Chapter

Chapter 70
70
Management
Management ofof Patients
Patients With
With
Oncologic
Oncologic or
or Degenerative
Degenerative
Neurologic
Neurologic Disorders
Disorders
Brain Tumors

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Brain Tumors

• Symptoms depend on the location and size of the lesion and the
compression of associated structures
• Manifestations
– Localized or generalized neurologic symptoms
– Symptoms of increased ICP
– Headache
– Vomiting
– Visual disturbances
– Seizures
• Hormonal effects with pituitary adenoma
• Loss of hearing, tinnitus, and vertigo with acoustic neuroma

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Oncologic Tumors

• Brain tumors
– Benign or malignant
– Classification is based on location and histologic
characteristics
• Primary or Secondary
– Primary originate from cells within the brain;
progress locally; rarely metastasize outside CNS
– Secondary develop from structures outside the
brain; metastatic

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Oncologic Tumors

• Types of brain tumors

– Gliomas: 30% of primary brain tumors; astrocytoma
most common; can’t be totally removed without
causing considerable damage to vital structures
– Meningiomas: common benign encapsulated tumors;
slow growing; most common in middle-aged women
– Acoustic neuromas: eighth cranial nerve; slow
growing; benign; cause hearing loss, tinnitus, vertigo,
staggering gait
– Pituitary adenomas: more common in older adults;
rarely malignant

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Clinical Manifestations of Brain Tumors

• Increased ICP
– Skull contains brain matter, intravascular blood, and
CSF
– Monro-Kelli doctrine explains the dynamic equilibrium
of the cranial contents
• If any component of the skull increases in volume,
ICP increases unless one of the other components
decreases in volume
– Compression of intracranial veins, reduction of CSF
volume, decreased cerebral blood flow, reduction of
intra- and extracellular brain tissue mass

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Clinical Manifestations of Brain Tumors

• Headache
– Most common in early morning; worsens with coughing, straining,
or sudden movement; deep, expanding, dull, unrelenting
• Vomiting
– Seldom related to food intake, may be projectile
• Visual disturbances
– Compression of third cranial nerve; diplopia, hemianopia, varying
levels of blindness
• Seizures
– Common, occur in 60%; greatest risks in frontal, parietal, and
temporal lobe tumors

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Common Brain Tumor Sites

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diagnostic Evaluation

• Neurologic examination
• CT scan
• MRI
• PET scan
• EEG
• Cytologic study of cerebrospinal fluid
• Biopsy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

MRI of the Brain Showing a Low-Grade
Glioma

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Medical Management

• Specific treatment depends on the type, location, and

accessibility of the tumor
• Surgery
– Goal is removal of tumor without increasing
neurologic symptoms or to relieve symptoms by
decompression
– Craniotomy, transsphenoidal surgery, stereotactic
procedures
• Radiation therapy
– Cornerstone of treatment for many brain tumors
• Chemotherapy
• Pharmacologic therapy

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Stereotactic Image of Brain Tumor and
Computerized Image of Prescribed Radiation
Dose

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Spinal Cord Tumors

• Classified according to their anatomic relation to the

spinal cord
– Intramedullary: within the cord (primary)
– Extramedullary: extradural; outside the dural
membrane (secondary)
• Manifestations include pain, weakness, loss of motor
function, loss of reflexes, loss of sensation
• Treatment depends on the type of tumor and location
– Surgical removal
– Measures to relieve compression: dexamethasone
combined with radiation

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Process: The Care of the Patient
With Cerebral Metastases or Inoperable Brain
Tumors—Assessment

• Baseline neurologic exam with focus:

– Patient function, moving, and walking; adapting to
weakness and paralysis and to loss of vision and
speech; dealing with seizures
• Pain, respiratory symptoms, bowel and bladder function,
sleep, skin integrity, fluid balance, and temperature
regulation
• Nutritional status and dietary history
• Family coping and family process

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Process: The Care of the Patient
With Cerebral Metastases or Inoperable Brain
Tumors—Diagnoses

• Self-care deficit
• Imbalanced nutrition
• Anxiety
• Interrupted family processes

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Process: The Care of the Patient
With Cerebral Metastases or Inoperable Brain
Tumors—Planning

• Major goals may include:

– Compensating for self-care deficits
– Improving nutrition
– Reducing anxiety
– Enhanced family coping skills
– Absence of complications

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Interventions

• Encourage independence for as long as possible

• Measures to improve cognitive function
• Allow patient to participate in decision making
• Allow patient to express fears and concerns
• Presence of family, friends, spiritual advisor, and health
care personnel may be supportive
• Referral to counselor, social worker, home health care,
support groups
• Referral for hospice care

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Improving Nutrition

• Oral hygiene before meals

• Plan meals for times when patient is comfortable and well
rested
• Measures to make mealtimes as pleasant as possible
• Offer preferred foods
• Dietary supplements
• Daily weight
• Record dietary intake

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Parkinson Disease

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Parkinson Disease

• Slow, progressive neurologic movement disorder

associated with decreased levels of dopamine
• Manifestations:
– Cardinal: tremor, rigidity, bradykinesia/akinesia,
postural instability
– Autonomic: sweating, drooling, flushing, orthostatic
hypotension, gastric and urinary retention
– Dysphagia
– Psychiatric changes: depression, anxiety, dementia,
delirium, hallucinations

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Pathophysiology of Parkinson Disease

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Parkinson Disease: Medical Management

• Treatment directed toward controlling symptoms and

maintaining functional independence.
• Pharmacologic treatment
– Levodopa: most effective
– Table 70-1: Selected Medications used to Treat Parkinson
Disease
• Surgical procedures
– Stereotactic Procedures
– Neural transplantation
– Ongoing research

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Process: The Care of the Patient
With Parkinson’s Disease—Assessment

• Focus on the degree of disability and function of the

patient including ADLs, IADLS, and cognitive function
• Medications and responses to medications
• Emotional responses and individual coping
• Family processes and coping
• Home care and education needs
• Fall risk assessment
• Manifestations and potential complications related to the
specific disorder

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Process: The Care of the Patient
With Parkinson’s Disease—Diagnoses

• Impaired physical mobility and risk for activity intolerance

• Disturbed thought processes
• Self-care deficits
• Imbalanced nutrition
• Constipation
• Impaired verbal communication
• Ineffective coping and compromised family coping
• Deficient knowledge
• Risk for injury

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Process: The Care of the Patient
With Parkinson’s Disease—Planning

• Major goals may include:

– Improved functional ability
– Maintaining independence in ADLs
– Achieving adequate bowel elimination
– Attaining and maintaining acceptable nutritional
status
– Achieving effective communication
– Developing positive individual and family coping skills

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Improving Mobility

• Daily program of exercise

• ROM exercises
• Postural exercises
• Consultation with physical therapy
• Walking techniques for safety and balance
• Frequent rest periods
• Proper shoes
• Use of assistive devices

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Interventions

• Enhancing self-care ability

– Encourage, educate, and support independence
– Environmental modifications
– Use of assistive and adaptive devices
– Consultation with occupational therapy
• Support of coping
– Set achievable, realistic goals
– Encourage socialization, recreation, and independence
– Planned programs of activity
– Support groups and referral to supportive services:
counselors, social workers, home care
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Huntington Disease

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Huntington Disease

• A chronic progressive hereditary disease that results in

choreiform movement and dementia
• Transmitted as an autosomal dominant trait
• Pathology involves premature death of cells in the
striatum of the basal ganglia (control of movement) and
the cortex (thinking, memory, perception, judgment)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Huntington Disease

• Triad of symptoms
– Motor dysfunction
• Chorea; disorganized gait, eventually unable to walk;
loss of bladder and bowel control
– Cognitive impairment
• Attention, emotion recognition; dementia in later stage
– Behavioral features
• Nervous, irritable, impatient; uncontrollable fits of
anger; depression, apathy, anxiety, psychosis,
euphoria; impaired judgment and memory

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Amyotrophic Lateral Sclerosis (ALS)

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Amyotrophic Lateral Sclerosis (ALS)

•Loss of motor neurons in the anterior horn of the spinal

cord and loss of motor nuclei of the lower brainstem
•Manifestations (depends on the location of the affected
motor neurons)
– Progressive weakness and atrophy of muscles
cramps, twitching, and lack of coordination
– Spasticity, deep tendon reflex brisk and overactive
– Difficulty speaking, swallowing, breathing
•Diagnosed based on signs and symptoms
•No cure

Copyright © 2018 Wolters Kluwer · All Rights Reserved