nursing process

1. Chapter XV

2.  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.  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.  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.  Skull radiographs
 CT scan
 EEG
 Lumbar puncture
 Angiogram
 MRI
 Functional MRI
 Stereotactic biopsy/surgery

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

8.  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.  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. 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.  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.  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

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

25.  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.  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. 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.  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.  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