This document discusses intracranial neoplasms (brain tumors). It notes that brain tumors can originate in the central nervous system or metastasize from other sites. Symptoms vary depending on the location of the tumor in the brain and can include headaches, vomiting, seizures, and neurological deficits. Diagnostic testing includes imaging like CT scans and MRI. Treatment aims to relieve increased intracranial pressure and neurological deficits but can result in further deficits or death. Nursing care focuses on pain management, prevention of injury, reducing anxiety, optimizing nutrition, and supporting family coping.

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