Transcript Care Of A Patient with Brain Cancer After A Craniotomy

Care Of A Patient with Brain
Cancer After A Craniotomy
Brittani Allen
St. Cloud State University
SCH Ortho/Neuro Summer Nurse Intern
2009
Brain Facts
Primary brain tumors compose a heterogeneous group of neoplasms that
vary widely by site of origin, morphologic features, growth potential, extent
of potential invasiveness and tendency for progression, and recurrence and
treatment response.
Types:
Benign brain tumor- slow-growing cells, distinct borders, rarely spreads, may be life
threatening because of its location in the brain, often needs only a craniotomy
resection
Malignant brain tumor- fast-growing cells, invasive of surrounding tissues, often
spreads to other places in the CNS, very life-threatening, requires many therapy
treatments like a craniotomy, radiation & chemotherapy
Anatomical Locations:
Brain, cranial nerves spinal cord, meninges, ventricle, cerebellum, pituitary, pineal, nasal
cavity, other CNS,
Classifications:
 Tumors of neuroepithelial tissue (i.e., astrocytic tumors, oligodendroglial
tumors, ependymal tumors, glioblastoma multiforme tumor)
 Tumors of the meninges (i.e., meningioma)
 Tumors of cranial and spinal nerves (i.e., schwannoma, neurofibroma)
 Hematopoietic neoplasms (i.e., malignant lymphoma)
 Germ cell tumors (i.e., teratoma)
 Cysts and tumors such as lesions (i.e., Rathke cleft cyst, epidermoid cyst)
 Tumors of the sellar region (i.e., pituitary adenoma)
 Local extensions from regional tumors (i.e., paraganglioma, chordoma)
 Metastatic tumors
Craniotomies for Brain Cancer Patients
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Craniotomy with maximal surgical excision of a brain tumor provides the
best treatment for prolongs survival and improving neurological status of
patients with brain tumors (Sawaya, 1998).
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Craniotomy for surgical resection of a brain tumor may not be curative in
some cases. However, it does offer more accurate diagnosis than needle
biopsy, improvement in symptoms with decreased ICP and theoretically an
increased response to other treatments such as chemotherapy and
radiation.
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Postoperative craniotomy complications can often lead to permanent
neurologic injury if gone unrecognized. Prompt recognition of neurological
decline and timely diagnosis and intervention by the multidisciplinary team
improves patient outcomes and subsequent quality of life.
Post-op Craniotomy
Complications
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Reversal agents for anesthetic complications
Needed if a pre-op LOC is not obtained
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Respiratory complications
Decrease LOC, inability to protect airway
Development of edema around the brain stem
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Interventions: Narcan, Flumazenal, anticholinesterase agents,
anticholinergic agents
Interventions: neutral neck position, SpO2>94%, IS, ABGs, Swallow Eval
Cardiovascular complications
Hypovolemic shock: tachycardia, decreased BPs, shallow fast
respirations, cool, pale skin, decreased UOP
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Interventions: Fluid resuscitation, isotonic & hypertonic saline
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Hypertension: may cause hemorrhage
Hypotension: may cause hypoperfusion and ischemia in surrounding
brain
Blood pressure:
Cardiac arrhythmias: based on hx and increased sympathetic
discharge
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Interventions: obtain cardiac enzymes, check K+ & Mg+, aggressively
treat MI
GI complications- gastric stress ulceration &
hemorrhage
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GI irritation caused by some neurological drugs (Decadron,
Phenytoin)
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Interventions: Antacids, H2 blockers, Sucralfate, Proton pump
inhibitors. Hgb, Hct and stools should be monitored closely
Endocrine complications
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Diabetes insipidus- caused by the disturbance of the pituitary
gland. Due to the secretioon of an insufficient amount of
ADH. Often self limiting.
 Look for: polydipsia, low UOP, Na+ levels > 145 mEq/L
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Interventions: replace excess UOP with IV fluids or oral fluids,
Desmopresin acetate, Aqueous vasopression
Syndrome of inappropriate ADH (SIADH)
 Look for: high levels of ADH, continually reabsorbed H2)
from the kidney tubules, Na+ < 135 mEq/L, low UOP,
increased weight
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Interventions: Fluid restriction < 1000ml, replace Na+ with
hypertonic saline
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Infection complications
Meningitis- inflammation of the protective barrier over the brain and spinal
cord
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Look for: fever, headache, malaise, photophobia, hemiparesis, altered
mental status, seizures, petichial rash
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Brain abscess- puss that may be encapsulated in the brain tissue usually
related to infection of another body part
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Look for: headache, nausea & vomiting, altered LOC, focal neurological
deficits, seizures, fever, purulent discharge
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Interventions: antibiotics, surgeries such as craniotomy or Burr hole aspiration,
insertion of drains
Wound infection- usually caused by staphylococcal organisms
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Look for: redness and drainage from wound, foul odor from wound,
elevated WBC, fever, warmth and tenderness at site
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Interventions: pathogen-specific broad spectrum antibiotics, corticosteroid
therapy, surgical intervention
Interventions: antibiotics, craniotomy for surgical irrigation & debridement,
prophylactic antibiotics pre-op, intra-op & post-op
Hematological complications
DVTs- deep vein thrombosis. Incidence- 1.6%-4.0%. Causes pulmonary
embolism
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Look for: redness, tenderness, warmth, swelling, positive Homan’s
sign
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Preventative interventions: PROM, early ambulation, sequentials & TEDS, lowdose anticoagulants (Lovenox, heparin, Coumadin)
Interventions: bedrest with elevated affected extremity, heparin drip (PTT 1.52), vena cava filter
Neurologic complications
– Hemorrhage- bleeding into the subdural, epidural,
intraparenchymal, or intraventricular space
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Look for: sudden hemiplegia, depressed LOC, signs and
symptoms of ICP
– Interventions: obtain coagulopathy labs and correct abnormalities,
immediately intervene to prevent irreversible cerebral damage and
death
– Increase intracranial pressure- caused by
hemorrhage, diffused edema, surgical trauma,
hydrocephalus, retraction on brain, interference with
venous drainage, cerebral infarct
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Look for: decreased LOC, headache, papillary abnormalities,
visual disturbances, sixth nerve palsy, hemiparesis, Cushing’s
response (hypertension, respiratory irregularity, bradycardia)
– Interventions: place external ventricular drainage catheter with
drainage, maintain cerebral perfusion, elevate HOB to 30-45 degrees,
Mannitol, hypertonic saline, hypothermia, hyperventilation
– Hydrocephalus
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Look for: mental status changes with lethargy and
confusion, generalized weakness
– Interventions: placement of ventriculostomy to drain CSF,
surgical shunting
– Seizures- may be generalized convulsions or
focal seizure activity
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Look for: hx of seizures, 40% of seizures occur with
tumors in the frontal, temporal, and parietal lobes, 14%
of seizures occur with tumors in the occipital lobe
– Interventions: order CT and basic laboratory profile after seizure
activity, obtain EEG, monitor anticonvulsant level frequently
– CSF Leak
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Look for: rhinorrhea or otorrhea with clear fluid, may
not be at craniotomy site, salty-sweet taste in mouth
– Interventions: bedrest, HOB > 30 degrees, avoid straining,
Diamox, lumbar drain, surgical exploration
Common Post-op Interventions
 Head dressing & incision care–
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Neurological:
Monitor for drainage
Change as needed, usually removed after 24 hours
Monitor incision for signs of infection
Keep staples or stitches dry
 Drains-
– Monitor amounts of drainage
– Maintain patency
– Know location of drain
 Post-op imaging
– Views changes from new tumor, residual tumor, or radiation effects
– CT images postoperative blood or edema
– MRI is baseline scan before treatment with radiation or chemotherapy
Cardiovascular:
 Monitor cardiac rate & rhythm
 Monitor BPs
Respiratory:
 Prevent atelectasis & pneumonia
 Maintain SaO2>94%
 Encourage incentive spirometry q 2 hours at least
Nutrition:
 Begin with clear liquids, advance as tolerated
 Swallow evaluation
 Assess for nausea and vomiting, administer antiemetics as ordered.
Blood Glucose:
 Hyperglycemia disrupts the blood-brain-barrier and increases edema
 Steroids increase blood glucose levels
 Monitor blood glucose levels before meals, at bedtime and as needed, administer
hypoglycemic as needed
IV Fluids:
 Titrate IV fluids down once the patient is taking adequate food and liquids to prevent
fluid overload & potential edema
 Hypertonic solutions are used with patients with fluid restrictions and edemas
 Do not use fluid with dextrose
Activity:
 Early ambulation is important to prevent pneumonia, atelectesis, DVTs, and
deconditioning.
 Physical therapy and occupational therapy consults are strongly recommended
Pain:
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Assess pain every 4 hours using appropriate pain scale
Administer ordered pain medications as needed
Reassess pain up to 1 hour after giving pain medication
Suggest alternative pain relief therapies (deep breathing, music, ice, darken room)
Reference
American Association of Neuroscience Nurses. (2006). Guide to the Care of the
Patient with Craniotomy Post–Brain Tumor Resection. Glenview, IL: Author.
Thank You!
Roxanne Reining
Jenni Polkhamp
Ortho/Neuro Nursing Staff
St. Cloud Hospital