Transcript A Case Study of a Patient with Brain Tumor Presented by

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Name:
Age:
Sex:
Nationality:
Date of Admission:
Diagnosis :
Patient X
76years old
Male
Saudi
27/09/2012
Brain Tumour
Central Nervous System
 Upon
admission LOC: Vegetative state, GCS:
Eye-4 Verbal-1 Motor-1 = 6. Pupil Size of 23mm (both pupils), Language and
communication: unable to talk , not able to
follow simple commands. Not responsive to
both verbal and physical stimuli, positive
seizure episode.
Cardiovascular System
 Vital
signs: BP: 101/68mmHg, HR: 72bpm, T:
36.4 degree Celsius, O2 sat 96-98 %. With no
neck vein enlargement, Pink mucus
membrane noted, (-) heart murmurs,
Capillary Refill: 2-3 secs. Full and equal
peripheral pulses, No edema noted, No
cyanosis.
Respiratory System
 Symmetric
chest expansion, no retractions,
clear breath sounds, No nasal flaring
 . . Breathing pattern is regular and not in
respiratory distress. With mild white
Secretions noted upon suctioning.
Gastrointestinal System
 With
nasogastric tube inserted on right
nostril intact and patent, Flabby, soft, nontender abdomen, With normoactive
abdominal bowel sounds (15 per minute). On
Ensure plus 200ml plus 100ml of water per
flushing.. Bowel pattern of every other day
or every after 3 days (fleet enema). Stool is
semi solid in moderate amount. No
abdominal pain
Urinary System
 He
was on foleys catheter before and
currently on condom catheter via urine bag
draining well with straw colour urine output.
No bladder distension with Urine output of
1,400 – 1,900ml in 24 hours. No urgency nor
dysuria noted.
Integumentary System
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Fair in complexion with good skin turgor, with a wrinkled
skin due to loss of elastic fiber and decreased
subcutaneous fat from hypodermis secondary to aging. skin
integrity is intact, dry and warm skin. With no active
dermatosis, no evidence of impending decubitus formation
noted. No edema and No IV access. With bedsores on both
buttocks stage 3 which means full thickness skin loss
involving damage or necrosis of subcutaneous tissue, which
may extend down to but not through underlying fascia. The
ulcer presents clinically as a deep crater with or without
undermining of adjacent tissue. Tunneling, granulating,
epithelization and exudates purulent discharge. Length of
3.1cm, width of 3cm and depth of 0.5cm
Musculoskeletal System
 Patient
is on complete bed rest, Turning is
done every 2 hours with Hours of sleep: 2-3
hours, interrupted during feeding.. unable to
move with Muscle Strength of 1/5( both
upper extremities and both lower extremities
muscle contraction is noted but no
movement occurs. The muscle is not strong
enough to lift the particular body part
against gravity or move it when in a gravity
reduced position). unable to turn side-to-side
Past Medical History
 Patient
X who have been known to have
DM,HTN,brain tumor in right temporal area
with craniotomy on chemotherapy treatment
was shifted from RMH to AAHon 28/06/2012
for long term treatment.On admission
patient is receving food and medicine orally.
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Present Medical History
Patient X is now admitted here in Dr.Abanamy
Hospital for long term nursing care and
management. Currently, he is on NGT (naso
gastric tube).On admission patient was
conscious,GSC 13/15 ,disoriented.His vital signs
are stable.He is on cap.phenytion 200mg
bid,clonazepam,atenolol,NPH insulin. Radiation
completed.Due to general weakness and
detoriation chemotherapy was discontinued.
Past surgical history:
 Patient undergone craniotomy
on16/09/2012, due to epidural hematoma.
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BRAIN TUMOR
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It is a abnormal proliferation of cells in the central
nervous system.A tumour is a mass of cancerous cells
with in the brain.
Brain tumors include all tumors inside the cranium or
in the central spinal canal. They are created by an
abnormal and uncontrolled cell division, usually in
the brain itself, but also in lymphatic tissue, in blood
vessels, in the cranial nerves, in the brain envelopes
(meninges), skull, pituitary gland, or pineal gland.
Within the brain itself, the involved cells may be
neurons or glial cells (which include astrocytes,
oligodendrocytes, and ependymal cells). Brain tumors
may also spread from cancers primarily located in
other organs (metastatic tumor.
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 The
cranium
 The brain is protected by a bony covering
called the cranium (which, along with the
bones of the face, make up the skull). Inside
the cranium, the brain is surrounded by the
meninges. The meninges is made up of 3
layers of tissue
 The
cerebrum
The largest part of the brain located in the
front. It is responsible for movement, body
temperature, touch, vision, hearing,
judgment, reasoning, problem solving,
emotions and learning.
 The
brainstem
 The brainstem is located in front of the
cerebellum in he middle of the brain. It is
the main control panel for the body that
passes messages back and forth between the
brain and other parts of the body. The
cerebrum, the cerebellum, and the spinal
cord are all connected to the brainstem.
 The
cerebellum
 Behind the cerebrum at the back of the head
is the cerebellum. The cerebellum is
primarily a movement control center,
responsible for voluntary muscle movements,
fine motor skills, maintaining balance,
posture, and equilibrium. Unlike the
cerebrum, the
Cranial nerves
 The brain also contains 12 pairs of cranial nerves
each responsible for specific functions in the body:
 Olfactory nerve – smell
 Optic nerve – vision
 Oculomotor – eye movements, eyelid opening
 Trochlear – eye movements
 Trigeminal – facial sensations, chewing
 Abducens – eye movements
 Facial – taste, facial expressions
 Vestibulocochlear – hearing, balance
 Glossopharyngeal – taste, swallowing
 Vagus – swallowing, taste
 Accessory – neck and shoulder muscles
 Hypoglossal – tongue movement
Medulla Oblongata
 Located above spinal cord. It regulates vital
functions, such as heartbeat and breathing.
The Medulla Oblongata is responsible for
coughing, sneezing, vomiting, salivating,
swallowing, gaging
 Spinal
Cord
This structure is responsible for basic vital life
functions such as breathing, heartbeat, and
blood pressure.
Anterior frontal lobe
 Long/short term memory loss
 Difficulty in problem solving/concentrating
and calculating
 Slowness of reaction
 Behavioural changes
 Emotional liability
 Loss of social behaviour
Posterior frontal lobe
 Fluent speech deficit
 Difficulty with word findings
 Motor weakness
 Focal seizure activity
Parietal lobe
 Deficit in sensation
 Inability to recognise common
object/numbers/letters
Temporal lobe
 Psychomotor deficits
 Weakness
 Seizures
 Visual field deficit
 Memory deficit
 Hallucination
 Amnesia
Occipital lobe
 Visual deficit
 Visual hallucination
 Unable to follow commands
Hypothalamus region
 Visual deficit
 Head ache
 Acromegaly
 hypopituitarism
lateral and third ventricle
 head ache
 nausea
 vomiting
 increase ICP
Fourth ventricle
 head ache
 nausea
 vomiting
 increase ICP
 ionizing
radiation: from high dose xray(radiation therapy)cause cell damage.
 Family history: people with various inherited
diseases such as multiple endocrine
neoplasia,neuro fibromatosis are high risk of
developing brain tumour.
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Aside from exposure to vinyl chloride or ionizing
radiation, there are no known environmental factors
associated with brain tumors. Mutations and
deletions of so-called tumor suppressor genes are
thought to be the cause of some forms of brain
tumors. People with various inherited diseases, such
as Von Hippel-Lindau syndrome, multiple endocrine
neoplasia, neurofibromatosis type 2 are at high risk
of developing brain tumors.
Although studies have not shown any link between
cell phone radiation and brain tumors,[4] the World
Health Organization has classified mobile phone
radiation on the IARC scale into Group 2B – possibly
carcinogenic. That means that there "could be some
risk" of carcinogenicity.
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Due to etiological factor
Like chemical and radiation Exposure.
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Irritation and damage to brain cells
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Changes in cell morphology
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DNA gene mutation
Inactivation of tumor suppressor and activation of
oncogenes
Un controlled cell division and decreased apoptosis.
Hyperplasia of the brain cells
Brain tumour.
TYPES
 Tumors can be benign or malignant, can occur
in different parts of the brain, and may or may
not be primary tumors. A primary tumor is one
that has started in the brain, as opposed to a
metastatic tumor, which is something that has
spread to the brain from another part of the
body.[6] The incidence of metastatic tumors are
more prevalent than primary tumors by 4:1.
 [7] Tumors patient has symptoms, others show up
incidentally on an imaging scan, or at an
autopsy.
The most common primary brain tumors are:
 Gliomas(50.4%)
 Meningiomas(20.8%)
 Pituitary adenomas(15%)
 Nerve sheath tumors(8%)
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BrainTumor are classified as grade
1,2,3and4. Most common type of primary brain
tumours among adults are menigioma and
astrocytoma.
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For children Meduloblastoma grade 1 or 2
,astrocytoma,ependymoma.
The symptoms of brain tumors depend on their size and location in the
brain. Symptoms often are caused by damage to vital tissue and pressure
on the brain as the tumor grows within the limited space in the skull.
They may be caused by swelling and a buildup of fluid around the tumor,
a condition called edema. Symptoms also may be due to hydrocephalus,
which occurs when the tumor blocks the flow of cerebrospinal fluid and
causes a build-up in the ventricles.
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If a brain tumor grows very slowly, its symptoms may not appear for some
time. The most frequent symptoms of brain tumors include:
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Headaches that tend to be worse in the morning and ease during the day
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Seizures or convulsions
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Nausea or vomiting
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Weakness or loss of feeling in the arms or legs
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Stumbling or lack of coordination in walking
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Abnormal eye movements or changes in vision
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Drowsiness
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Changes in personality or memory
 Changes
in speech
 Double vision
 Hearing loss
 These symptoms may be caused by brain
tumors or by other problems. Diagnostic tests
can be performed to determine if the cause
of your symptoms is a brain tumor and if it is
a primary or secondary one .
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When a brain tumor is
diagnosed, a medical
term will be formed to assess the treatment options
presented by the leading surgeon to the patient and
his/her family. These various types of treatment are
available depending on neoplasm type and location
and may be combined to give the best chances of
survival:
Surgery:complete or partial resection of the tumor
with the objective of removing as many tumor cells
as possible.
Radiotherapy:the most commonly used treatment for
brain tumors ;the tumor is irradiated with beta,x
rays or gamma rays.
Multiple meastatic tumors are generally treated with
radiotherapy and chemotherapy rather than surgery
and the prognosis in such casese is determined by the
primary tumor,but is generally poor.
 Give
well education regarding the
medication that the patient is receive.
 Control and management of side effects
during the administration of chemotherapy
agents.
 Control of
nausea,vomiting,stomatits,alopecia and
anorexia.
 This are the most common side effects of
chemotherapy.
 Prior
to starting radiation inform patient and
family about the various activities that will
occur during the administration of radiation.
 Provide proper skin care to radiation site.
 Administer anti emeitics.
 Manage anorexia.
 Note the result of CBC with WBC and
platelet counts.
 Provide emotional support.
 Drug
SD.docx
Prognosis greatly depends on all of the following
extent of the disease
Types of tumour
 size and location of the tumour
 presence or absence of metastasis
 Tumour response to therapy
 your age,over all health and medical history
 your tolerance of specific medications,procedures
or therapies
 new development in treatment
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CT Brain
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MRI
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EEG
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BIOPSY OF TUMOR
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LUMBAR PUNCTURE
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MYELOGRAM
 Assess
and moniter ABG
 Identify the signs and symptoms like
headache,vomiting,double vision.
 Changes in sensation.
 Observation of vital signs and level of
consciousness.
 Observation of fluid and electrolyte balance.
 Moniter continue vitalsigns.
 GCS scale.
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Acute pain related to brain mass,surgical intervention
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Risk for injury related to altered LOC,possible seizure,increased
intra cranial pressure,sensory and motor deficits.
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Imbalanced nutrition less than body requirement related
compromised neurologic function and stress of injury
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Acute pain related to increased ICP
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Disturbed body image related to hair loss secondary to radiation
therapy
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Ineffective tissue perfusion related to circulatory damage caused
by tumor suppression.
Providing analgesics
 Place the patient in a upright position to reduce
cerebral venous congestion
 Alter diet as tolerated, if patient has pain on
chewing .
 Provide a darkened room or sun glasses if the
patient is photophobic.
 Maintain a quiet environment to increase patient
pain tolerance.
 Maintain the head of the bed at 15-30* to
reduce cerebral venous congestion.
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 weakness
 Neurologic
deficits from expanding tumour
or treatment.
 Vision changes
 Headache
 Hearing loss
 Seizure.
 Increased ICP and brain herniation ;death
 ncp1.docx
 ncp2.docx
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Explain the importance of continuing
corticosteroids and how to manage adverse effects,such
as weight gain and hyperglycemia.
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Encourage the use of community resources for physical and
psychological support,such as transportation to medical AP
(Poinm, Ents,financial assistace and respite care.
Explain the adverse effects of treatment.
Encorage close follow up after diagnosis and treatment.
Remain the patient/family about the importance of
following medication regimen.
Reduce the environmental stimulation.
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This is a case of 72 yrs old male with the diagnosis of brain
tumor.A tumor is a mass of cancerous cells with in the brain.
For patients diagnosed with brain cancer, new antiangiogenic
treatments are dramatically altering the way this disease is being
treated. While bevacizumab is presently the only FDA approved
angiogenesis inhibitor for brain cancer, other drugs are in late
stage clinical trials and some are being used in the clinic in
patients who have stopped responding to front-line treatments.
Improved outcomes with antiangiogenic therapies are now
common, compared to the harsher, less effective treatments of
the past. Therapies that block the growth of tumor blood vessels
give patients reason for hope and optimism.
It is important for patients and their families to remember that
clinical trials are an important cutting edge cancer therapies.
Clinical trials also contribute to the advancement of medical
knowledge that can benefit future generations.
BIBILIOGRAPHY
nursingfile.com/.../nursing-interventions-for brain
tumor.
 www.nhlbi.nih.gov/health/prof/lung/ brain
/nurs_gde.pd
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www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001196
www.medicinenet.com/ /article.htm
Murray, J. and J. Nadel. Textbook of neurological
disorders. Third edition.
Philadelphia: W.B.
Saunders Company, 2000.
Lippincott manual practice 9th edition page no:558564.
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