Brain Tumors
- 1. By WONG PEI YIN (Charissa) BSN, SRN
- 2. • To further understand and gain extensive knowledge regarding brain tumors. • To review and evaluate literature about brain tumors with a focus on the adult patient with an admitting diagnosis brain tumor- right sphenoid wing meningioma and to provide consistent, current and evidence based care to patients with brain tumors and their families. • To create reference for neuroscience nurses. *
- 3. * Brain tumor is an abnormal growth of the tissue in the brain. *The brain tumors can be mainly divided into two primary brain tumors and secondary/metastatic brain tumor
- 4. * • Originate in the brain. • Can grouped into benign tumors and maglinant tumors. PRIMARY • Originate in other organs and disseminate to the brain. • For example, cancers of the lung, breast, colon and skin. SECONDARY
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- 6. • A meningioma grows from the arachnoid cells that form the middle layer, and are firmly attached to the dura mater. • Most are noncancerous (benign) • Meningioma occur most commonly in older women *
- 7. * GRADE 1 (BENIGN) GRADE 2 ( ATYPICAL) GRADE 3 (MALIGNANT/ANAPLASTIC) Approximately 78-81% of meningiomas are benign Approximately 15-20% of meningiomas are atypical Approximately 1-4% of meningiomas are malignant Easily recognized Faster growing Poorly differentiated cells Grow slowly May grow back after treatment Aggressive type of brain tumor that recur rapidly
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- 11. * *Clear, colorless fluid *Produced by choroid plexus *Found in ventricles of the brain Subarachnoid space ( between arachnoid and Pia mater ) around the brain and spinal cord.
- 12. * FOROMEN OF MONRO AQUEDUCT OF SLYVIUS
- 13. A. OLFACTORY GROOVE Forms along the nerves connecting the brain to the nose B. SUPRASELLAR Forms in the center of the base of the skull C. PETRO-CLIVAL Forms along the petrous pyramid or into the cavernous sinus and middle fossa D. SPHENOID RIDGE Forms on the skull base behind the eyes E. FORAMEN MAGNUM Arise from arachnoid at the craniospinal junction. *
- 14. As brain tumor grows Vasogenic edema compressed surrounding tissue Increase permeability of capillary endothelial cells of cerebral white matter Leakage plasma into extracellular space and between the layers of the myelin sheath Alter the electrical potential of cells Mass effect develops Signs and symptoms continue develop Cerebral herniation syndromes and death PATHOPHSIOLOGY
- 15. • RADIOTHERAPY • HEAD TRAUMA • VIRAL INFECTION • ESTROGEN RECEPTORS
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- 17. * *Physical examination & history : An examination of the body to check general signs of health, and history of the patient’s health habits and past illnesses and treatments. *Neurological examination : To checks a person’s mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. *Visual field/visual acuity assessment : Any loss of vision may be a sign of a tumor that has damaged/pressed on the parts of the brain that affect eyesight. *MRI : These scans usually give a very clear picture of the brain and will almost certainly show up any brain tumor that is present. *CT scan: These scans takes a series of detailed pictures of head. The contrast material makes abnormal areas easier to see.
- 19. * *NAME : Madam N *AGE : 60 Years old *SEX : Female *RACE : Malay *STATUS : Married. Staying with husband. *OCCUPATION : Housewife. *CHILDREN : 3 childrens aged 29 years old, 33 years old, 35 years old. *DATE OF ADMISSION : 19/9 *DATE OF DISCHARGE: 1/10 *DIAGNOSIS : Right Sphenoid Wing Meningioma *PROCEDURE : Right Craniotomy and Tumour Debulking
- 20. * *Presented to the ED on 19/9. Alleged frequent fall today x5 in the house due to unsteady gait. *No past medical history. *Noted past 3months upper and lower limbs weakness and progressive unsteady gait. *Presenting with left facial asymmetry, right eye ptosis and slurring of speech for 2weeks. *Complaint of headache, giddiness, blurring vision and loss of appetite for 1month. *Denied SOB, chest pain, fever, vomiting and also denied bowel/ bladder incontinence. No history of fit or loss of consciousness.
- 21. * 1. VITAL SIGN •BP : 140/83mmHg •PULSE : 89bpm •TEMPERATURE : 37°c •DEXTROSTIX : 7.5mmol/L •Spo2 : 98% (room air) 2. GENERAL •Alert •Orientated to place, person but not time •GCS E4V4M6 14/15 •Pupil 3/3mm reactive 3. Cardiovascular system (CVS) •DRNM (dual rhythm no murmur) 4. Auscultate lungs •clear 5. Palpate abdomen •soft & non distended 6. Palpate breast and thyroid •normal
- 22. * Part Of Assessment Right left Tone Normal Reduced Power Shoulder abducen 5/5 4/5 Elbow flexion 5/5 4/5 Elbow extension 5/5 4/5 Wrist flexion 5/5 4/5 Wrist extension 5/5 4/5 Reflex 2+ 2+ Sensation Intact Intact Grip Good Poor UPPER LIMBS Part of assessment Right Left Tone Normal Reduced Power Hip flexion 5/5 4/5 Hip extension 5/5 4/5 Knee flexion 5/5 4/5 Knee extension 5/5 4/5 Ankle dorsiflexion 5/5 4/5 Reflex 2+ 2+ Sensation Intact Intact Babinski reflex Toes down Toes down LOWER LIMBS
- 23. * CN 1 Intact CN 2 Poor visual acuity CN 3 Right eye ptosis CN 4 Intact CN 5 V1,V2, V3 intact CN 6 Intact CN 7 Left umn CN7 palsy CN 8 Hearing intact CN 9 Intact CN 10 Intact CN 11 Intact CN 12 Intact
- 24. * Right parietal-occipito white matter oedema, midline shift 0.9cm, ipsilateral ventricle compressed
- 25. * Patient was admitted into wad via wheelchair accompanied by family members. On arrival, general condition patient stable, GCS 14/15 E4V4M6. Open eyes spontaneously, orientated to place and person but disoriented to time of day, able obey command. Vital sign B/P 137/75mmHg, Pulse 63bpm, Respiration 18/min, Temperature 37°c, spo2 98% (room air). Both pupil size 3mm/3mm reactive to light. PLAN 1. For MRI+IGS brain urgent 2. T. Dilantin 100mg TDS 3. T. Dexamethasone 4mg QID 4. T. Ranithidine 150mg BD 19/9@ 10.30am
- 26. * *Closely monitor GCS and vital sign *Continue T. Dexamethasone 4mg QID and T. Dilantin 100mg TDS *For MRI+IGS Brain urgent on 21/9 *Operation on 24/9 after consult and explanation done to patient’s family *Refer for anesthesia for operation *Preparation for pre operation
- 27. 21/9 • MRI+IGS BRAIN done 23/9 • Consult patient’s husband regarding operation of right craniotomy and excision of tumor 23/9 • Reviewed by Anaesthesia • PLAN • 1. GXM 4pint packed cell for OT • 2. Repeat all blood investigation • 3. Neuro ICU back up post operation • 4. NBM 12midnight for 6hours prior to OT • 5. Anesth to review prior to OT • 6. High risk consent 24/9 • Sent patient to OT @ 4PM. • General condition stable, GCS 14/15 E4V4M6 . Pupil 3/3mm reaction. • B/P 128/68mmHg, Pulse 72 bpm, Respiration 18/min, Temperature 37°c
- 28. * MRI sagital view, horizontal view, and coronal view
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- 30. * *Monitor GCS closely at NICU 2days *Keep NBM and IVD normal saline until extubation *Repeat CT scan post operation and extubated done on 25/9 and transfer to neuro ward on 26/9 *Off drain, oxygen and CBD *Start oral feed (Soft Diet) *Refer physiotherapist *Family learn nursing care plan *GCS improved 15/15 *Discharge after STO (STO done and union good) on 1/10
- 31. * 25/9 • Off sedation • Change SIMV mode to CPAP mode • Repeat ABG in 1hour later • Repeat CT brain today • Aim to extubation after review CT brain 26/9 • Extubated done. • Gag reflex present. • Put on Ventimask 60% 15L/min • Transfer to Neuro ward • GCS 10/15 E4V1M5. Both pupil sizes 2/2mm reaction 27/9 • Change Ventimask to 40% monitor Spo2 then off • Off drain and CBD • Prop up 30° • Start oral feed • Refer physiotherapist 1/10 • STO today and discharge patient after STO • TCA neurosurgical 2/52
- 32. * *1. Involve the family in care, as possible to teach essential aspects of care and reinforce the explanation of medical management. *2. Explain suture care to the family. *3. Teach the patient and family observe for sign and symptom of wound infection. *4. Explain to the patient and family the importance of reporting new onset signs and symptom *5. Emphasize the importance of follow up and not to defaulted. *6. Explain the need for a regular exercise program and teach ROM exercise. *7. Teach the patient the importance of balance diet. *8. Teach the patient the names of medications, dosage, time of administration, and side effects . *9. Teach the patient and family about seizure which is the complication of craniotomy.
- 33. Potential wound infection related to surgical procedure *1. Monitor vital sign 4hourly especially temperature and heart rate = may reflect a developing infection. *2. Assess the wound site to identify local sign of wound infection. *3. To do daily dressing or dressing prn = to decrease the risk of infection to the wound site. *4. Monitor WBC result. Elevated of WBC may indicate an infection. *5. Instruct patient not to touch the wound site = bleeding and infection. *6. Administration antibiotic = as prophylaxis postoperatively.
- 34. Care of radivac drain 1. To ensure the drain is below the site of insertion = prevent bleeding and pain. *2. Assess drain insertion site for signs of leakage, redness or signs of ooze = prevent blocked drain tube. *3. Assess patency of drain and document amount and type of fluid in radivac drain chart = increased ooze at the drain site may indicate sign of infection. *4. Maintain the adequate vacuum pressure in radivac drainage = preventing it from accumulating in the body. *5. Ensure radivac drainage tube is not entangled with other leads = lead to accidently removal of the tube. *6. Drains should be removed as soon as practicable as ordered by doctor = prevent the high risk of infection.
- 35. 1. Assess neurologic status and monitor vital sign hourly such as GSC and pupil reaction = to detect early sign increase of ICP . 3. Maintain head position 30° and head and neck in a neutral alignment = promote venous return and prevent increase of ICP. 4. Maintain oxygen and ventilator setting as prescribed level = promote adequate ventilation. 5. Administer analgesic and sedation = reduce pain and cerebral blood volume and metabolism. 6. Maintain normothermia because hyperthermia can change rate of cerebral metabolism which can lead to increase ICP. 7. Prevent patient from manuever vasalva = prevent increase intrathoracic and intraabdominal pressure 8. Monitor for seizure activity and administer anticonvulsant = as prophylaxis of seizure because seizure may increase cerebral metabolic rate and ICP. Altered cerebral tissue perfusion related to increase intracranial pressure
- 36. * *From onset of symptoms to diagnosis, patient run the full spectrum of emotions due to unable to walk steadily, severe headache and giddiness which may cause mood disturbance. *Patient experience low self-esteem due to changes in body image. *Patient’s family appear very worried about patient’s condition and facing some difficulty in taking care of the patient due to lack of knowledge regarding the disease.
- 37. Counselling and discussion session should be held separately with patient’s family. Explanation clearly regarding the disease process and care required to gain a positive emotional support from her family and patient will minimize the feeling of fear and anxiety. Craniotomy surgery recommended as soon as possible by surgeon to prevent sign and symptom worsening and may lead to death. Teach essential nursing care to patient’s family members to promote effective management at home. *
- 38. • Patients with brain tumors can achieve good functional outcomes with a shorter length of stay. • Nurses should have knowledge regarding brain tumors in order able to give essential nursing care to patient. • Craniotomy is the one of the surgical treatment to remove brain tumor sphenoid wing meningiomas and respond well to treatment. *
- 39. CT SCAN plain pre operation CT SCAN plain Post operation
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