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Nursing

care for patients


with brain tumor
Erna Rochmawati, PhD

Universitas Muhammadiyah Yogyakarta


Overview
a. Definition, incidence and type
b. Risk factors and clinical manifestations
c. Diagnostic evaluations
d. Treatment
e. Nursing assessment
f. Nursing care plan based on the given case

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Case
CL, berusia 44 tahun adalah penyiar berita televisi. Saat bertugas pada suatu malam, dia
mengalami kebingungan beberapa kali terkait berita yang dibacakan sehingga penyiar yang
lain mencoba membetulkannya. Ny CL marah dan mengatakan dia tidak membutuhkan
bantuan dan kemudian meninggalkan lokasi syuting. Saat dia keluar, dia terlihat perot dan
menyeret kakinya. Produser acara menanyakan adakah sesuatu yang salah, Ny CL berteriak
tidak ada yang salah dan menyatakan dia hanya pusing. Produser mengikutinya dan
menannyakan tentang sakit kepalanya. Ny CL mengatakan pusingnya datang dan pergi dan
akhir-akhir ini memburuk. Produser menanyakan apakah kakinya terluka, Ny Cl mengatakan
jika kakinya terasa lemas karena dia capek. Saat produser meninggalkan ruangan, Ny CL
mengalami kejang dan jatuh ke lantai, produser memanggil ambulans.
Ny Cl dirawat di bangsal neurologi. Pemeriksaan CT scan, MRI dan EEG dilakukan dan
diidentifikasi adanya massa di intrakranial. Hasil biopsi menunjukkan adanya sel
keganasan/maligna. Diidentifikasi adanya glioma di lobus fronta dan dijadwalkan dilakukan
pembedahan.

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Case
ASSESSMENT
When Clara Rosetti,RN, enters Ms.Lange’s room, she sees
Ms.Lange looking at her shoulder-length hair in the mirror.
Ms. Lange tells Ms.Rosetti that she has never in her life worn
her hair any shorter, and “Now you’re going to cut it all off!”
She paces the room and makes the statement,“I guess the hair
isn’t really important if I survive this situation.” She also says
that she has a headache.
Source: Burke, K, Bauldoff G, LeMone, PT, Gubrud P, Medical Surgical Nursing, 6th edition

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Case
ASSESSMENT
Saat perawat memasuki kamar Ny CL, dia melihat Ny CL
sedang memandang rambut sebahunya. Ny Cl mengatakan dia
tidak pernah memiliki rambut pendek, dan ’sekarang kamu
akan memotong semuanya’. Ny Cl mengatakan “kayaknya
rambut bukan hal penting jika saya bisa hidup’. Dia juga
mengeluh jika pusing.
Source: Burke, K, Bauldoff G, LeMone, PT, Gubrud P, Medical Surgical Nursing, 6th edition

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Definition
• a localized intracranial lesion which occupies space with the skull
and tends to cause a rise in intracranial pressure.

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Incidence
• The annual rate of newly diagnosed brain tumors is 17,000, with an
estimate of 13,100 deaths
• The brain is a frequent site of metastasis. Brain tumors rank as fourth
cause for death of people between the age group of 35 to 54 years.
• Whites have a higher risk of malignant tumors compared with blacks.
• Meningiomas are the common brain tumors in Africa

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Type
Based on origin
• Primary-Arising from the tissues within the brain
• Secondary-It results from metastasis from a malignbant neoplasm that originates in some other
parts of the body

Based on malignancy
• Benign brain tumors do not contain cancer cells. Usually, benign tumors can be removed, and
they seldom grow back. The border or edge of a benign brain tumor can be clearly seen. Cells
from benign tumors do not invade tissues around them or spread to other parts of the body.
However, benign tumors can press on sensitive areas of the brain and cause serious health
problems. Unlike benign tumors in most other parts of the body, benign brain tumors are
sometimes life threatening.
• Malignant brain tumors Very rarely, a benign brain tumor may become malignant containing
cancer cells. Malignant brain tumors are generally more serious and often life threatening. They
are likely to grow rapidly and crowd or invade the surrounding healthy brain tissue. Very rarely,
cancer cells may break away from a malignant brain tumor and spread to other parts of the brain,
to the spinal cord, or even to other parts of the body. The spread of cancer is called metastasis

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Brain tumor grade

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Risk factors
• Being male (1.5 : 1)
• Race
• Age
• Family history
• Being exposed to radiation or certain chemicals at work

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Clinical manifestations
Peningkatan tekanan intra kranial (TIK)
• Headaches (usually worse in the morning)
• Nausea or vomiting
• Papilledema
• Perubahan personality dan defisit fokal (motorik, sensori, disfungsi
syaraf kranial)

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Locations and clinical manifestations
• FRONTAL LOBE TUMORS –Unilateral hemiplegia,seizures,memory
deficit,personality and judgement changes,visual disturbances.
• PARIETAL LOBE-Speech disturbance( If the tumor is in the dominant
hemisphere inability to write,unilateral neglect
• OCCIPITAL LOBE- Blindness and seizures.
• SUBCORTICAL- Hemiplegia,other symptoms may depend on the area of
infiltration
• MENINGEAL TUMORS- Symptoms are associated with compression of the
brain
• METASTATIC TUMORS- Headache,nausea or vomiting because of increased
ICP
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Clinical manifestations
Localized symptoms such as:
• Aphasia
• Personality changes as in case of frontal lobe tumor
• Sensory defects ( smell, hearing).
• Seizures.
• Motor abnormalities

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Diagnostic evaluation
• Physical examination - The doctor checks general signs of health.
• Neurologic examination - The doctor checks for alertness, muscle strength,
coordination, reflexes, and response to pain. The doctor also examines the eyes
to look for swelling caused by a tumor pressing on the nerve that connects the
eye and brain.
• CT scan - An x-ray machine linked to a computer takes a series of detailed
pictures of the head. The patient may receive an injection of a special dye so the
brain shows up clearly in the pictures. The pictures can show tumors in the brain.
• MRI - A powerful magnet linked to a computer makes detailed pictures of areas
inside the body. These pictures are viewed on a monitor and can also be printed.
Sometimes a special dye is injected to help show differences in the tissues of the
brain. The pictures can show a tumor or other problem in the brain.

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Diagnostic evaluation …cont
• Angiogram - Dye injected into the bloodstream flows into the blood vessels
in the brain to make them show up on an x-ray. If a tumor is present, the
doctor may be able to see it on the x-ray.
• Skull x-ray - Some types of brain tumors cause calcium deposits in the brain
or changes in the bones of the skull. With an x-ray, the doctor can check for
these changes.
• Spinal tap - The doctor may remove a sample of cerebrospinal fluid (the
fluid that fills the spaces in and around the brain and spinal cord). This
procedure is performed with local anesthesia. The doctor uses a long, thin
needle to remove fluid from the spinal column. A spinal tap takes about 30
minutes. The patient must lie flat for several hours afterward to keep from
getting a headache. A laboratory checks the fluid for cancer cells or other
signs of problems.

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Diagnostic evaluation …cont
• Myelogram - This is an x-ray of the spine. A spinal tap is performed to
inject a special dye into the cerebrospinal fluid. The patient is tilted to
allow the dye to mix with the fluid. This test helps the doctor detect a
tumor in the spinal cord.
• Biopsy - The removal of tissue to look for tumor cells is called a
biopsy. A pathologist looks at the cells under a microscope to check
for abnormal cells. A biopsy can show cancer, tissue changes that may
lead to cancer, and other conditions. A biopsy is the only sure way to
diagnose a brain tumor.

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Treatment
• Surgery
• Chemotherapy
• Radiotherapy

Supportive care include:


• Steroids
• Anticonvulsant drugs

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Nursing assessment

the frontal lobe In the occipital lobe Temporal lobe the parietal lobe

• occurred personality • visual disturbance • auditory hallucinations • the inability to


disorders, • headache • visual or gustatory distinguish left – right,
• affective disorders, • psychomotor seizures, sensory deficit
• the motor system • aphasia (contralateral)
dysfunction,
• seizures,
• aphasia.

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Nursing assessment
Increased ICT: Mental

• lethargy • Personality changes


• decreased HR • depression
• decreased level of consciousness • decreased memory and ability to make
• papilledema decisions
• projectile vomiting
• seizures
• changes in breathing patterns
• changes in vital signs

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Nursing assessment…...cont
Assessment for Brain Tumor (Intracranial Tumor)
• Pituitary dysfunction. Cushing’s syndrome, acromegaly, giantisme,
hypopituitarism.
• Pain. Persistent headache.
• Seizure activity.
• Fluid status. Nausea and vomiting, decreased urine output, dry mucous
membranes, decreased skin turgor, decreased serum sodium, BUN, Hb,
Hct, hypotension, tachycardia, weight decreased.
• Psychosocial. Anger, fear, mourning and hostility.

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Nursing diagnoses
• Acute pain (headache), related to tumor and increase in intracranial
pressure
• Disturbed body image, related to upcoming hair loss and cranial
incision
• Anxiety, related to unknown future following surgery

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Nursing problems
Preoperative • Deficient knowledge about the planned surgical treatments
• Anxiety related to cancer diagnosis
• Fear related to specific treatments and body image changes
• Risk for ineffective coping (individual or family) related to the diagnosis of
breast cancer and treatment options
• Decisional conflict related to treatment options
Post operative • Pain and discomfort related to surgical procedure
• Disturbed sensory perception related to nerve irritation in affected arm,
breast, or chest wall
• Disturbed body image related to loss or alteration of the breast
• Risk for impaired adjustment related to the diagnosis of cancer and surgical
treatment
• Self-care deficit related to partial immobility of upper extremity on
operative side

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Preoperative nursing interventions
Deficient knowledge about Providing Education and Preparation about Surgical Treatments
the planned surgical • Review treatment options by reinforcing information provided to
treatments the patient and answer any questions.
• Fully prepare the patient for what to expect before, during, and
after surgery.
• Inform patient that she will often have decreased arm and
shoulder mobility after an ALND; demonstrate range-of motion
exercises prior to discharge.
• Reassure patient that appropriate analgesia and comfort measures
will be provided.

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Preoperative nursing interventions
Fear related to specific Reducing Fear and Anxiety and Improving coping Ability
treatments and body image • Help patient cope with the physical and emotional effects of
changes surgery.
• Provide patient with realistic expectations about the healing
process and expected recovery to help alleviate fears (eg, fear of
pain, concern about inability to care for oneself and one’s family)
• Inform patient about available resources at the treatment facility
as well as in the breast cancer community (eg, social workers,
psychiatrists, and support groups); patient may find it helpful to talk
to a brain tumor survivor who has undergone similar treatments.

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Post operative nursing interventions
Relieving Pain and Discomfort
• Carefully assess patient for pain; individual pain varies.
• Encourage patient to use analgesics.
Pain and discomfort related to • Prepare patient for a possible slight increase in pain after the first few days
surgical procedure of surgery; this may occur as patients regain sensation around the surgical
site and become more active.
• Evaluate patients who complain of excruciating pain to rule out any
potential complications such as infection or a hematoma.
• Suggest alternative methods of pain management (eg, taking warm
showers, using distraction methods such as guided imagery).

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Expected outcomes
• Verbalize the causes of pain.
• Verbalize an understanding of the changes in body appearance that
are associated with the scheduled intracranial surgery
(e.g., shaving of the head prior to surgery, cranial incision, facial
swelling postoperatively).
• Identify measures that will help minimize the effect of the hair loss.
• Verbalize a reduction in anxiety.

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PLANNING AND IMPLEMENTATION

• Assess level of discomfort using a rating scale of 0 to 10.


• Provide a quiet, nonstimulating environment.
• Position the client for comfort, keeping the head of the bed elevated
to promote venous drainage.
• Assess level of consciousness for potential increases in ICP.
• Encourage to verbalize feelings about the surgery.
• Suggest measures that may help minimize the hair loss, such as
the use of turbans, scarves, hats, and wigs.
• Suggest relaxation techniques to decrease anxiety.
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Evaluation

Expected Patient Outcomes


• Exhibits knowledge about diagnosis and treatmen options
• Verbalizes willingness to deal with anxiety and fears
• Demonstrates ability to cope with diagnosis and treatment
• Makes decisions regarding treatment options in a timely manner
• Reports pain has decreased and states pain management strategies
• Identifies postoperative sensations and recognizes that they are a normal part of healing
• Exhibits clean, dry, and intact surgical incision without signs of inflammation or infection
• Lists signs and symptoms of infection to be reported
• Verbalizes feelings regarding change in body image

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Evidence based practice
(Ah, Jensen & Allen 2014)

Interventions Effectiveness
1. Cognitive behaviour training Effectiveness not established
2. Cognitive training (eg program to improve memory
performance and attention)
3. exercise Likely to be effective

4. EEG or neurofeedback
5. meditations, mindful-based stress reduction
6. Structured rehabilitation
7. Ginkobiloba Unlikely effective
8. Erythopoesis stimulating agent Not recommended

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