Voicethread: Brain & Spinal Cord

What is herniation of the brain

-A mass that causes the rest of the brain to move. A lumbar puncture can cause a hernia. It can also cause secondary vascular damage. -This is why it is important to watch for altering ICP especially after a lumbar puncture.

What is an acoustic neuroma

-A tumor of the 8th cranial nerve -It Grows slowly over time, and may be very large by the time it is diagnosis

What is the purpose of the brain stem

-ABC affected -Breathing -Blood pressure -Heartbeat -Swallowing

What is a brain tumor

-Abnormal growths of tissue found inside the skull or the bony spinal column, which are the primary components of the central nervous system (CNS) -A brain tumor is a localized intracranial lesion, which occupied space within the skull -Localized intracranial lesion

What is a critical step in diagnosing a spinal cord tumor

-Accurate history & physical examination to help pinpoint the affected area. These include x-rays, bone scans, MRI -MRI is the most helpful tool

What is the purpose of chemo & ommaya reservoir

-Allows for the chemo drug to be delivered directly into the tumor. -This has improved the treatment outcomes for many patients with brain tumors. There are also less systemic effects.

Ways to promote patient safety

-Anticonvulsant therapy preoperatively to prevent post-op seizures -Seizure precautions -Care is taken with the confused patient to prevent injury as a result of pulling out IV, ICP monitors, may need a 1:1 sitter. -Maintain head in a neutral alignment & avoid valsalva maneuver, coughing & vomiting should be avoided. If suctioning has been ordered, it should only be done as necessary. Should be done very gently in short limited passes of the catheter, to limit coughing & associated hypoxia.

Nursing diagnosis for patients with a tumor

-Anxiety: need a lot of support, causes decrease in attention span -Impaired thought process -Disturbed body image related to chemo surgery -Risk for infection related to treatment modalities -Risk for injury -Ineffective protection

What is included in pre-op care

-Baseline neurological & physiologic data -Encourage pt & family to verbalize fears, the patient may appear scary to their family when they come back for their surgery. -Explain all treatments & procedures -Antiseptic shampoo may be ordered -Prepare the family for post-op appearance -They are going to have a head dressing, edema, ecchymosis of face, changes in mental status,

What is a pituitary adenoma

-Benign tumor of anterior pituitary cells

What are the types of brain tumors

-Benign, malignant or metastatic. -Regardless of their origin or the presence of malignancy, problems of ICP will occur due to limited area in the brain for the expansion to go. -Malignant tumors rarely metastasize outside the CNS -Classification is based upon location & histological characteristics

What are issues that occur with a pituitary tumor

-Causes hormonal changes. -They cause symptoms due to pressure on the surrounding structures, this could be hormonal changes which result in hypo or hyper function of the pituitary

What are issues with chemo in patients with a brain tumor

-Chemo loses effectiveness when administered IV for brain tumors, only a small portion, if any crosses the blood brain barrier. -Many meds can become useless -Alternate route for chemo drugs is used

What is the treatment of a meningioma

-Complete removal or partial dissection.

Manifestations of ICP

-Decreased LOC -Changes in pupils -Changes in speech -Restlessness -Weakness/paralysis -Headaches -Seizures -Vomiting -Sensory disturbances -Rapid rise in body temp -Respiratory & pulse changes

Examples of steroids that may be used

-Dexamethasone, prednisone, methylprednisolone

What types of radiations are used for brain tumors

-External beam radiation -Brachytherapy -Stereotactic

What are clinical manifestations of an occipital lobe tumor

-Focal seizures -Hallucinations -Hemianopsia

What is an angioma

-Form within the vessels. -On the surface of the brain or within the brain. -Composed largely of abnormal blood vessels. -These patients are at risk for CVA & patients who have a CVA younger than 40 usually suggest the possibility of an angioma.

What are spinal cord tumors

-Found in or near the spinal cord. Because it is housed with a rigid, bony structure (Spinal column) any abnormal growth can exert pressure on sensitive tissues & impair function. -Any tumor located near a sensitive spinal cord nerve can cause both pain & weakness. Most common in young to middle aged adults.

Ways to promote nutrition & electrolyte balance

-Frequent assessment of blood glucose & electrolyte -Fluids can be resumed when the patient is alert & has an adequate gag reflex

What is the purpose of surgery in brain tumors

-Goal is removal of tumor without increasing neurological symptoms or to relieve symptoms by decompression -Goal is also to obtain a diagnosis, decrease tumor mass effects on the brain, remove as much of the tumor as can be done safely. -Craniotomy, transsphenoidal surgery, steritactic procedures

What are clinical manifestations of the triad of ICP

-Headache -Nausea -Vomiting -You also have Cushing's triad with increasing ICP

What are clinical manifestations of a frontal lobe tumor

-Headaches (usually a bilateral frontal headache) -Personality changes -Focal seizures -Blurred vision -Altered thought processes

What should you do to prevent gastric ulcerations

-Histamine H2 blocker or proton pump inhibitor may be prescribed -Carafate &/or antacids depending upon the pH of gastric secretions

Spinal cord tumor assessment

-History -Neuro exam -Assess for weakness, motor function, paralysis -Assess for pain -Assess for loss of reflexes

What assessments should be done in patent with a suspected brain tumors

-History (Ask family about changes since the patient may not even notice the changes) -Neuro status -Use glasgow coma scale (used for state & LOC) -ICP

What is the purpose of the pituitary gland

-Hormones -Growth -Fertility

Causes of pathophysiologic events with a brain tumor

-ICP & cerebral edema -Seizure activity & focal neurological signs -Hydrocephalus -Altered pituitary function

What is the purpose of the parietal lobe

-Intelligence -Reasoning -Telling right from wrong -Language -Sensation -Reading

What is a gliomas

-Intracerebral tumors -Originates in neural tissue, usually malignant. Develop from glial cells. Astrocytoma & glioblastoma are different types of gliomas. Tend to grow in cerebral hemispheres, can also occur in the brain stem, the optic nerves, spinal cord & cerebellum.

What is a key sign of a brain tumor

-Key sign is a seizure. If they have not had one in the past, a full work up need to be completed.

Manifestations of a spinal cord tumor

-Localized/shooting pain, weakness, & progressive loss of motor function, loss of reflexes, paralysis & loss of sensation below the level of the tumor. -Even a small tumor can cause a lot of issues

Why is safety an issue in a patent with a brain tumor

-Loss of coordination -Parietal lobe: visual loss, motor/sensory focal seizures, loss of coordination, tremors, nystagmus in cerebellar region.

Where are common places for brain tumors to metastasis

-Lungs, breast, kidney & site of a malignant melanoma.

What is the goal of an inoperable brain tumor

-Major goals include compensating for self-care deficits, improving nutrition, reducing anxiety, enhancing family coping skills, & minimal/absence of complications.

What is the medical management of a spinal cord tumor

-Medical management will depend on the type & location of the tumor. Can include surgery, decompression, radiation, medications & chemotherapy.

What should you remember

-Monitor for any deterioration in a patient, with brain or spinal cord tumors, including the pre/post op patients -Sudden onset of a deficit is an ominous sign!!

What should be included in post-op care

-Monitor vital function -Promote decrease in ICP -Promote comfort -Promote patient safety -Promote nutrition & electrolyte balance -Promote mobility

What is post-op assessment that should be completed

-Monitor vital signs, assess neuro status, promote decreased ICP, promote comfort, assess the incisions & drainage. -Promote patient safety at all times, seizure precautions as well as nutrition.

What is the purpose of the frontal lobe

-Movement Itelligence -Reasoning -Behavior -Memory -Personality -Planning -Decision making -Judgment -Initiative -Inhibition -Mood

What diagnostic testings should be done in those with a brain tumor

-Neurological examination -CT scan: gives specific information on the tumor location, size density as well as if edema is present. Contrast will be used. -MRI: most helpful in diagnosis in tumors especially small ones, as well as tumors in the brain stem & pituitary region. -PET scan -EEG -Cytological study of cerebral spinal fluid: malignant cells can shed into the CSF -Biopsy: In may cases the tumor is so characteristic that no biopsy is actually needed, so the biopsy may not be necessary, especially when a tumor is in a difficult spot.

Ways to promote comfort

-Non-opioid analgesics to prevent CNS depression, but may need codine -Ice cap for headache -Assess incision & drainage -Head bandage needs to be assessed frequently along with the assessment of the drainage. The drainage should be minimal, clear or yellowish drainage may indicate a CSF leak. -Keep HOB elevated at least 30 degrees to help with venous drainage & reduce edema. -Treat nausea, keep bright lights/loud noises to a minimum.

What are the causes of brain tumors

-Only known risk factor for a brain tumor is ionizing radiation exposure, which can have a latency period of 10-20 years after exposure. -Other possible causes; hair dye, high tension wires, nitrates (processed food), cell phones -Head trauma -Viruses -Chemical exposures on job -Nerve gas exposures (veterans)

What is a secondary brain tumor

-Originate from other parts of the body

What is a primary brain tumor

-Originate in the brain or supporting structures -Can be slow growing or rapid growing -Grade 1 (less aggressive) up to grade 4 (most aggressive)

What is an Extramedullary, extradural tumor of the spinal cord

-Outside the dural membrane

Ways to promote mobility

-Parameters for activity orders -Deconditioning is expected in those who have no gotten out of bed in a long time -Postural hypotension is common -Elevate HOB first before getting them up -Early ambulation is encouraged

Examples of anti-convulsants

-Phenytoin, carbamazepine, valproate

What is a gliadel wafer

-Placed in the brain after the tumor is removed

What are nursing care for tumors

-Pre-op care -Post-op care -Pain control -Provide referral to counselor, social worker, home health care, support groups as needed -Provide referral for hospice care

What is the problem with the treatment of a glioma

-Presents a problem not being able to remove the tumor without damaging vital structure. A rapidly developing hemiparesis is an indication of a highly malignant tumor. -Treatment depends on the grade of the tumor & location, usually combined therapy, normally external beam radiation.

What is the purpose of the cerebellum

-Safety issue is a priority -Balance -Coordination -Fine muscle control

What are clinical manifestations of a temporal lobe seizure

-Seizures -H/A -Receptive aphasia -Tinnitus -Papilledema

What can be affected with a brain tumor

-Since brain tumors are located at the central center for thought, emotion & movement, their effects on an individuals physical & cognitive abilities can be devastating

When a brain tumor is present, intervention is needed

-Skull is unable to accommodate the increasing size of tumor -What does this lead to ICP

What are the 2 parts of the ommaya reservoir

-Small dome shaped container that is put under the scalp -Catheter leading from the dome

Ways to promote decrease in ICP

-Space activities allow for rest -Coughing & vomiting should be avoided -Suction should be avoided

What should you do prevent diabetes insipidus

-Specific gravity is assessed frequently. Commonly occurs due to pituitary surgery but can occur after any head trauma or any other intracranial surgical procedures.

What is the purpose of the temporal lobe

-Speech -Behavior -Memory -Hearing -Vision -Emotions

What drugs are used for brain tumors

-Steroids: -Anticonvulsants -Antiemetics -Certain pain medications

Ways to monitor vital functions

-Subtle changes need to be reported ASAP-immediate surgery may be required -Assessment incision & drainage -May have a direct ICP monitor -Report changes in behavior such as restlessness (ICP or hemorrhage)

What is a meningioma

-Supporting structure tumors -Most common tumor outside the brain, usually benign. -Slow growing & encapsulated

What are treatments of brain tumors

-Surgery -Radiation -Chemotherapy -Steroids (To reduce the swelling)

What is the treatment of spinal cord tumors

-Surgical removal -Measures to relieve compression: dexamethasone (steroid) combined with radiation

Manifestations of brain tumors

-Symptoms of increased ICP -Headache, not always present & when they are they are more common in the morning. Can be worse with coughing, straining, sudden movement, can be described as dull as well as deep. -Slurred speech -Lethargy -Nausea/Vomiting is usually related to irritation of the vehicle centers in the medulla. -Visual disturbances, decreased visual acuity, double vision, visual field deficit, color vision disturbances.

What are common post-op complications

-Syndrome of inappropriate antidiuretic hormone (SIADH) -Cerebral salt wasting -Hematomas -Hemorrhage -Shock -Meningitis -Monitor urine output -Corneal abrasions -Gastric ulcerations -Diabetes insipidus

What are the drug choices for a glioma

-Temozolomide -Methotrexate

What should you know about brain tumors

-The headaches are usually worse in the morning -The n/v are not usually related to food intake

Manifestations of a acoustic neuroma

-They may have tinnitus, pain & hearing loss

What should be done to prevent corneal abrasion

-Trauma, surgery or dysfunction in the area of the 7th cranial nerve -Nursing assessment & interventions

What types of chemo are used for brain tumors

-Usually a secondary therapy -Problem with blood brain barrier

What is the purpose of the occipital lobe

-Vision

Manifestations of spinal cord tumors

-When a tumor in the spinal cord or it exerts pressure on it, it can cause various symptoms including pain, & weakness.

What is an Extramedulary-intradural tumor of the spinal cord

-Within or under the spinal dura

What is a intramedullary tumor of the spinal cord

-Within the cord

Are there ways to prevent brain tumors

-Yes