A 57-year-old housewife is happily married with grown children and 2 new grandchildren.

She made an appointment with her optometrist to explore a progressive right sided visual loss over a 9-month period. Her eye exam was essentially normal, and the optometrist referred her to a neurologist. After the workup, a 2.5 cm brain mass was found, and surgery was scheduled. Her only past medical history is hypertension for which she takes nifedipine XL (Procardia XL) 60 mg daily. Her past surgical history includes T&A as child, cholecystectomy, and a TAH at age 42. She also takes a conjugated estrogen (Premarin) 0.625 mg daily.
1. Name four tests that can be done to evaluate for brain tumor.

Tests that can be performed to evaluate a brain tumor include:

CT Scan MRI Scan Brain Biopsy PET Scan

Although non-specific in nature, the CEA lab test does assess for the presence of Cancer Antigens, which can indicate a malignant process occurring somewhere in the body. Typically, to rule out METS, the MD, ARNP, or PA obtains a body scan using radioactive dye that highlights abnormal accumulations of possibly cancerous cells.

There is no standardized, universally accepted system of classifying brain tumors. They can be classified according to histologic basis, intraaxial vs. extraaxial, or malignant vs. benign.
2. Using the term benign when discussing brain tumors is somewhat misleading. Why?

The reasoning for the term Benign to describe brain tumors as being misleading is twofold. First, pressure (ICP) forces exerted from the tumor itself can lead to severe neurological damage. In addition, based purely on the location of the tumor, a Benign tumor might be considered malignant. For example, if the tumor is near the brainstem, then it could cause changes in the vital centers located throughout the Medulla and Pons.

3. Onset of neurologic symptoms is usually insidious, and they exhibit symptoms in relation to the area of the brain where the tumor is located List six general symptoms associated with many brain tumors.

Six general symptoms associated with brain tumors include:

HA (Most CommonCerebral) Vomiting (Cerebral) Changes in Visual Acuity and Diplopia from Papilledema (Cerebral) Hearing Loss (Brainstem) Nystagmus (Brainstem) Ataxia/Dysarthria (Cerebellar)

4. Dexamethasone (Decadron) is commonly prescribed when a tumor is diagnosed and the presence of increased intracranial pressure (IICP) is demonstrated. It is administered preoperatively and postoperatively, and in conjunction with radiation and chemotherapy. Why is Decadron prescribed, and why should it not be abruptly stopped?

Decadron is a corticosteroid that is employed to decrease cerebral edema in individuals with bleeds, trauma, or tumors. When a patient is started on an exogenous steroid treatment regimen, abrupt discontinuation can lead to problems associated with the biofeedback mechanism involved in internal corticosteroid secretion from the adrenal glands. To compensate for the external source of steroid, the anterior pituitary of the brain decreases ACTH, which causes an overall decrease in secreted cortisol levels from the adrenals. Abrupt cessation can cause Acute Adrenal Crisis, with symptoms similar to Addisons Disease:

Hypoglycemia Weaknesss Confusion Tachycardia A/N/V HA/Lethargy Hyponatremia Dysrhythmias Metabolic Acidosis

5. Other common supportive medications include anticonvulsants, diuretics, H2 blockers, analgesics, antiemetics, and antidepressants. Indicate why each is needed.

These medications are used to elicit the following effects:

H2 Blockers: These drugs include Zantac, Pepcid, and Axid, which work to block histamine receptors in the gut, which decreases overall acid secretion. In the case of an ICU patient or an individual with a brain tumor, such agents are used to combat production of Curlings Ulcer, a nonpainful condition in which patients develop ulcerations of the stomach lining. Up to 40% of ICU patients can develop this complication. HA is a common adverse effect of these medications. Analgesics: These agents are used to control pain, which can be manifested through HA, general malaise, etc. in an individual with a brain tumor. Antiemetics: These agents are used to help control nausea and emesis in patients with increased ICP resulting from a brain tumor. Depending on the location of the tumor, N/V can be elicited and as a result, a patient may vomit. Vomiting increases ICP significantly and must be reduced at all costs. Antidepressants: These drugs are used to combat depression in individuals who have received a possible grave diagnosis. Serotonin Selective Reuptake Inhibitors (SSRIs) including Prozac, Zoloft, or Paxil can help curb depressive symptoms. Adverse effects of this drug class include HA, irritability, excitability/insomnia, and suicide. TriCyclics are also used though less often (Elavil--watch for Anticholinergic effects and drowsiness). Newer mood stabilizers are also being used such as WellButrin.

6. Once the diagnosis is made, the patient and family must be involved in the plan for treatment. Treatment depends on the type and location of the tumor and can include surgery, radiation, chemotherapy, or any combination of these. The client also has the right to refuse treatment. Identify four other considerations for the medical team, the client, and the family to consider in devising a treatment plan.

Devising a treatment plan for the individual with a brain tumor is never an easy tack. Overall prognosis will depend on what treatment options are available to help destroy the tumor. The RN is a collaborative participant in the care team and could consider the following in helping to create a care plan for the patient:

Familial Expectations Patient Expectations: Note, sometimes these expectations differ. Invasiveness of the tumor Any contraindications the patient may possess that prohibits one or more diagnostic test or intervention.

7. Describe common responses to a diagnosis of a brain tumor.

The diagnosis of a serious illness, such as a brain tumor can be totally devastating to patients and loved ones. Psychosocially, the patient is going to have to prepare for extensive education regarding the invasiveness of the tumor, what the plan of Tx if going to be, what the adverse effects of Tx options are, and what long-term sequalae could result from the tumor and/or eradication procedures. Common responses include extreme anxiety, stress, strain on interpersonal relationships, fear, and overall depression.
8. List two nursing diagnoses related to this clients role/relationships.

Two Nursing Dx r/t the diagnosis of brain tumor which corresponds with the clients role/relationships include:

Ineffective Coping related to anxiety and fear as evidenced by pt. stating, I am so scared.I dont know how Ill be able to live a normal life now. Caregiver Strain related to increased demands of care for a severe illness as evidences by partner stating, This is going to be so stressfulI just dont know how I will ever be able to provide all of this care.

9. The client draws up a living will and health care power of attorney after she hears the diagnosis. She also sits down with her family and makes her wishes known. Why is this important for this client in particular and for everyone in general?

Living wills express what interventions a client wishes upon the presentation of a serious, life-threatening illness. For example, a Do Not Resuscitate (DNR) advanced directive can be declared through a living will. A durable Power of Attorney allows an individual to make decisions on the behalf of a client who is unable to make such decisions on his or her own. Although the main focus is to carry-out the patients wishes, the declarations made by the Power of Attorney are legally binding. These documents are salient because they serve to allow the patient to direct which care/interventions should be followed in the event of a lifethreatening clinical presentation.
10. You enter this clients room to take VS and she says What if I come out of surgery and Im different? Or what if I die? My grandbabies will never know me. You hear concern in her voice. Suggest several ways that this client can communicate with her loved ones in the event that her surgery in unsuccessful.

This client is anxious and is going to need empathy when discussing the various implications her surgery has on her loved ones. A communication technique that could be employed for this patient is an assisted discussion between the Nurse, Patient, and her loved ones regarding the various adverse effects of the procedures, longterm sequelae of the tumor/ eradication procedures, and possible support-groups that can help assist the client and family with possible life-style changes if her condition worsens of if surgery is not successful. False hopes and reassurances are never appropriate; accuracy in information provided and honesty is best in all communication approaches.

11. The client has the surgery and is admitted to ICU post op. She does very well and remains neurologically intact (q1hr neuro checks). Her BP is slightly elevated (147/68); the rest of her VS are normal; she has 2 peripheral IVs, TED hose, O2 at 4L/nc, and a Foley. Postoperatively, the clients potassium level drops to 2.7 mmol/L, and her glucose is 202 mg/dl. Describe possible reasons why these two laboratory values are abnormal and identify what treatment will be ordered to correct each.

Post-operatively, this patient will probably be receiving Decadron to help reduce cerebral edema. An adverse effect of Decadron and any corticosteroid is hyperglycemia, which results from fluctuations in circulating cortisol levels. Potassium loss can be multifactor. Replacement of K+ will probably be completed through strict adherence to the Potassium Replacement Protocol of the institution. A sliding insulin scale will probably be ordered by the MD, ARNP, or PA to help keep glucose levels within a range of 80-120 mg/dl.

Conclusion of Case Study: This client did suffer mild neurologic damage as a result of surgery. She was discharged to a rehabilitation facility, and eventually recovered most of her lost function. She continues to enjoy an active life and has become involved in helping others facing similar experiences.