NUR 205 Ch 44 Patients With Oncologic Disorders of the Brain and Spinal Cord

Nursing Management: Assessing the Patient Postoperatively

- Pt is monitored for deterioration in neurologic status. A sudden onset of neurologic deficit is an ominous sign & may be due to vertebral collapse a/w spinal cord infarction. - Freq neurologic checks are carried out, w/ emphasis on movement, strength, & sensation of the upper & lower extremities. - Staining of the dressing may indicate leakage of CSF from the surgical site, which may lead to serious infection or to an inflammatory reaction in the surrounding tissues that can cause severe pain in the postop period

Nursing Management: Providing Preoperative Care

- The objectives of preop care include recognition of neurologic changes through ongoing assessments, pain control, & the management of altered ADLs. - The nurse assesses for weakness, muscle wasting, spasticity, sensory changes, bowel & bladder dysfunction, & potential respiratory problems, esp if a cervical tumor is present. - The pt is also evaluated for coagulation deficiencies. Postop pain management strategies are discussed w/ the pt before surgery.

Clinical Manifestations (Figure 44-1)

- Brain tumors can produce focal (localized) or generalized neurologic sx. Sx reflect either brain invasion, compression by the mass on adjacent structures, or increased ICP. - Pt can experience seizures, n/v, cognitive impairment, & visual disturbances. - Additionally, specific s/s result from tumors that interfere w/ functions in specific brain regions. These focal sx may also include weakness, sensory loss, aphasia, visual dysfunction, & other manifestations r/t specific neurological dysfunction b/c of localized involvement.

Medical Management of Primary Brain Tumors: Pharmacologic Therapy and Chemotherapy

- Chemo may be given intravenously, orally, or intrathecally (injected directly into the subarachnoid space). - The newer oral chemo agent Temozolomide (Temodar) is often part of the systemic therapy b/c of its ability to pass through the blood-brain barrier. Chemo that is given by intrathecal injection bypasses the blood-brain barrier. - Other chemo agents are usually given as salvage therapy after initial treatments fail

Clinical Manifestations: Increased Intracranial Pressure [Headache]

- HA, although not always present, is most common in the early morning & is made worse by coughing, straining, or sudden movement. HAs may improve w/ vomiting. - HA is thought to be caused by the tumor's invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor. Thus, HAs are r/t intracerebral edema & increasing ICP; they do not appear to be directly r/t tumor size. - HAs are usually described as deep or expanding or as dull but unrelenting. Frontal tumors usually produce a bilateral frontal HA; pituitary gland tumors produce pain radiating b/w the 2 temples (bitemporal); w/ cerebellar tumors, the HA may be located in the suboccipital region at the back of the head. **The nurse is aware that HAs in the morning are suggestive of a tumor. When the pt complains of a HA, the nurse assesses the pt's temperature. The nurse knows that fever w/ HA is a/w an infectious process whereas HA w/o fever may be a/w a tumor or intracerebral bleeding.

Nursing Management: Promoting Home and Community-Based Care

- In preparation for discharge, the pt is assessed for the ability to function independently in the home and for the availability of resources to assist in care giving. - Safety is a key component when arranging for home care: - Pts w/ residual sensory involvement are cautioned about the dangers of extremes in temperature. They should be alerted to the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters). The pt is taught to check skin integrity daily. - Pts w/ impaired motor function r/t motor weakness or paralysis may require training in ADLs & safe use of assistive devices, such as a cane, walker, or wheelchair. - The pt & family members are instructed about pain management strategies, bowel & bladder management, & assessment for s/s of neurologic dysfunction, which should be reported promptly.

Clinical Manifestations: Increased Intracranial Pressure [Personality Changes]

- Location, pressure, & degree of infiltration of the tumor, & edema, if present, influence the changes in personality & mental status. - Pt may experience difficulties concentrating, memory loss (ST memory may be more affected than LT memory), confusion, & changes in temperament.

Spinal Cord Tumors

- Tumors within the spine are classified according to their anatomic relation to the spinal cord: - Intramedullary tumors arise from within the spinal cord. - Intradural-extramedullary tumors are within or under the spinal dura but not on the actual spinal cord. - Extradural tumors are located outside the dura & often involve the vertebral bodies. - These tumors may be either primary or metastatic in nature. - Spinal tumors causing cord compression are considered a neurological emergency.

Clinical Manifestations: Increased Intracranial Pressure [Fatigue]

- Fatigue is a sx experienced both by pts w/ malignant & nonmalignant brain tumors. Etiology of fatigue can be multifactorial. - The tumor itself, surgery, meds, chemo, & radiation may all contribute to increased fatigue. - Pts may complain of a constant feeling of exhaustion, weakness, & lack of energy. - Important to identify underlying conditions such as stress, anxiety, & depression, which may play a role in fatigue

Medical Management of Primary Brain Tumors: Surgical Management

- Surgical intervention provides the best outcome for most tumor types. - The objective of surgical management is removal of part of or the entire tumor w/o increasing the neurologic deficit. - The surgical approach depends on the type of tumor, its location, & its accessibility. Options include stereotactic biopsy, open biopsy, craniotomy w/ debulking, & subtotal or gross total tumor resection

Nursing Management: Managing Pain

- The prescribed med should be administered in adequate amounts & at appropriate intervals to relieve pain & prevent its recurrence. - Early sx of spinal cord tumors include stiffness & pain that continues to worsen. Pain is the hallmark of spinal metastasis. - Pain may increase in the recumbent position, which is not the case in degenerative joint disease. Bone pain at night is another concerning sx for metastatic disease. The bed is usually kept flat initially. - The nurse turns the pt as a unit, keeping shoulders & hips aligned & the back straight. The side-lying position is usually the most comfortable, b/c this position imposes the least pressure on the surgical site. - Placement of a pillow b/w the knees of the pt in a side-lying position helps to prevent extreme knee flexion.

Spinal Cord Compression: Medical Management

- Treatment of spinal cord tumors depends on the type, location, presenting sx, & physical status of the pt. - Surgical intervention, if appropriate, is the primary treatment for most tumors. Other treatment modalities include partial removal of the tumor w/ decompression of the spinal cord. - For metastatic lesions of the spine, radiation therapy can be used to decrease the size of the tumor. B/c of the blood-brain barrier, chemo for malignant spinal cord neoplasms is of limited benefit. - Dexamethasone is used temporarily to reduce edema & improve neurologic function until other treatments can take affect. - Tumor removal is desirable but not always possible. The goal is to remove as much tumor as possible while sparing uninvolved portions of the spinal cord to avoid neurologic damage. - Microsurgical techniques have improved the prognosis for pts w/ intramedullary tumors. Prognosis is r/t the degree of neurologic impairment at the time of surgery, the speed w/ which sx occurred, & the origin of the tumor. - Pts w/ extensive neurologic deficits before surgery usually do not make significant functional recovery, even after successful tumor removal. - Palliative care may be an option for the medical management of some pts. Relief from sx & pain control are the goal of care. - Pts may receive palliative treatments such as radiation & then transition into hospice care when supportive treatments fail to control tumor growth. - Other integrative (complementary/alternative) therapies consist of music, massage, Reiki, & guided imagery

Medical Management of Primary Brain Tumors

A variety of medical treatment modalities, including chemo & external-beam radiation therapy, are used alone or in combo w/ surgical resection. - Depending on the type & extent of the tumor, medical treatments may be done for sx management purposes rather than to cure the pt of a brain tumor. This type of medical management is referred to as palliative care & will help improve the pt's quality of life when cure is not possible.

Clinical Manifestations: Increased Intracranial Pressure [Visual Disturbances]

Papilledema is a/w visual disturbances, such as decreased visual acuity, diplopia (double vision), & visual field deficits.

Nursing Management (Box 44-2)

The effects of increased ICP caused by the tumor mass are reviewed in Ch 45. - Nurse performs neurologic checks, monitors vital signs, maintains a neurologic flow chart, spaces nursing interventions to prevent a rapid increase in ICP, & reorients pt when necessary to person, time, & place. - Pts w/ changes in cognition caused by their lesions require freq reorientation & the use of orienting devices (e.g., personal possessions, photos, lists, & a clock). - Supervision of and assistance w/ self-care, ongoing monitoring, & interventions for prevention of injury may be required. Pts who have seizures are carefully monitored & protected from injury. The nursing process for pts undergoing neurosurgery is discussed in Ch 45. - Pt w/ a brain tumor may be at increased risk for aspiration due to cranial nerve dysfunction. If the pt is at risk for aspiration, he or she should be placed in a side-lying position w/ HOB elevated 10-30 degrees. Nurse must ensure that suction equipment is at the bedside. - Preop, the gag reflex & ability to swallow are evaluated by gently touching each side of the posterior pharyngeal wall w/ a cotton swab or suction cath & noting the strength of the gag. The nurse expects to observe a simultaneous elevation of the uvula & "gag" w/ stimulation of the posterior pharynx. - Function should be reassessed postoperatively b/c changes can occur b/c of alterations in cranial nerves IX (glossopharyngeal) & X (vagus) or the pons or medulla. - If gag reflex is impaired, the HCP is notified & food/fluid are withheld until eval of swallowing is determined.

Clinical Manifestations: Increased Intracranial Pressure [Vomiting]

Vomiting, seldom r/t food intake, is usually the result of irritation of the vagal centers in the medulla. Forceful vomiting is described as projectile vomiting.

Assessment and Diagnostic Findings (Figure 44-3)

- The hx of the illness, the manner & time frame in which the sx evolved are key components in the dx of a brain tumor. - A neuro exam can be helpful in indicating the areas of the CNS that are involved. - To assist in identifying the precise location of the lesion, a battery of tests may need to be performed: - MRI is the gold standard for detecting brain tumors, particularly smaller lesions, & tumors in the brainstem & pituitary regions, where bone is thick. - CT enhanced by a contrast agent, can give specific info concerning the #, size, & density of the lesions & the extent of secondary cerebral edema. CT can also provide info about the ventricular system. - PET (measures brain's activity rather than its structure) is useful in differentiating tumor from scar tissue or radiation necrosis. - Computer-assisted stereotactic (three-dimensional) biopsy is being used to diagnose deep-seated brain tumors. - Cerebral angiography provides visualization of cerebral blood vessels & can localize most cerebral tumors. - Cytologic studies of the CSF may be performed to detect malignant cells b/c CNS tumors can shed cells into the CSF.

Clinical Manifestations: Localized Symptoms (Figure 44-2)

- Common focal sx are hemiparesis (weakness on one side of the body), seizures, & mental status changes. - When specific regions of the brain are affected, additional local s/s occur, such as sensory & motor abnormalities, visual alterations, changes in hearing, alterations in cognition, & language disturbances. - The progression of the s/s is important, b/c it indicates tumor growth & expansion. For ex, if a tumor is present in the cerebellar area, the nurse might expect to see changes in balance & coordination.

Medical Management of Primary Brain Tumors: Pharmacologic Therapy and Chemotherapy Cont'd

- Corticosteroids are used during treatment to reduce cerebral edema & to reduce the side effects of treatment such as n/v. They are also helpful in relieving HA & alterations in LOC. - Antiseizure agents are used to treat seizures if they occur. Special consideration is given when managing seizures, r/t a potential serious interaction b/w antiseizure meds & antineoplastic agents. - Pts w/ brain tumors are at a higher risk for the development of DVT and PE. Careful consideration is taken when prescribing anticoagulant therapy due to the risk of CNS hemorrhage. - Pain is managed by means of a stepped progression w/ regard to the dosing, delivery method, & type of analgesic agents needed for relief. - HA is often a common complaint of pain in this population of pts. If pt has severe pain, morphine can be infused into the epidural catheter placed as near as possible to the spinal segment where the pain is projected. Small doses of morphine are administered at prescribed intervals

Spinal Cord Compression: Assessment and Diagnostic Findings

- Initial sx may present as radicular pain (pain that radiates along the dermatome [sensory distribution] of a nerve), weakness, sphincter dysfunction, & sensory changes. - Neurologic exam & diagnostic studies are used to make the dx. Neurologic exam includes assessment of pain, loss of reflexes above the tumor lvl, progressive loss of sensation or motor function, & the presence of weakness & paralysis. - These changes in neurological function are r/t the mass exerting pressure & compression of the nerve roots or spinal cord. - MRI is the most commonly used diagnostic tool, detecting epidural SCC & metastases - SCC is considered a medical emergency & requires immediate treatment to prevent permanent neurological damage. - Treatment goal is to relieve cord compression w/ the use of IV steroids such as dexamethasone (Decadron) to reduce edema. - Additionally, chemo, radiation, or surgery to debulk the tumor is expected to preserve neurologic function. - W/ early intervention, 75%-100% of pts who were ambulatory before SCC remained so after therapy

Primary Brain Tumor

- Primary brain tumors are localized intracranial lesions that begin in the brain & occupy space within the skull. - The tumor is an abnormal growth of cells that forms a mass, but it also can grow diffusely. - Effects of neoplasms (seizure activity & focal neurologic signs) are caused by the compression or infiltration of tissue, or both. - Tumors may be benign or malignant. Benign tumors: usually slow growing but can occur in a vital area, where they can grow large enough to cause serious effects. Malignant tumors: rapidly growing in nature, can spread into surrounding tissue, & considered life-threatening. - Primary brain tumors rarely spread to other areas of the body. - Oncologic disorders of the brain include several types of neoplasms, each w/ its own biology, prognosis, & treatment options. B/c of the unique anatomy & physiology of the CNS, this collection of neoplasms is challenging to diagnose & treat.

Medical Management of Primary Brain Tumors: Radiation Therapy

- Radiation therapy, the cornerstone of treatment for many brain tumors, decreases the incidence of recurrence of incompletely resected tumors. - External-beam radiation therapy may be used alone or in combo w/ surgical resection. Stereotactic radiation therapy may be performed using a linear accelerator or gamma knife. - These procedures allow treatment of deep, inaccessible tumors, often in a single session. Precise localization of the tumor is accomplished by the stereotactic approach & by minute measurements & precise positioning of the pt. - Brachytherapy is done by implanting radiation seeds close or into the tumor. This therapy is not standard treatment & is not found to be helpful in all types of brain tumors.

Clinical Manifestations: New Onset of Seizures

- Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combo of these), which result from abnormal paroxysmal electrical discharges in the brain. - May be triggered by irritation of the brain directly by the tumor, by rising ICP, or by altered electrical potential in the brain. - Approx 50% of pts w/ brain tumors have seizures during their illness. Seizures may be the initial presenting sx. - Type & frequency of seizure vary, r/t tumor size, site, & type. Simple partial seizures, complex partial seizures, & generalized tonic-clonic seizures are those more commonly seen

Spinal Cord Compression

- Spinal cord compression (SCC) occurs b/c of tumor extension into the epidural space. The cord can be compressed at any area of the spine, resulting in permanent paralysis if not treated. - Pts w/ myeloma or lymphoma, as well as those w/ breast, lung, prostate, or renal cancers, are at an increased risk for developing SCC. - Nurse is alert for early complaints of back pain, which occurs in the region of the tumor. The pain typically increases when the pt is in the prone position. - Early sx a/w SCC also include bladder & bowel dysfunction (urinary incontinence or retention; fecal incontinence or constipation). - Later sx include evidence of motor weakness & sensory deficits progressing to paralysis. - Radiological tests are used to diagnose SCC; MRI is considered the test of preference

Clinical Manifestations: Increased Intracranial Pressure

- Sx of increased ICP result from compression of the brain by the enlarging tumor or edema. - Vasogenic (cerebral) edema plays a major role in sx r/t an increase in mass. Edema can exceed the mass itself, creating increased pressure & disrupting local blood flow. - Sx often include HA, nausea w/ or w/o vomiting, & papilledema (edema of the optic disk). Personality changes & a variety of focal deficits, including motor, sensory, & cranial nerve dysfunction, are common. - Nurse remains alert for changes in the pt's LOC & notifies the PCP of any alterations in mental status - Late signs a/w rising ICP r/t the vital signs: htn w/ a widening pulse pressure (difference b/w systolic & diastolic pressure), bradycardia, & respiratory depression is termed Cushing's triad.