Oncologic or Degenerative Neurologic Disorders

Brain tumors

• Benign or malignant

• Classification is based on location and histologic characteristics

• Types of primary tumors

  • Gliomas

  • Meningiomas

  • Acoustic neuromas

  • Pituitary adenomas

• Angiomas: masses of abnormal blood vessels

• Metastatic tumors

Manifestations of 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 → Cushings triad: Bradypnea/ irregular Cheyne-Stokes, Bradycardia, HTN (widened pulse pressure)

  • Headache

  • Vomiting

  • Visual disturbances

  • Seizures

• Hormonal effects with pituitary adenoma

• Loss of hearing, tinnitus, and vertigo with acoustic neuroma

What are the common brain tumor sites and what are the diagnostic evaluation of brain tumors?

• Neurologic examination

• CT scan

• MRI

• PET scan

• EEG

• Cytologic study of cerebrospinal fluid

• Biopsy

Medical management of brain tumors

• 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

Spinal Cord Tumors

• Classified according to their anatomic relation to the spinal cord

  • Intramedullary: within the cord

  • Extramedullary: intradural; within or under the spinal dura

  • Extramedullary-extradural: outside the dural membrane

• 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

  • Antinausea: Zofran

Assessment of the Patient with Nervous System Metastases or Primary Brain Tumors

• 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

Nursing interventions for patient with Nervous System Metastases or Primary Brain Tumors

• 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

• 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

Parkinson’s Disease

• Slow, progressive neurologic movement disorder associated with decreased levels of dopamine

• Manifestations:

  • Cardinal: tremor, rigidity, bradykinesia/akinesia →pill rolling, postural instability

  • Autonomic: sweating, drooling, flushing, orthostatic hypotension, gastric and urinary retention

  • Dysphagia

  • Psychiatric changes: depression, anxiety, dementia, delirium, hallucinations

Assessment of the patient with Parkinson’s Disease

• Focus on the degree of disability and functional changes that occur throughout the day, such as responses to medication

  • Almost every patient with a movement disorder has some functional alteration and may have some type of behavioral dysfunction

• Quality of speech, loss of facial expression, swallowing deficits (drooling, poor head control, coughing), tremors, slowness of movement, weakness, forward posture, rigidity, evidence of mental slowness, and confusion

• Fall risk assessment

Medical management of Parkinson’s Disease

• Treatment directed toward controlling symptoms and maintaining functional independence

• Pharmacologic treatment

  • Levadopa/Cardopa- Sinemet (is combination of both)

  • Table 65-1

  • Surgical procedures

  • Stereotactic Procedures; thalamotomy, pallidotomy

• Neural transplantation

  • Ongoing research

Nursing interventions for Parkinson’s Disease

• Improving mobility

  • Progressive daily program of exercise (stretching, ROM, postural)

  • Consultation with physical therapy

  • Walking techniques for safety and balance

  • Frequent rest periods

  • Proper shoes and use of assistive devices

• Enhancing self-care activities

  • Encourage, educate, and support independence

  • Environmental modifications

  • Use of assistive and adaptive devices

  • Consultation with occupational therapy

• Supporting coping abilities

  • 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

Huntington Disease

• A chronic progressive hereditary disease that results in choreiform movement and dementia → repetitive, unstable movement

• 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)

• Refer to Chart 65-4

Amyotrophic Lateral Sclerosis (ALS)

• “Lou Gehrig disease”

• Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei of the lower brainstem → Upper & lower motor neurons: all over

• Manifestations

  • Progressive weakness and atrophy of muscle cramps, twitching, and lack of coordination

  • Spasticity, deep tendon reflex brisk, and overactive

  • Difficulty speaking, swallowing, breathing

Muscular Dystrophies

• Incurable disorders characterized by progressive weakening and wasting of skeletal and voluntary muscles

• Most are inherited disorders

• Duchenne muscular dystrophy is the most common and inherited as a sex-linked trait

• Common characteristics:

  • Varying degrees of muscle wasting and weakness

  • Abnormal elevation in serum levels of muscle enzymes

Degenerative Disc Disease

• Low back pain is a significant public health disorder and has significant economic and social costs

• Most back problems are related to disc disease

• Degenerative changes occur with aging or are the result of previous trauma

• Radiculopathy produces pain

• Continued pressure may produce degenerative changes in the nerves with resultant changes in sensation and motor responses

• Treatment is usually conservative: rest and medications

• Surgery may be required

Post-Polio Syndrome

• Occurs at least 15 years after polio exposure

• Symptoms include new musculoskeletal weakness, fatigue, and musculoskeletal pain

• Cause is unknown; researchers suspect that with aging or muscle overuse, the neurons not destroyed by the poliovirus continue generating axon sprouts

• No specific medical or surgical treatment available

Assessment of the Patient Undergoing a Cervical Discectomy

• Determining the onset, location, and radiation of pain

• Assessing for paresthesia, limited movement, and diminished function of the neck, shoulders, and upper extremities

• Determine whether the symptoms are bilateral

• Cervical spine palpated to assess muscle tone and tenderness

• Range of motion in neck and shoulders is evaluated

• Health issues

• Mood and stress levels

• Patient education

Nursing Interventions for the Patient Undergoing a Cervical Discectomy

• Relieving pain

• Improving mobility

• Monitoring and managing potential complications

• Promoting home, community-based, and transitional care