CENTRAL NERVOUS SYSTEM TUMORS nursing care process

nursing process

1. CENTRAL NERVOUS SYSTEM TUMORS Chapter XV

2. BRAIN TUMORS Intracranial neoplasms are the result of abnormal proliferation of cells within the CNS. A tumor is a mass of cancerous cells within the brain.

3. Pathophysiology and Etiology May originate in the CNS or metastasize from tumors elsewhere in the body. May be benign or malignant May arise from any tissue of the CNS.

4. Clinical Manifestations Generalized symptoms (due to increased ICP) headache (especially in the morning), vomiting, papilledema , malaise, altered cognition and consciousness. Focal neurologic deficits (related to region of tumor): Parietal area: sensory alterations, speech and memory disturbances, neglect, visuospatial deficits, right-left confusion, depression Frontal lobe: personality, behavior, and memory changes; contralateral motor weakness; Broca's aphasia Temporal area: memory disturbances, auditory hallucinations, Wernicke's aphasia, complex partial seizures, visual field deficits Occipital area:visual agnosia and visual field deficits Cerebellar area: coordination, gait, and balance disturbances, dysarthria

5. Brain stem: dysphagia , incontinence, cardiovascular instability, respiratory depression, coma, cranial nerve dysfunction Hypothalamus: loss of temperature control, diabetes insipidus , SIADH Pituitary/ sella turcica : visual field deficits, amenorrhea, galactorrhea , impotence, cushingoid symptoms, elevated growth hormone, panhypopituitarism Referred symptoms (related to the vasogenic [extracellular] edema of the tumor presence): usually present symptoms of ischemia of region distal to the actual lesion. Seizures.

6. Diagnostic Evaluation Skull radiographs CT scan EEG Lumbar puncture Angiogram MRI Functional MRI Stereotactic biopsy/surgery

7. Complications Increased ICP and brain herniation ; death Neurologic deficits from expanding tumor or treatment

8. Nursing Assessment Assess vital signs and signs of increased ICP . Assess cranial nerve function, LOC, mental status, affect, and behavior. Monitor for seizures. Assess level of pain using visual analogue scale (0 to 10) or face scale as indicated. Assess level of anxiety. Assess patient and family patterns of coping, support systems, and resources.

9. Nursing Diagnoses Acute Pain related to brain mass, surgical intervention Risk for Injury related to altered LOC, possible seizures, IICP, and sensory and motor deficits Anxiety related to diagnosis, surgery, radiation, and/or chemotherapy Imbalanced Nutrition: Less Than Body Requirements related to compromised neurologic function and stress of injury Disabled Family Coping related to changes in roles and structure

10. Nursing Interventions Relieving Pain Provide analgesics around the clock at regular intervals that will not mask neurologic changes. Maintain the head of the bed at 15 to 30 degrees to reduce cerebral venous congestion. Provide a darkened room or sunglasses if the patient is photophobic. Maintain a quiet environment to increase patient's pain tolerance. Provide scheduled rest periods to help patient recuperate from stress of pain. Instruct the patient to lie with the operative side up. Alter diet as tolerated if patient has pain on chewing. Collaborate with patient on alternative ways to reduce pain such as use of music therapy.

11. Preventing Injury Report any signs of increased ICP or worsening neurologic condition to health care provider immediately. Adjust care to reduce risk of increased ICP; body positioning without flexion of head, reduce hip flexion, distribute care throughout the 24-hour period to allow ICP to return to baseline. Monitor laboratory data, CSF cultures and Gram stains, and communicate results to medical staff. Monitor intake and output, osmolality studies, and electrolytes; prevent overhydration , which can worsen cerebral edema. Monitor response to pharmacologic therapy including drug levels. Initiate seizure precautions; pad the side rails of the bed to prevent injury if seizures occur; have suction equipment available.

12. Maintain availability of medications for management of status epilepticus . Initiate fall precautions; side rails up at all times, call light within reach at bedside, assist with toileting on a regular basis. Gradually progress patient to ambulation with assistance as tolerated, enlist help from physical therapist, occupational therapist early as indicated to prevent falls. If the patient is dysphagic or unconscious, initiate aspiration precautions: elevate head of the bed 30 degrees and position patient's head to the side to prevent aspiration.

13. If dysphagic , position the patient upright and instruct in sequenced swallowing to maintain feeding function . Maintain oxygen and suction at the bedside in case of aspiration. For the patient with visual field deficits, place materials in visual field. Provide appropriate care and teaching for patient receiving chemotherapy . Provide appropriate care and teaching for the patient receiving radiation . Provide routine postoperative care for the patient undergoing craniotomy .

14. Minimizing Anxiety Provide a safe environment in which the patient may verbalize anxieties. Help patient to express feelings related to fear and anxiety. Answer questions and provide written information. Include the patient/family in all treatment options and scheduling. Introduce stress management techniques. Provide consistency in care, and continually provide emotional support. Assess the patient's usual coping behaviors, and provide support in these areas. Consult with social worker for community resources.

15. Optimizing Nutrition Medicate for nausea before position changes, radiation, or chemotherapy, and as needed. Maintain adequate hydration within guidelines for cerebral edema. Offer small, frequent meals as tolerated. Consult with dietitian to evaluate food choices and provide adequate caloric needs through enteral or parenteral nourishment if unable to take oral nutrition. Alter consistency of diet as necessary to enhance intake.

16. Strengthening Family Coping Recognize stages of grief. Foster a trusting relationship. Provide clear, consistent explanations of procedures and treatments. Encourage family involvement in care from the beginning. Establish a means of communication for family with patient when verbal responses are not possible. Consult with social worker and mental health provider when family needs assistance in adjusting to neurologic deficits. Assist family to use stress management techniques and community resources such as respite care. Encourage discussion with health care provider about prognosis and functional outcome.

17. Patient Education and Health Maintenance Explain the adverse effects of treatment. Encourage close follow-up after diagnosis and treatment. Explain the importance of continuing corticosteroids and how to manage adverse effects, such as weight gain and hyperglycemia. Encourage the use of community resources for physical and psychological support, such as transportation to medical appointments, financial assistance, and respite care.

18. Evaluation: Expected Outcomes Reports satisfactory comfort level No new neurologic deficits, seizures, falls, or other injuries Expresses decreased anxiety Nutritional intake meeting metabolic demands Patient and family verbalize understanding of treatment and available resources

19. TUMORS OF THE SPINAL CORD AND CANAL

20. TUMORS OF THE SPINAL CORD AND CANAL Tumors of the spinal cord and canal may be extradural (existing outside the dural membranes), including chordoma and osteoblastoma ; intradural-extramedullary (within the SAS), including meningiomas , neurofibromas , and schwannomas ; or intramedullary (within the spinal cord), including astrocytomas , ependymomas , and neurofibromatosis “dumbbell tumors.â €‌ Vascular tumors can affect any part of the spinal cord or canal.

21. Pathophysiology and Etiology Astrocytomas , characterized by asymmetrical expansion in the spinal cord, are more common in children than adults. Ependymomas , usually with a cyst, are the most common intramedullary tumor in the adult, but are rare in children. These tumors are central in the spinal cord. Vascular tumors can affect the spinal cord in various ways. Hemangioblastomas often cause edema and syrinx formation. Cavernomas are located on the dorsal surface of the spinal cord. Approximately 85% of all patients with cancer develop bony metastasis, with the spinal column as the primary site. Spinal cord compression due to cancer typically presents with incomplete paraplegia involving the thoracic spine. Cause for abnormal cell growth is unknown. Extradural tumors spread to the vertebral bodies. Spinal cord and/or nerve compression results.

22. Clinical Manifestations Depends on location and type of tumor and extent of spinal cord compression. Back pain that is localized or radiates; may be absent in more than 50% of patients Weakness of extremity with abnormal reflexes Sensory changes Bladder, bowel, or sexual dysfunction

23. Diagnostic Evaluation A plain X-ray or CT scan can detect a pathologic fracture, collapse, or destruction resulting from a mass. MRI is sensitive to tumor detection. CT myelography with lumbar puncture is sensitive to tumor detection but may be uncomfortable and result in complications from lumbar puncture.

24. Complications Spinal cord infarction secondary to compression Nerve or spinal compression from tumor expansion Tetraplegia or paraplegia due to spinal cord compression

25. Nursing Assessment Perform motor and sensory components of the neurologic examination. Assess pain using scale of 0 to 10 as indicated. Assess autonomic nervous system relative to level of lesion: pupillary responses, vital signs, bowel, and bladder function. Assess for spinal or nerve compression: progressive increase in pain, paralysis or paresis, sensory loss, loss of rectal sphincter tone, and sexual dysfunction.

26. Nursing Diagnoses Anxiety related to surgery and outcome Pain related to nerve compression Disturbed Sensory Perception (tactile, kinesthetic) related to nerve compression Impaired Urinary Elimination related to spinal cord compression Risk for Injury related to surgery

27. Nursing Interventions Relieving Anxiety Provide a safe environment for patient to verbalize anxieties. Provide explanations regarding all procedures. Answer questions or refer patient to someone who can answer questions. Refer to cancer and SCI support groups as needed. Provide the patient/family with written information regarding disease process and medical interventions. Reduce environmental stimulation. Promote periods of rest to enhance coping skills. Involve the family in distraction techniques. Provide options in care when possible.

28. Relieving Pain Administer analgesics as indicated and evaluate for pain control. Instruct the patient in the use of patient control analgesia, if available. Instruct the patient in relaxation techniques, such as deep breathing, distraction, imagery. Position patient off surgical site postoperatively.

29. Compensating for Sensory Alterations Reassure patient that degree of sensory/motor impairment may decrease during the postoperative recovery period as the amount of surgical edema decreases. Instruct the patient with sensory loss to visually scan the extremity during use to avoid injury related to lack of tactile input. Instruct the patient with painful paresthesias in appropriate use of ice, exercise, and rest. Assess the patient with sensory and motor alterations, and refer to physical therapy for assistance with ADLs, ambulation.

30. Achieving Urinary Continence Assess the urinary elimination pattern of the patient. Instruct the patient in the therapeutic intake of fluid volume and relationship to elimination. Instruct the patient in an appropriate means of urinary elimination and bowel management

31. Providing Additional Postoperative Care Provide routine postoperative care to prevent complications. Monitor surgical site for bleeding, CSF drainage, signs of infection. Keep surgical dressing clean and dry. Clean surgical site as ordered. Pad the bed rails and chair if the patient experiences numbness or paresthesias , to prevent injury. Support the weak/paralytic extremity in a functional position.

32. Patient Education and Health Maintenance Encourage the patient with motor impairment to use adaptive devices. Demonstrate proper positioning and transfer techniques. Instruct the patient with sensory losses about dangers of extreme temperatures and the need for adequate foot protection at all times. If the patient has suspected or confirmed neurofibromatosis, suggest referral to genetic counselor. Also, encourage follow-up for MRI every 12 months to monitor disease progression. Refer to cancer and SCI support groups as needed.

33. Evaluation: Expected Outcomes Asks questions and discusses care options Reports that pain is relieved Reports decreased paresthesias ; ambulatory postoperatively Voids at intervals without residual urine Incision healing, skin intact