of scalp is then stitched back in place.

If its not possible, or advisable, to remove the whole tumour, only part of the
tumour is removed. This is called partial resection or debulking.

Sometimes the only way for the surgeon to remove the tumour is to go
through a healthy part of the brain, which may cause damage. The effects of this will
vary depending on the area of the brain involved. Your surgeon will talk this over with
you very carefully beforehand to make sure that youre fully aware of how the
surgery may affect you.

In some situations it will be too difficult or dangerous to remove even a small

part of the tumour, or the doctors may think that other treatments are more suitable.
Your surgeon or doctor will discuss the most appropriate type of operation with you
and, if you like, with a close relative or friend. Before any operation, do ask questions
so that you know exactly whats involved. No operation or procedure will be done
without your agreement.

After operation

The length of your stay in hospital will depend on the extent of the operation
and how well you are. For about the first 12 hours after the operation, youll be
closely observed, probably in the intensive care unit (ICU/ITU). You will probably have
frequent observations taken to begin with. These are known as neurological
observations, or neuro obs. They include checking how alert you are, testing your
reflexes, checking that your pupils react to light as well as checking your pulse, blood
pressure, the amount of oxygen in your blood and number of breaths each minute. At
first you may be cared for on a machine, which maintains your breathing (a
ventilator).

Its likely that your head will be bandaged and you may have a tube in the site
of the operation, which drains into a bottle. This is used to drain excess blood from
the head wound and is usually removed within a day or two. Your face and eyes may
be swollen and bruised after the operation. The swelling should go down within 48
hours and the bruising within a few days. You may also have a drip of salt water
(saline) to replace any fluids you may have lost and to keep you hydrated.

30
 You may have a headache when you wake up after the operation and youll be
given painkillers to help relieve this.

Its unusual to get a lot of pain after surgery to the brain, but tell your nurse or
doctor if you are in pain or the pain starts to get worse.

These descriptions may sound dramatic but the effects of the operation
should settle fairly quickly and once staff are confident with your condition youll go
back to the ward to continue your recovery.

ShuntsBrain tumors can cause a wide variety of symptoms.

These are usually caused by a rise in pressure within the brain (raised
intracranial pressure). This happens when the tumour blocks the flow of the
cerebrospinal fluid (CSF) around the brain (this is called hydrocephalus). A shunt (also
called a ventricular catheter) may be inserted to drain excess fluid from the brain.
This will stop any further rise in intracranial pressure.

A shunt is a long, thin tube that is placed in the brain and then threaded under
the skin to another part of the body, usually into the lining of the abdominal cavity
(peritoneum). The tube allows excess fluid from the brain to drain into the abdominal
cavity where the body reabsorbs it. The shunt has valves in place so that fluid can
drain away from the brain but not back towards it.

The shunt is not visible outside of the body and you wont be able to feel it.

Steroids and anticonvulsant drugs

Before and after brain surgery, you'll be given steroid therapy and often
medicines known as anticonvulsant drugs to help to prevent seizures.

Steroid therapy

Steroids are drugs that are used to reduce the swelling that often surrounds
brain tumours. Although steroids don't treat the tumour itself, they help to improve
symptoms and make you feel better. They may be used before or after surgery, or
during or after radiotherapy.

Side effects of steroids

If you are taking steroids for some time, you may have temporary side effects.
These can include putting on weight, indigestion, raised blood pressure and a slightly
greater risk of getting infections, such as thrush (candida) in the mouth. Some people
also have mood changes, feel low or depressed; find it difficult to get to sleep or feel
'hyper' or over-active.

You may also develop a higher than normal level of sugar in the blood. If this
happens, your doctor will prescribe drugs, which you will need to take every day to
bring your blood sugar level back to normal. You may have to do a simple daily test

31
to check for sugar in your urine. You'll be shown how to do this.

If you take steroids for a long time you may notice that you put on weight or
that your thigh muscles are weaker. Your skin may bruise more easily and feel
thinner.

These side effects may seem hard to bear at the time, but it's important to remember
that they are temporary and will gradually disappear as the steroid dose is lowered.
While you are having steroid treatment you should carry a steroid card (which your
doctor or nurse will give you) to show the type of steroid and the dose you are taking.

It's important not to stop taking steroids suddenly as this can make you very
ill. Your doctor will gradually reduce the dose.

Anticonvulsant medicines

If you have had seizures or fits you may also have to take anticonvulsants
(drugs to prevent epileptic fits). These medicines are often used for people who have
brain tumors and also after brain surgery.

There are several different types of anticonvulsants. Some commonly used

types include phenytoin (Epanutin), Levetiracetam (Keppra), carbamazepine
(Tegretol), sodium valproate (Epilim) and lamotrigine (Lamictal). Let your doctor
know if you have any side effects. Sometimes it's necessary to take more than one
type of anticonvulsant tablet.

Radiotherapy for brain tumours

Radiotherapy treats cancer cells by using high-energy rays to destroy the

cancer cells while doing as little harm as possible to normal cells. It's usually given
using beams delivered from outside the body (external radiotherapy).

Radiotherapy is often used after surgery to treat any cancer cells that may
have been left behind. It can also be given to treat secondary brain tumours, or when
a primary brain tumour cant be removed or has come back after surgery.
Radiotherapy may sometimes be given along with chemotherapy tablets to treat
high-grade gliomas.

Radiotherapy is given in the hospital radiotherapy department. It's usually

given as a series of short, daily sessions from Monday to Friday, with a rest at the
weekend. The length of your treatment will depend on the type and size of brain
tumour, but it is usually 26 weeks. Some people will have different treatment plans
and may have treatment on only three days a week. Your doctor will discuss your
treatment plan with you beforehand.

You may need to wear a radiotherapy mask that covers the whole of your face
and front of your head. This mask is usually made from perspex (a type of plastic) or
from a type of mesh plastic, which is moulded to fit the shape of your face.

32
 A radiotherapy mask keeps your head as still as possible during treatment.
This is to make sure that exactly the right area is treated. Your mask will be made
before your treatment is planned. It allows you to see and breathe normally but it
may make some people feel claustrophobic. You will only have it on for a few minutes
at a time and most people soon get used to it.

For secondary brain tumours and some high-grade tumours, a smaller dose of
radiotherapy is given to the whole head, so a mask may not be needed.

A radiotherapy mask being used during treatment planning your treatment

Radiotherapy has to be carefully planned to make sure that it's as effective as

possible. This is done using a CT scanner (sometimes called a CT simulator), which
takes CT scans of the area to be treated. These CT scans provide lots of images from
different angles to build up a three-dimensional picture of the area to be treated.

At the same time, therapy radiographers will take measurements from you
which are needed for treatment planning. The radiographer's measurements and the
information from the scans are fed into the radiotherapy planning computer to help
your doctors plan your treatment more precisely.

Treatment planning is a very important part of radiotherapy and it may take a

few visits before the clinical oncologist (the doctor who plans and supervises your
treatment) is satisfied with the result.

Having your treatment

Before each session of radiotherapy the radiographer, who gives you your
treatment, will position you carefully on the couch and make sure you are

33
comfortable.

During your treatment, which will only take a few minutes, you'll be left alone
in the room but you can talk to the radiographer, who will watch you carefully from
the next

room. Radiotherapy is not painful but you do have to be still for a few minutes during
treatment.

Stereotactic radiotherapy and radiosurgery

These types of radiotherapy enable doctors to direct radiation more

accurately at brain tumours. The aim is to deliver higher doses of radiotherapy to the
tumour while doing as little harm as possible to surrounding brain tissue and to
minimise the side effects of treatment. It is sometimes given after standard external
radiotherapy or to treat small tumours that cannot be removed with surgery.

Stereotactic radiotherapy

This type of radiotherapy gives the treatment from a standard radiotherapy

machine which has been adapted. The machine gives concentrated beams of
radiation from several different angles which overlap at the brain tumour. This is
done either by moving the machine during treatment or by aiming individual beams
from a number of different directions.

The radiotherapy dose to the tumour is very high and the dose to surrounding
healthy tissues is very low. Several doses are given.

Before treatment, several scans of the brain are taken. These scans arethen analysed
by computers to ensure that the radiotherapy is precisely targeted to the brain
tumour. A special head frame will be made for you before you start treatment. This
frame helps to keep your head still while having the radiotherapy.

This treatment is only available in specialist hospitals and is not suitable for everyone
with a brain tumour. You could ask your clinical oncologist whether it would be
appropriate in your particular situation.

Stereotactic radiosurgery (gamma knife)

This is a type of stereotactic radiotherapy. It's sometimes called gamma knife

treatment, named after one of the machines that can be used to give this treatment.
Unlike stereotactic radiotherapy, sterotactic radiosurgery is given over one session,
as a single-dose treatment, taking about 4-5 hours.

It does not use a knife, but uses targeted beams of gamma radiotherapy given from
many different angles, which cross at the point of the tumour. You will have several
scans and x-rays to find the precise area for the treatment to be given. A special
head frame will be made for you before your start treatment. Thos frame helps to
keep your head still while having the radiosurgery.

34
Again, this treatment is only available in specialist hospitals and is not suitable for
everyone with a brain tumour. It may be helpful to discuss with your clinical
oncologist whether it's a suitable treatment for you.

Side effects of radiotherapy to the head

Side effects can be mild or more troublesome depending on the amount of

radiotherapy given and the length of your treatment. Radiotherapy can cause general
side effects such as tiredness, headaches, hair loss and feeling sick (nausea).

Tiredness

As radiotherapy often makes you feel tired, try to get as much rest as you can,
especially if you have to travel a long way for treatment each day.

JASCAP booklet on fatigue has helpful tips on ways of saving energy and dealing with
tiredness.

Headaches

Some people have headaches while they are having their radiotherapy. These
can be controlled with painkillers and sometimes steroids which will be prescribed by
your doctors.

Hair loss

You will lose hair within the area treated. Most hair loss is temporary but,
unfortunately, it may be permanent for some people. This will depend on the dose of
treatment you have had. Sometimes hair grows back with a slightly different colour
and texture and perhaps not as thickly as before. It usually starts to grow back within
23 months of finishing treatment.

Skin changes

Some people develop a skin reaction, similar to sunburn, while having

radiotherapy. This normally happens 34 weeks after the start of treatment. People
with pale skin may find that the skin in the treatment area becomes red and sore or
itchy. People with darker skin may find that their skin becomes darker and can have a
blue or black tinge. The amount of the reaction depends on the area being treated
and the individual persons skin. Some people have no skin problems at all.

Your radiographers will be looking for these reactions but you should also let
them know if you feel any soreness.

Staff at the radiotherapy department will be able to give you advice on skin
care. As the skin is sensitive it is best not to over-expose it to the sun or cold winds.
Try wearing a soft cotton or silk scarf or hat to cover the area when you go outside.

Somnolence (feeling drowsy)

35
 Four to eight weeks after finishing after radiotherapy, you may find that you
generally slow down, have very little energy and feel much less active. You may also
feel drowsy and spend more time sleeping. It gradually gets better over a few weeks.

Feeling sick

Occasionally some people may feel sick but this can usually be treated
effectively by anti-sickness drugs (called anti-emetics), which your doctor can
prescribe. You may also find that food tastes different and you may have a metallic
taste in your mouth. If you dont feel like eating, you can replace meals with
nutritious, high-calorie drinks. These are available from most chemists and can also
be prescribed by your GP.

We have more information and helpful tips on how to cope with different
eating problems in our diet and cancer section.

After your treatment

Some people find the symptoms of the brain tumor temporarily get worse
after the treatment has finished. This can make them think their tumor is getting
worse. In fact it is either a reaction to the radiotherapy treatment or may be because
steroid treatment has been reduced or stopped.

If you find this happening to you it's important to discuss it with your doctor or
nurse, who'll be able to provide the right treatment and support.

Chemotherapy for brain tumors

Chemotherapy is the use of special anti-cancer (cytotoxic) drugs, which work

by disrupting the growth of cancer cells.

Chemotherapy is not used to treat all brain tumors. It may be used for people
with high-grade primary brain tumors where the tumor has come back. In this
situation chemotherapy is unlikely to be able to cure a brain tumors completely, but
it can sometimes shrink a tumor down or slow its growth and so can reduce
symptoms.

Chemotherapy drugs which may be used to treat primary brain tumours

include: lomustine (CCNU), procarbazine, vincristine and temozolomide (Temodal).
Some are given as tablets or capsules, and some are given by injection into a vein
(intravenously). Sometimes lomustine, procarbazine and vincristine are used
together and this combination of chemotherapy drugs is known as PCV.

Another way of giving chemotherapy is by an implant, which can be placed

into the area of the brain tumors during surgery. These implants (called Gliadel
implants) are small gel wafers or discs, which contain the chemotherapy drug
carmustine. As the gel wafer dissolves, the drug is slowly released.

The type of chemotherapy you have will depend on the type and stage of the

36
brain tumors. Chemotherapy to treat brain tumors can usually be given to you as an
outpatient. Chemotherapy may sometimes be used after surgery, or with, and after
radiotherapy in people who have just been diagnosed with a brain tumor.

The National Institute for Health and Clinical Excellence (NICE) is an

independent body that was set up by the government. NICE assesses medicines and
treatments and gives guidance to doctors on how they should be used in the NHS in
England and Wales. The equivalent body in Scotland is the Scottish Medicines
Consortium (SMC).

C urrent NICE guidance on the use of carmustine (Gliadel) implants and

temozolomide recommends carmustine implant as a possible treatment for people
with newly diagnosed high-grade glioma only if 90% or more of their tumors has been
removed. People should have carmustine implants only at specialist treatment
centres under the care of a team of experts. Temozolomide is recommended as a
possible treatment for people with a type of high-grade glioma called a glioblastoma
who are newly diagnosed and fit and well enough to have it.

Both of these drugs have been assessed by the SMC and have been approved for use
in Scotland.

Side effects

Chemotherapy can cause side effects, which can be unpleasant, and for some
people chemotherapy may have little effect on the tumors. So they will have the side
effects without any noticeable benefits. The fitter a person is, the more likely they are
to benefit from the chemotherapy and the less likely to have side effects.

Making decisions about treatment under these circumstances is always difficult. It will
be helpful to discuss with your doctors the possible benefits and side effects of
chemotherapy in your situation. You can also speak to our cancer support specialists.

Many people have few side effects and those that occur can often be well controlled
with medicine. The main side effects are described here, together with some of the
ways they can be reduced.

Lowered resistance to infection

While the drugs are acting on the cancer cells in your body they also
temporarily reduce the number of normal white blood cells. When these cells are
reduced you're more likely to get an infection and you may tire more easily. During
chemotherapy your blood will be tested regularly and, if necessary, you may be given
antibiotics to treat any infections.

If your temperature goes above 38C (100.5F), or you suddenly feel unwell even
with a normal temperature, contact your doctor at the hospital straight away.

37
Anemia

If the level of red blood cells in your blood is low you will become very tired
and lethargic. You may also become breathless. These are symptoms of anemia. If
you become very anemic, you may be given a blood transfusion.

Bruising and bleeding

Platelets are a type of cell that helps to clot the blood. If the number of
platelets in your blood is low you will bruise very easily and may bleed heavily from
even minor cuts or grazes. If you develop any unexplained bruising or bleeding, such
as nosebleeds, blood spots or rashes on the skin, or bleeding gums, contact your
doctor or the hospital immediately.

Feeling sick

Some chemotherapy drugs may make you feel sick (nauseated) and can also
make you be sick (vomit). There are now very effective anti-sickness drugs (anti-
emetics) to prevent or greatly reduce nausea and vomiting. Your doctor can prescribe
these for you.

If you dont feel like eating during treatment, you could try replacing some meals
with nutritious drinks or a soft diet - our section on eating well, has some useful tips
on coping with eating problems.

Hair loss

The chemotherapy drugs commonly used to treat brain tumors don't usually
cause hair loss but some may cause hair-thinning. If your hair does fall out while you
are having chemotherapy, it will grow back over a period of 36 months.

Tiredness

It is important to remember that chemotherapy affects people in different

ways. Some people find that they are able to lead a fairly normal life during their
treatment, but many others find they become very tired and have to take things
much more slowly. Just do as much as you feel like and try not to get too tired.

Although the side effects may be hard to bear at the time, they will gradually
disappear once your treatment is over.

38
39
 V. Pathophysiology

Non-Modifiable Factors: Modifiable Factors:

Common in children ages 13 Etiology: Chemical exposure

y/o Unknown Exposure to radiation
Not genetically linked

Formation of mass in
pineal region of the brain

Compression in the
adjacent structures

(+) H/A
(+) nausea
(+) vomiting
(+) Fatigue
(+) Visual Impairment
(+) Memory Problems
(+) Seizure

Caused by aqueducal
compression

40
 OBSTRUCTIVE HYDROCEPHALUS

Cerebrospinal Fluid is produced by

Choroid Plexus

Goes to the lateral ventricles

through Interventricular Foramen
(Foramen of Monroe)

CSF goes to third ventricle through

Cerebral Aqueduct (Aquaduct of
Sylvius)

Aqueduct Sylvius is narrowed or

Aqueductal Stenosis completely occluded

Fluid cannot reach the

subarachnoid space

Cerebrospinal fluid cannot flow

to the other pathways

However production of CSF still

continues

Enlarge the lateral ventricles

(Ventricular dilatation)

Increase Intracranial Pressure

Brain will be compress in the

skull

41
 Developmental delay
Since, fontanels are closed in
adults no enlargement of the
brain manifestation

Causes Neurological problems

(+) S/P
VENTRICULOPERITONEAL
SHUNTING (RIGH POSTERIOR

(+) Shunt Malfunction

Neuromuscular Learning Abilities
Skills

(+) Inability to perform

Impaired
(+) Poor activities such as
neuromuscular
motor skills swallowing and
coordination
coughing out

(+) Unable Risk for aspiration

Loss of
to stand or related to difficulty of Poor intake of fluids and food
control
sit swallowing
and (+) NPO & NGT
awareness

(+) Secretions cannot be Manifested by Sunken

(+) Friction and poor coughed out fontanels, (+) dry skin and
perfusion on the skin (+) poor skin turgor
Risk for
Secretions will be
injury Fluid volume deficit
retained and
(+) Risk for related to related to inadequate
accumulated in the
formation of bed neuromuscul intake
sore ar Ineffective airway
impairment clearance related to
Impaired skin inability to
integrity related expectorate mucus
to immobility

42
VI. Laboratory Examination Results

Analysis and
Diagnostic/ Normal Value (Units Interpretation of
Date ordered Indications or
Laboratory Results used in the results
Date Results in Purposes
Procedures hospital)

1. Complete Blood CBC is a screening

Count test, used to
diagnose and
manage numerous
diseases. The
results can reflect
problems with
fluid or loss of
blood.

43
a. Hemoglobin Date ordered/ Hemoglobin Hgb: 13.1 N: 14.1-18.1 g/L The hemoglobin level
determines the is below normal. This
Date of Results: RBC that carries indicates that RBC is
oxygen and not capable of carrying
July 27, 2015
carbon dioxide O2 and CO2
throughout the throughout the body.
body

Date ordered/ The result indicates

Hct: 37.5
Hematocrit below normal
Date of Results:
b. Hematocrit determines the N: 43.5-53.7 concentration of RBC
July 27, 2015 concentration of within the blood
RBC within the volume.

blood volume

44
 RBC: 4.71

c. RBC Date ordered/ N:4.7-5.1

Date of Results: An RBC count is a The result is within

blood test that normal range which
July 27, 2015 measures how indicates that the
many red blood body's RBCs containing
cells (RBCs) you hemoglobin,carrying
have. oxygen to the body's
tissues are functioning
normally.

RBCs contain
hemoglobin,
which carries
oxygen. How
much oxygen
your body tissues
get depends on
how many RBCs
you have and
how well they
work.

45
 Date ordered/

Date of Results: WBC: 14.30

d. WBC July 27, 2015 N: 4.5-10.2 x 109/L

White blood cells WBC is high which

(WBCs), also indicates that there is
called leukocytes, infection presented in
are an important the body.
part of the
immune system.
These cells help
fight infections
by attacking
bacteria, viruses,
and germs that
invade the body.
White blood cells
originate in the
bone marrow, but
circulate
throughout the
bloodstream.

46
DIFFERENTIAL COUNT

Date ordered/
Lymphocytes: 45 %
Date of Results:

A.Lymphocytes July 27, 2015 N: 100-500 %

A low normal to low

absolute lymphocyte
Lymphocytes are concentration is
responsible for associated with
immune increased rates of
responses. There infection after surgery
are two main or trauma.
types of
lymphocytes: B
cells and T cells.
The B cells make
antibodies that
attack bacteria
and toxins while
the T cells attack
body cells
themselves when
they have been
taken over by
Date ordered/ viruses or have
become 0.00
Date of Results: cancerous.

47
 July 27, 2015 Lymphocytes
secrete products
c. Eosinophils (lymphokines) N: 0.00-0.7.0
that modulate
the functional
activities of many The result is below the
other types of normal range. Which
cells and are indicates no
often present at significant.
sites of chronic
inflammation.

Eosinophils are a
specific type of
white blood cell
that protects
Date ordered/
your body
Date of Results: against certain
kinds of germs, 3.5
July 27, 2015 mainly bacteria
and parasites.
d. Monocytes They're also what N: 0.0-14.0
causes you to
have allergic
reactions.

The result is normal.

Which indicates that

the body can fights off
bacteria, virus and
fungi,

Monocytes are a
type of white

48
 blood cell that
fights off bacteria,
Date ordered/ viruses and fungi.
Monocytes are the
Date of Results:
biggest type of
July 27, 2015 white blood cell in 0.1
the immune
system. Originally
formed in the
e. Basophils bone marrow, N: 0.0-1.5
they are released
into our blood and
tissues. When
certain germs
enter the body, The result is normal,
they quickly rush which indicates that
to the site for body is active for
attack. inflammatory
response.

Basophils are
granulocytic
white blood cells
that are active in
the inflammatory
response. They
are mostly found
Date ordered/
in the skin and
Date of Results: mucosa tissues,
which are the
July 27, 2015 tissues lining the
openings into the

49
 body. They Platelet Count:
represent about
1% of all white 311
blood cells in the
Platelet Count Platelet Count:
body.
14.7 sec.

150- 400 x 109/L

Date ordered/ The result is within the

normal range indicates
Date of Results: that there is enough
platelet produces for
July 27, 2015 coagulation.

14.7 sec.
A platelet count
Prothrombin Time
is a test to
measure how 11.3-15.3 sec.
many platelets
you have in your
blood. Platelets
are parts of the
blood that help
the blood clot.
They are smaller The result is within the
normal range.
than red or white
blood cells.

50
 Date ordered/ Prothrombin time
(PT) is a blood
Date of Results: test that
measures how
July 27, 2015
long it takes
blood to clot. A
prothrombin time
test can be used
to check for
Activity bleeding 82%
APTT
problems. PT is
70-100%
also used to
check whether
medicine to
prevent blood
clots is working.

The result is within the

normal range.

Date ordered/

Date of Results:

July 24, 2015

A factor VIII
activity blood test
Diagnostics: lets doctors

51
MRI evaluate the
functioning of a
protein that helps
blood to clot.
The PTT is used
primarily to
investigate
unexplained
bleeding or
clotting. It may be
ordered along with The clients CT scan
a prothrombin time result indicates
(PT) test to abnormalities of
evaluate
hydrocephalus.
hemostasis, the
process that the
body uses to form
blood clots to help
stop bleeding.
These tests are
usually the starting
points for
investigating
excessive bleeding
Date ordered/ or clotting
disorders.
Date of Results:

July 24, 2015

CT SCAN

Magnetic
resonance imaging
(MRI), nuclear
magnetic
resonance imaging

52
 (NMRI), or
magnetic .
resonance The clients CT scan
tomography (MRT) result indicates
is a medical abnormalities of
imaging technique
hydrocephalus.
used in radiology
to investigate the
anatomy and
physiology of the
Date ordered/ body in both health
and disease. MRI
Date of Results: scanners use
magnetic fields
July 28, 2015 and radio waves to Color:
form images of the
body. The Yellow Yellow
technique is widely
used in hospitals
for medical
Urinalysis diagnosis, staging Transparency:
of disease and
follow-up without Slightly turbid Amber
exposure to
ionizing radiation.

SP Gravity:

1.020 clear 4.8-7.8

The result has a normal
color
Sugar: negative

1.015-1.025
A CT scan has
Protein: +2
many uses, but is The result is normal
particularly well-
suited to quickly

53
examine people
who may have
internal injuries Negative
from car accidents
RBC: 2.5 There is no presence of
or other types of
sugar
trauma. A CT scan
can be used to Pus cells: 1-3
visualize nearly all Negative
parts of the body
and is used to
diagnose disease Epithelial cells: There is no presence of
0.1/HPF protein
or injury as well as
few
to plan medical,
surgical or
radiation 0.2/HPG Indicate presence
treatment. Mucus threads: of

few Infection

Few
Indicates no presence of
infection
Urinalysis yields
a large amount of
information about
possible The kidney is in normal
disorders of the function.
kidney and lower
urinary tract, and
systemic
disorders that
alter urine
composition

54
55
Nursing Responsibilities:
BEFORE
1. Explain to the patient the procedure and its purposes.
2. If the patient has eaten a meal with high sodium content in the past 24 hours, this
should be noted.
3. Be sure not to draw blood, which has infused IVF.
4. Note if patients on a diet that restricts sodium and other nutrients.
5. Note other conditions such as diabetes.
6. Carefully watch for signs of electrolyte imbalance.
7. Perform a complete cephalocaudal assessment especially cardiac assessment and
vital signs.
8. Make sure to have the right patient, specimen and method.
DURING
1. Clean injection site with alcohol.
2. Lower the patients arm to dilate the veins.
3. Apply tourniquet and ask the patient to open and close fist.
4. Remove the tourniquet when drawing the final tube of blood.
AFTER
1. Note for any signs of discomfort or bruising at the puncture site.
2. Provide pressure at the puncture site to stop bleeding and reduce bruising.
3. Apply warm compress to puncture site to relieve discomfort.
4. Send the specimen at the laboratory.

56
B. Blood Chemistry
Analysis and
Normal Value
Diagnostic/ Interpretation of
Date ordered Indications or (Units used
Laboratory Results results
Date results in Purposes in the
Procedures
hospital)

2. CLINICAL
CHEMISTRY TEST

Date ordered: A serum creatinine 67.70 umol/L N: 45-104 The result which
Creatinine test which umol/L indicate that the
July 27, 2015 measures the level kidney has normal
of creatinine in function in a male
your blood can body builder
Date of Results: indicate whether
your kidneys are
July 27, 2015 working properly.

Sodium Date ordered: It regulates body Na: 138.10 N: 1135-145 The result is within
water along with normal range, it

57
 July 27, 2015 potassium. It is mmol/L indicates no
responsible for presence of
nerve conduction hypernatremia or
and contraction of hyponatremia
Date of Results:
muscle.
July 27, 2015

Potassium Date ordered: It is a mineral, The result is within

which with Sodium normal range,
July 27, 2015 and Calcium K: 4.10 N: 3.5-5.3 which indicates no
maintains normal mmol/L presence of
heart rhythm and hyperkalemia or
Date of Results: regulates water hypokalemia
balance.
July 27, 2015

58
NURSING RESPONSIBILITIES

BEFORE

1. Confirm the patients identity using two patient identifiers according to facility policy.
2. Explain the procedure and the indication.
3. Inform the patient that the test requires blood sample, and explain that he may
experience slight discomfort from the tourniquet and the needle puncture.
4. Instruct the patient that he doesnt need to restrict food and fluids. For triglycerides
she should not eat 12 hours before procedure.
5. Notify the laboratory and practitioner about any medications the patient is taking
that may affect test results; they may need to be restricted.
DURING

1. Perform venipuncture and collect the sample in a 3- or 4-mL clot activator tube.
2. Handle sample gently to prevent hemolysis.

AFTER

1. A report of the results will be sent to the requesting Health Care Provider, who will
discuss the results with the patient.
2. Depending on the results of this procedure, additional testing may be performed to
evaluate or monitor progression of the disease process and determine the need for a
change in therapy.
3. Evaluate test results in relation to the patient's symptoms and other tests performed.

59
Nursing Responsibilities for Urinalysis:

BEFORE

1. Check the doctors order.

2. Check the right client.
3. Encourage the SO to increase the fluid intake of the patient.
4. Apply warm on hypogastric region.

DURING

1. Provide privacy.
2. Decrease discomfort, and anxiety, allows adequate time.
3. Tell the patient to assume a normal voiding position.
4. Introduce stimuli for voiding.
5. Pour warm water over the perineum.
6. Collect a clean catch urine sample during midstream urination.

AFTER

1. Ensure that the specimen label and laboratory requisition form are filled out correctly.
2. Securely attach the label to the container.
3. Send the specimen to the laboratory at once.
4. Document what you have done.

60
VII. Gordons Assessment

A. Health Perception and Management

o Client cant recall well if he was completely immunized.

o Client was brought to the hospital for management.
B. Nutrition/ Metabolism

o Fond of eating meats and fruits

C. Elimination

o Voids usually 5 times a day

o Urine color is yellow
o Defecates usually every other day.
D. Activity/Exercise

o Bedrest with semi-fowlers position.

o Minimal movements
E. Sexuality/Reproductive

o Single
o No history of STDS
F. Cognitive/Perceptual

o Is not oriented to time due to post-op surgery.

o Responds to stimuli physically.
o Undergrad
o Not in a normal thought process due to condition and surgery.
G. Roles/Relationship

o Single
o Well-supported by the family
H. Self-Perception/ Self-Concept

o Hopeful to be relieve and treated

o Manages healthy lifestyle before his condition
I. Value/Belief

o Born Again Christian

o Has a strong faith in God
J. Coping/ Stress

o S/P VPS in 2013

o Copes up with problems
K. Sleep/Rest

o Difficulties in sleeping
o Not enough rest intervals
L. Medication History

o Meds for his previous hospitalization in 2013

61
VIII. Nursing Care Plans

ASSESSMENT NURSING SPECIFIC PLANING NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION
S: 1. Do/perform 1. To help
tepid sponge decrease bo
O:Patient Hyperthermia ENTRY OF PATHOGEN Short Term: bath dy Short Term:
manifested the r/t increase IN THE SYSTEMIC temperature
following: Intracranial CIRCULATION 2. Assess body
After 2-3 hours of The patient
pressure temperature 2. To know
nursing shall
>Febrile, T=38C from time to what is the
intervention the Demonstrated
in both axilla; time response of
warm to touch patient will be able temperature
REGULATION OF client to TSB
with flushing to decrease body 3. Do not apply within normal
TOXIN IN THE BODY
temperature from alcohol for 3. Alcohol range, from
Patient may 40 C to 37C. TSB increases 40C to 37.5C
manifest: peripheral
4. Advise the so vascular
RELEASE OF PYROGEN
Nausea to increase constriction
Long Term: oral fluid &CNS Long Term:
Vomiting intake of the depression
After 2 days of patient
STIMULATION OF THE The patient
Fatigue nursing 4. Additional
HYPOTHALAMUS
5. Remove shall have
intervention the fluids help
excess demonstrated
Pallor patient will be to prevent
clothing and behaviors to
maintain normal elevated
covers monitor and
Initial Vital body temperature temperature
INCREASE OR promote
signs: associated
ALTERRATION OF normothemia
with
THERMOREGULATION
BP: 145/79 dehydration

5. These
PR: 95
decrease
INCREASE BODY
warmth and
RR: 39 TEMPERATURE
increase
evaporative
T: 40
cooling

HYPERTHEMIA

62
SP02: 100%

63
64
 Independent: 1. To be able to
identify
S: Ineffective Intracranial Short Term: present Short
cerebral pressure physiologic Term:
perfusion After 2-3 hours 1. Assess disturbances
of nursing patient The So shall
related to
O: Patient intervention the condition have
interruption 2. Reduces
manifested of blood flow SO will verbalized
arterial
the verbalized 2. Position pressure by understandi
Pressure exerted
following: understanding head slightly promoting ng of
in the cranium
of condition, elevated and venous condition,
by its content
therapy in neutral drainage and therapy
regimen and position may improve regimen and
>Unconscious when to contact cerebral when to
perfusion.
health provider contact
3. Take
patients health care
Brain, blood and provider
temperature 3. Hyperthermia
Patient may cerebrospinal at least 4 causes
fluid Long Term:
manifest: hours increased ICP
hypothermia
After 2 days of
nausea causes
nursing 4. Keep decrease
intervention the patients in cerebral
vomiting patient will neutral perfusion
Associated with demonstrate alignment pressure Long Term:
fatigue vasospasm or behaviors and
obstruction in The patient
life style
the arteries 5. Provide 4. To keep the shall have
changes to
supplying the quite, restful carotid flow
improve environment unobstructed Demonstrat
Initial Vital brain with blood circulation such . thereby ed
signs taken: as relaxation promoting behaviors
techniques. perfusion and life
BP: 145/79 6. Note history
style
of
brief/intermit 5. Continual changes to
PR: 95 Increase
tent periods stimulation improve
vascular or black out. can increase circulation

65
 resistance can 7. Monitor ICP. such as
RR: 39 result due to patients relaxation
increase ICP behavior and techniques.
T: 40 mental 6. Because this
status for suggest
onset of transient
SP02: 100%
restlessness, ischemic
agitation attacks
Leading to confusion 7. Changes in
Dependent: behavior and
decrease and or
mental status
absence of blood 8. Administer are sign of
flow to the brain supplementa altered
cells l oxygen. cerebral
perfusion

8. Reduces
hypoxemia,
Because of this which can
there will be cause cerebral
decrease or vasodilatation
absence of and increase
pressure/
oxygen supply to
edema
the brain cells formation.

So there is
ineffective
cerebral
perfusion

66
ASSESSMENT NURSING Scientific PLANING NURSING RATIONALE EVALUATIO
DIAGNOSIS EXPLANATION INTERVENTION N

67
S: 1. Assess 1. To be able
patient to identify
O: Patient Risk for injury Altered neuronal Short Term: condition present Short
related to physiologic
manifested cells 2. Keep padded Term:
neuromuscula disturbance
the After 2-3 hours side rails up s
following: r impairment of nursing with bed in The
intervention the the lowest 2. Minimizes patients
> Unconscious Increased patients position injury while seizures
seizures will be patient is in shall be
frequency and 3. Provide bed
Patient may amplitude lessen information lessen
manifest: regarding 3. To promote
the condition awareness
dizziness that may
result in risk 4. to
Neuronal firing
for injury. determine
fall spreads the severity
Long Term: 4. Assess of body Long Term:
nausea muscle weakness
After 2 days of strength and to be The
nursing gross and able to patients
Initial Vital Seizures
fine motor perform
signs taken: intervention the seizures
coordination appropriate
patients seizures shall be
interventio
BP: 145/79 will be remove 5. Keep the n removed
Unpredictable patients 5. to promote
PR: 95 movement or room free individual
from clutter safety
behavior
RR: 39

T: 40

Risk for Injury

SP02: 100%

68
IX. DRUG STUDY

Medical Management
IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc.

a. IVF

MEDICAL
DATE ORDERED, CLIENTS
GENERAL INDICATION OR
MANAGEMENT/ DATE PERFORMED, RESPONSE TO
DESCRIPTION PURPOSES
DATE CHANGE TREATMENT
TREATMENT

An aqueous solution
Date ordered: of 0.9 percent sodium This is indicated The patient is kept
PNSS 1L x KVO
chloride, isotonic with for fluid hydrated as
July 28, 2015
the blood and tissue replacement for evidenced by
fluid, used in hypotension. It is continuous infusion,
medicine chiefly for also used to dilute improvement in his
Date of Results: other IVs and condition and good
bathing tissue and, in
sterile form. medications. skin turgor. There
July 28 & 29, 2015
Combined with KCl to were no negative
maintain normal effects noted.
potassium level.

69
NURSING RESPONSIBILITIES

Prior to procedure:

Perform proper hand hygiene and observe other appropriate infection

control
procedures.

Verify prescriptions for IV therapy

Check solution label and identify patient
Explain procedure to the patient
Carry out hand hygiene and put on disposable non-latex gloves
Apply tourniquet 4-6 inches above the sites apply identify suitable vein
Choose site. Use distal veins of hands and arms first
Raise bed for comfortable working height and position for patient and
adjust lighting
During the procedure:

Explain to the client what you are doing to do, why it is necessary, and
how she can cooperate
Questions the patient carefully about sensitivity to latex, use blood
pressure cuff rather than latex tourniquet if there is sensitivity.
Clean site of insertion and observe aseptic technique.
Support patient hand and maintain aseptic technique.
Once in place, regulate the IVF as ordered.
Label IVF on the date and time started and on the infusion rate.

Apply a new tourniquet for each patient and palpate for a pulse distal
to the tourniquet
With hand not holding the venous access devise, steady patients arm
and use finger to pull skin taut
Hold needle bevel up and at 5-25 degree angle, depending on the
depth of the vein
If backflow of blood is visible, straighten angle and advance needle.
Additional steps for catheter is inserted over the needle
Hold needle hub, and slide catheter over the needle and vein

70
 Remove while pressing lightly on the skin over the catheter tip
Release tourniquet and attach infusion tubing; open clamp enough to
allow drip
Cover and tape the small loop of IV tubing onto the dressing
Calculate infusion rate and regulate flow of infusion

After the procedure:

Document, date and time therapy initiated

Check for any signs of inflammation
Monitor vital signs
Monitor the patency of the tube and the IV site.
Check the level of the IV as per hospital policy
Tape the IV lines
Dress and label the venipuncture according to the hospital policy

71
 b. Diet

TYPE OF DIET DATE ORDERED, GENERAL INDICATION SPECIFIC FOOD CLIENT'S

DATE DESCRIPTION TAKEN RESPONSE AND
TAKEN/GIVEN, REACTION TO
DATE CHANGED THE DIET

Date ordered: NPO stands for Patient cannot Patient cannot eat
take food or drink by mouth thought
Nothing Per Orem, None
NPO (Nothing per July 28, 2015 he can still receive
which means through mouth.
nutrients needed
Orem) by his body via
nothing by mouth.
NGT
Doctors use this
Date of Results: on orders when
they do not want
July 28 & 29, 2015
the patient to take
in any type of
food or liquid by
mouth. For
instance, when a
patient is getting
ready for a
surgery, they are
ordered for NPO.

72
Nursing Responsibilities (NPO):

Before:

Check for the doctors order for type of diet preferred.

Explain the importance and purpose of the prescribed diet.
Place an NPO sign on the bed.
Remove all foods at bedside and emphasize strict compliance on the diet
regimen.
During:

Monitor patient closely for compliance of the diet.

Reiterate diet frequently to the patient or SO.
Check bedside for presence of food, remove if necessary.
After:

Assess patients condition.

Document

73
TYPE OF DIET DATE GENERAL INDICATION SPECIFIC FOOD CLIENT'S
ORDERED, DESCRIPTION TAKEN RESPONSE
DATE AND REACTION
TAKEN/GIVEN, TO THE DIET
DATE
CHANGED

NGT These are It It is indicated to TEN and Patient was able

special
prevent further medications to get full
Date ordered: preparations for
patients who are increase in the nutrient from the
unable to digest patients blood TEN.
July 28, 2015
solid foods.
pressure and to
lower down
cholesterol
Date of Results:
levels.
July 28 & 29,
2015

74
75
c. Foley Catheter

76
 MEDICAL DATE ORDERED,
DATE
MANAGEMENT/ GENERAL DESCRIPTION
PERFORMED,
TREATMENT DATE CHANGE
Foley Catheter Date ordered: A Foley catheter is a
flexible tube that is
July 28, 2015
often passed through
the urethra and into
the bladder. The tube
Date of Results:
has two separated
channels, or lumens,
July 28 & 29, 2015
running down its length.
One lumen is open at
both ends, and
allows urine to drain out
into a collection bag.
The other lumen has a
valve on the outside
end and connects to
a balloon at the tip; the
balloon is inflated with
sterile water when it
lies inside the bladder,
in order to stop it from
slipping out.
CLIENTS
INDICATION OR
RESPONSE TO
PURPOSES
TREATMENT
To drain urine The treatment
when the resulted to a non-
bladder's muscles palpable bladder
or nerves are not with a proper
working properly. excretion of urine
and decreased risk
Also, certain
medications can for urine retention.
interfere with the
bladder's normal
emptying.
To drain urine in
patients who are
unconscious.
To measure urine
output in adults
who are
incapacitated
because of critical
illness or surgery.
To collect urine
during diagnostic
studies of the
urinary tract.
77
d. Medications

DATE ROUTE OR
NAME OF ORDERED, ADMINISTRATIO GENERAL CLIENTS
INDICATION
DRUGS, DATE N DOSAGE AND ACTION, RESPONSE TO
OR
GENERIC NAME, TAKEN/GIVEN, FREQUENCY OF MECHANISM OF THE
PURPOSES
BRAND NAME DATE ADMINISTRATIO ACTION MEDICATION
CHANGED N

Dosage: General Action: Relief of mild- Clients response

600mg to-moderate to medication is
Generic name: DO: July 28, Analgesics pain; effective as
2015 Route: treatment of
evidence by
Paracetamol IV Muscle Relaxants fever.
lowering down
DG: July 28 & 29,
Frequency: the patients
2015
q 6hrs temperature
Brand name: Mechanism of
Action:
Calpol
-Decreases fever
by inhibiting the
effects of
pyrogens on the
hypothalamus
heat regulating
centers & by a
hypothalamic

-Action leading to
sweating &
vasodilatation.

78
 ROUTE OR
DATE ORDERED, GENERAL CLIENTS
NAME OF DRUGS, ADMINISTRATION
DATE ACTION, INDICATION RESPONSE TO
GENERIC NAME, DOSAGE AND
TAKEN/GIVEN, MECHANISM OF OR PURPOSES THE
BRAND NAME FREQUENCY OF
DATE CHANGED ACTION MEDICATION
ADMINISTRATION

Dosage: General Action: Short term Client responded

30mg management of well with the
GENERIC NAME: DO: July 28, 2015 Nonsteroidal anti- pain (not to medication given
NAME OF DRUGS, DATE ORDERED,
Route: ROUTE OR
inflammatory GENERAL
exceedACTION,
5 days INDICATION
as evidenced by
Ketorolac DG: July
GENERIC NAME,28 & 29, IVDATE agents, nonopioid MECHANISM OFall
ADMINISTRATION total for OR PURPOSES CLIENTS
routes observations of
2015
BRAND NAME TAKEN/GIVEN, DOSAGE AND
analagesics ACTION RESPONSE TO
Frequency: combined) relieved pain.
DATE CHANGED FREQUENCY OF THE
q 8hrs
ADMINISTRATION MEDICATION
BRAND NAME:
Mechanism of
Toradol
Action:
Dosage: General Action: Moderate to Client shows
50mg moderately decrease
- Inhibits
GENERIC NAME: DO: July 28, 2015 Analgesics severe pain restlessness due
prostaglandin
Route: (centrally acting) to pain.
Tramadol DG: July 28 & 29, IV synthesis,
2015 producing
Frequency:
peripherally
q 8hrs PRN analgesia
mediated Mechanism of
BRAND NAME: Action:
- Also has
Ultram antipyretic and -Decreased pain.
anti-inflammatory
properties. -Binds to mu-opioid
receptors.
- Therapeutic
effect:Decreased -Inhibits reuptake of
pain serotonin and
norepinephrine in
the CNS.

79
 ROUTE OR
DATE ORDERED, CLIENTS
NAME OF DRUGS, ADMINISTRATION GENERAL ACTION,
DATE INDICATION OR RESPONSE TO
GENERIC NAME, DOSAGE AND MECHANISM OF
TAKEN/GIVEN, PURPOSES THE
BRAND NAME FREQUENCY OF ACTION
DATE CHANGED MEDICATION
ADMINISTRATION

Dosage: General Action: Treatment of Client responded

500mg severe localized well with the
GENERIC NAME: DO: July 28, 2015 Hemostatic agents bleeding medication as
Route: secondary to
evidenced by
Tranexamic Acid DG: July 28 & 29, IV Fibrinolysis hyperfibrinolysis
bleeding is
2015 inhibitors
Frequency: controlled.
q 8hrs
BRAND NAME:
Mechanism of
Lysteda Action:

Tranexamic acid
competitively
inhibits activation of
plasminogen
thereby reducing
conversion of
plasminogen to
plasmin
(fibrinolysin), an
enzyme that
degrades fibrin
clots, fibrinogen,
and other plasma
proteins, including

80
the procoagulant
factors V and VIII.

81
82
 ROUTE OR
DATE ORDERED, GENERAL CLIENTS
NAME OF DRUGS, ADMINISTRATION
DATE ACTION, INDICATION RESPONSE TO
GENERIC NAME, DOSAGE AND
TAKEN/GIVEN, MECHANISM OF OR PURPOSES THE
BRAND NAME FREQUENCY OF
DATE CHANGED ACTION MEDICATION
ADMINISTRATION

Dosage: General Action: Systemic Client responded

1gm infections well with the
GENERIC NAME: DO: July 28, 2015 Penicillinase caused by medication as
Route: penicillinase-
evidenced by
Oxacillin DG: July 28 & 29, IV producing
staphylococci infection is
2015
Frequency: Mechanism of controlled.
q 6hrs Action: Resistant
BRAND NAME: penicillin that
inhibits cell-wall
Bactocill
synthesis during
microorganism
multiplication;
bacteria resists
penicillins by
producing
penicilllinase
enzymes that
convert penicillins
to inactivate
penecillic acids.
Oxacillin resists
these enzymes.

83
NAME OF DRUGS, DATE ORDERED, ROUTE OR GENERAL ACTION, INDICATION OR CLIENTS
GENERIC NAME, DATE ADMINISTRATION MECHANISM OF PURPOSES RESPONSE TO
BRAND NAME TAKEN/GIVEN, DOSAGE AND ACTION THE
DATE CHANGED FREQUENCY OF MEDICATION
ADMINISTRATION
ROUTE OR
DATE ORDERED, GENERAL CLIENTS
NAME OF DRUGS, ADMINISTRATION
DATE ACTION, INDICATION RESPONSE TO
GENERIC NAME, DOSAGE AND
TAKEN/GIVEN, MECHANISM OF OR PURPOSES THE
BRAND NAME FREQUENCY OF
DATE CHANGED Dosage: General Action:
ACTION Treatment of Client responded
MEDICATION
ADMINISTRATION
1gm LRIT (e.g. well with the
GENERIC NAME: DO: July 28, 2015 Antimicrobial and bronchitis, medication as
Route:
Dosage: Antiparasitic
General Action: pneumonia, of
-Control Client responded
evidenced by
Ceftriaxone DG: July 28 & 29, IV
100mg bronchopneumo
grand mal well with the
Antiepileptic agent, nia, emphysema, infection is
GENERIC NAME: DO: 2015
July 28, 2015 (tonic-clonic) medication
Frequency: Hydantoin lungabscess), controlled. as
Route:
and evidenced by
Phenytoin DG: July 28 & 29, IV
q 12hrs Mechanism of skin and soft
BRAND NAME: psychomotor
tissue infections. treatment of
2015 Action:
Frequency: seizures
Pre-operative some episodes of
Rocephin q 8hrs Mechanism of Action: prophylaxis seizures
Inhibits bacterial
BRAND NAME: -Prevention and
toreduce chance
cell
Haswall synthesis,
antiepileptic of
treatment post-
of
rendering cell wall
activity without operative
Dilantin seizures
osmotically
causing general CNS surgical
occurring
depression;
unstable, stabilizes
leading to infections.
neuronal membranes during or
cell death
and prevents following
hyperexcitability neurosurgery
caused by excessive
stimulation; limits the -Control of
spread of seizure status
activity from an epilepticus of
active focus; also the grand mal
effective in treating type (parenteral
cardiac arrhythmias, administration)
especially those
induced by digitalis;
antiarrhythmic
properties are very
similar to those of
lidocaine; both are 84
class IB
antiarrhythmic
 ROUTE OR
DATE ORDERED,
NAME OF DRUGS, ADMINISTRATION GENERAL ACTION, CLIENTS
DATE INDICATION OR
GENERIC NAME, DOSAGE AND MECHANISM OF RESPONSE TO
TAKEN/GIVEN, PURPOSES
BRAND NAME FREQUENCY OF ACTION THE MEDICATION
DATE CHANGED
ADMINISTRATION

Dosage: General Action: Induces diuresis Client responded

100c by raising well with the
GENERIC NAME: DO: July 28, 2015 Electrolytic and osmotic pressure medication as
Route: water balance of glomerular increased urine
Mannitol DG: July 28 & 29, IV agent; osmotic filtrate, thereby output.
2015 diuretic
Frequency: inhibiting tubular
q 6hrs reabsorption of
BRAND NAME: water and
Mechanism of solutes. Reduces
Osmitrol elevated
Action:
intraocular and
In large doses, cerebrospinal
increases rate of pressures by
electrolyte excretion increasing
by the kidney, plasma
particularly sodium, osmolality, thus
chloride, and inducing
potassium. diffusion of water
from these fluids
back into plasma
and

extravascular
space.

85
 ROUTE OR
DATE ORDERED, GENERAL CLIENTS
NAME OF DRUGS, ADMINISTRATION
DATE ACTION, INDICATION RESPONSE TO
GENERIC NAME, DOSAGE AND
TAKEN/GIVEN, MECHANISM OF OR PURPOSES THE
BRAND NAME FREQUENCY OF
DATE CHANGED ACTION MEDICATION
ADMINISTRATION

Dosage: General Action: Used to treat The patient didnt

NAME OF DRUGS, DATE ORDERED, 500mg ROUTE OR GENERAL INDICATION
partial onset CLIENTS
respond well with
GENERIC NAME:
GENERIC NAME, DO: July 28,
DATE 2015 ADMINISTRATION anti-epileptic
ACTION, OR PURPOSES
seizures RESPONSE
the medicationTO
BRAND NAME TAKEN/GIVEN, Route: DOSAGE AND MECHANISM OF AEB pt.THE
Levetiracitam DG: July 28 & 29, Oral capsule anticonvulsant
DATE CHANGED FREQUENCY OF ACTION MEDICATION
experienced
2015
ADMINISTRATION
Frequency: headache and
BID dizziness.
Mechanism of
Dosage: General Action: Duodenal and Clients response
40mg Action:
BRAND NAME: gastric ulcer. to medication is
GENERIC NAME: DO: July 28, 2015 Gastrointestinal Gastroesophag well as evidenced
Route: Appears to inhibit
Keppra Agent; Proton eal reflux by controlled pain
Omeprazole DG: July 28 & 29, IV burst firing without
pump inhibitor disease
2015 affecting normal
Frequency: neuronal including
OD excitability and severe erosive
BRAND NAME: Mechanism
may of
selectively esophagitis
Action:
prevent
Losec
hypersynchronizati
An of
on antisecretory
epileptiform
burst firing that
compound and is a
propagation pump
gastric acid of
inhibitor.activity,
seizures
Suppresses gastric
acid secretion by
inhibiting the H+,
K+- ATPase
enzyme system
[the acid (proton
H+) pump] in the
parietal cells.

86
Nursing Responsibilities

Before:

Observe 10 Rs of administration of drugs '

Check doctors order three times and verify the patient
Check the label of the drug, its name and its expiration date
Wash hands before handling the medication
Assess patients vital signs prior to administering the medication
During:

Administer as indicated (right drug, right dosage, right frequency)

Clean the IV insertion for medication with a cotton ball with alcohol.
Gradually inject the drug into the port. Slow IV push to prevent infiltration and
phlebitis.
Administer cautiously and slowly with aseptic technique.

After:
Observe for the sensitivity and side effects to the drug
Reassess patients level of pain at least 15 and 30 minutes after parenteral
administration
Monitor circulatory and respiratory status and bladder and bowel function.
Caution ambulatory patient about getting out of bed or walking.

87
X. Health Teachings

Medications:

The client was given these medications due to his condition. He was advised
to take Levetiracitam 500mg tab BID.

Levetiracitam 500mg tab BID

Exercise:

Range of motion exercises as tolerated.

Avoid strenuous activities.

Therapy:

None

Health Teachings:

Instructed to have adequate rest periods.

Instructed Deep Breathing exercises.
Maintain Proper Hygiene.

Diet:

Instructed to eat foods low in salt and low in fat.

Increase oral fluids

88