Nursing Management of the Adult Client with Neurologic Alterations Neoplasms, Infections

1
Nursing Management of the Adult Client with
Neurologic AlterationsNeoplasms, Infections

• NURS 228
• Janie Best, RN, MSN, APRN, BC

2
Neoplasms

• Primary Brain Tumors
• Localized intracranial lesion
• gt 50 malignant
• Gliomas tumors most common
• Astrocytomas (80) highly malignant spread
  by infiltration
• Meningiomas benign, incapsulated

3
Neoplasms

• Neuroma acoustic slow growing
• Pituitary adenomas pressure to surrounding
  brain tissue
• Angiomas abnormal blood vessels ? CVA risk
• Metastatic tumors -

4
Brain Tumors Clinical Manifestations

• Generalized
• IICP
• Headache
• Vomiting
• Visual disturbances
• Localized (focal)
• Hemiparesis
• Seizures
• Mental status changes

5
Manifestations

• Parietal lobe
• Sensory deficits
• Paresthesia
• Loss of 2-point discrimination
• Visual field deficits
• Temporal lobe
• Psychomotor seizures

• Frontal lobe
• Inappropriate behavior
• Personality changes
• Inability to concentrate
• Impaired judgment
• Recent memory loss
• Headache
• Expressive aphasia
• Motor dysfunctions

6
Manifestations

• Pituitary tumors
• Endocrine dysfunction
• Visual deficits
• Headache

• Occipital lobe
• Visual disturbances
• Cerebellum
• Disturbances in coordination and equilibrium

7
Neoplasms

• Assessment
• Neuro exam
• History of illness
• Diagnostic Findings
• CT, MRI, PET, EEG, CSF cytologic studies

8
Gerontologic Considerations

• Overlook or incorrectly attribute changes as
  normal aging
• Incidence of primary Brain Tumors malignancy ?
  with age

9
Neoplasms Management

• Treatment Options
• Surgical removal
• Radiation therapy
• Brachytherapy
• Chemotherapy - local
• Corticosteroids

10
Neoplasms Medical Mgmt.

• Goals/Outcomes
• ICP WNL
• Maximal neurological functioning
• Free of pain/discomfort
• Awareness of long-term prognosis

11
Nursing Diagnoses

• Risk for aspiration
• Gag reflex / swallow test
• Risk for IICP
• Neuro checks
• Space nursing interventions
• Reorient as needed
• Prevention of injury

12
Nursing Diagnoses

• Self-care deficit (feeding, bathing, and
  toileting) related to loss or impairment of motor
  and sensory function and decreased cognitive
  abilities
• Imbalanced nutrition, less than body
  requirements, related to cachexia due to
  treatment and tumor effects, decreased
  nutritional intake, and malabsorption

13
Nursing Diagnoses

• Anxiety related to fear of dying, uncertainty,
  change in appearance, or altered lifestyle
• Interrupted family processes related to
  anticipatory grief and the burdens imposed by the
  care of the person with a terminal illness

14
Cerebral Metastases - Management

• Palliative
• Eliminating or reducing symptoms
• Limited survival time if no treatment
• Therapy
• Radiation, surgery, or a combination
• Chemo is of little use (Blood Brain barrier)
• Corticosteroids
• Relieve headache and alterations of LOC

15
Definitions

• Burr hole
• Craniotomy
• Craniectomy
• Cranioplasty

16
Craniotomy

• Surgical Opening
• Skull
• Performed for
• ? ICP relief
• Blood clot evacuation
• Hemorrhage control
• Tumor removal

17
Craniotomy

• Preoperative Management
• Baseline Neuro Assessment
• Client and Family Understanding
• Prep for Surgical Site
• Medications
• Anti-seizure, Corticosteroids, Osmotic/Loop
  diuretics

18
Craniotomy

• Postoperative
• Reducing Cerebral Edema
• Pain Relief
• Seizure Prevention
• Aspiration precautions
• Monitoring ICP, VS
• Infection Prevention
• Sensory/Cognitive

19
Spinal Cord Tumors

• Types
• Intramedullary lesions
• Extramedullary Intradural lesions
• Extramedullary - Extradural lesions

20
Spinal Cord Tumors

• Symptoms
• Localized or shooting pains
• Weakness
• Loss of reflexes above the tumor level
• Progressive loss of motor function and paralysis

21
Spinal Cord Tumors -Management

• Medical
• Chemotherapy
• Radiation therapy
• High dose dexamethasone
• Surgical
• Primary treatment tumor removal or debulking

22
Infectious Neurologic Disorders

• Meningitis
• Septic (Bacterial)
• Aseptic (Viral)
• Most Significant Bacterial Meningitis

23
Bacterial Meningitis
24
Bacterial Meningitis

• Nucal rigidity
• Stiff neck and soreness when neck is flexed
• Positive Brudzinskis sign
• Hips and knees are flexed in response to the
  nurse gently flexing the head toward the chest
• Positive Kernigs sign
• Pain and spasm of hamstring muscles when the knee
  thigh are extended from flexed position

25
Bacterial Meningitis
26
Bacterial Meningitis

• Diagnostic
• Blood cultures
• Lumbar puncture
• Bacterial culture
• Gram staining
• Prevention
• Vaccinations

27
Bacterial Meningitis

• Complications
• Arthritis
• Cranial nerve damage
• (III, IV, VI, VII, VIII)
• Hydrocephalus
• Thrombophlebitis in cerebral vessels

28
Bacterial Meningitis

• Goals/Outcomes
• Return of baseline neuro function
• Resolution of Infection
• Decreased pain/discomfort
• Treatment Patient and those in close contact
• Antibiotics (patient/close contact)
• Dexamethasone, IV fluids

29
Bacterial Meningitis Interventions
30
Viral Meningitis

• Aseptic
• Less severe
• Etiology - virus
• Similar manifestations to Bacterial, but milder

31
Viral Meningitis

• Photophobia
• Remains oriented
• Mild temp elevation
• Positive Brudzinski and Kernigs signs

32
Case Study 10 Brain Tumor

• Tests to evaluate
• Define benign
• List 6 general symptoms of brain tumor
• Discuss use of Decadron in tumors
• Identify supportive medications their use
• Treatment plan
• Common responses to diagnosis of brain tumor
• Living will and HCPOA
• Communication concerns
• Lab values (potassium, serum glucose)

33
NCLEX Questions

• Which of the following pathophysiologic events
  results in irregular respiratory patterns as LOC
  decreases?
• Brainstem responses to changes in PaCO2
• Loss of the oculocephalic reflex
• Pressure on the meninges
• Reflexive motor responses

34
NCLEX Questions

• Which of the following pathophysiologic events
  results in irregular respiratory patterns as LOC
  decreases?
• Brainstem responses to changes in PaCO2
• Loss of the oculocephalic reflex
• Pressure on the meninges
• Reflexive motor responses

35
NCLEX Questions

• When assessing the fluid dripping from the ear of
  the the patient with a head injury, the nurse
  tests for glucose. She is assessing for
• Blood.
• CSF.
• Infection.
• Serum.

36
NCLEX Questions

• When assessing the fluid dripping from the ear of
  the the patient with a head injury, the nurse
  tests for glucose. She is assessing for
• Blood.
• CSF.
• Infection.
• Serum.

37
Test Review Unit 4A

• IICP
• LOC definitions
• SIADH
• DI
• Clustering vs spacing activities
• Temp control in head injury

38
Monitoring Cerebral Oxygentation Lab Values
39
Test Review Unit 4A

• IICP - Nursing interventions
• Maintaining patent airway
• Hyperoxygenate before and after suctioning
• Suction lt 15 seconds
• Hypoxia leads to cerebral ischemia and edema
• Coughing is discouraged Increases ICP

40
Test Review Unit 4AIICP Nursing interventions

• Optimizing cerebral tissue perfusion
• Keep head in neutral (midline) position
• Avoid extreme rotation and flexion of neck
• Use cervical collar if necessary
• Elevate HOB at least 30 degrees
• Avoid hip flexion (? intra-abdominal and
  intrathoracic pressures)

41
Test Review Unit 4AIICP Nursing interventions

• Optimizing cerebral tissue perfusion
• Avoid straining at stool stool softeners
• Space nursing interventions to prevent transient
  increases in ICP
• Calm, quiet environment with minimal stimuli
• Keep room lights lowered

42
Medications

• Nimotop
• Calcium channel blocker
• Treats cerebral vasospasm
• Mannitol
• Osmotic diuretic
• Draws fluid out of brain cells
• Increases risk of seizures and fluid /
  electrolyte imbalance

43
Medications

• Propofol (Diprivan)
• Short acting IV anesthetic agent
• Used for sedation with IICP
• Monitor for respiratory depression and
  hypotention

44
Medications

• IV fluids in IICP
• Avoid hypo-osmolar solutions like D5W (causes
  IICP)
• Use 0.45 Normal Saline

45
References

• Hogan, M., Madayag, T. (2004). Medical-Surgical
  Nursing Reviews and rationales. Pearson
  Education, Inc. Upper Saddle River, NJ. Pp. 167
  210.
• Hudak, C., Gallo, B, Morton, P. (1998). Patient
  Management Nervous System. In Critical Care
  Nursing A holistic approach, 7th ed.
  Lippincott. Philadelphia. Pp. 613-637.
• Hudak, C., Gallo, B, Morton, P. (1998). Patient
  Management Endocrine System. In Critical Care
  Nursing A holistic approach, 7th ed.
  Lippincott. Philadelphia. Pp. 834-836.

46
References

• LeMone, P., Burke, K. (2008). Medical Surgical
  Nursing Critical thinking in client care.
  Pearson Education, Inc. Upper Saddle River, NJ.
  Pp. 1564- 1577.
• Smeltzer, S., Bare, B. (2004). Brunner
  Suddarths Textbook of Medical-Surgical Nursing.
  Lippincott, Williams, Wilkins. Philadelphia.
  Pp. 1821 -1886.