1Traumatic Brain Injury, Brain Tumors & Intracranial Surgery Student ObjectivesAt the completion of this unit, the student will be able to:Discuss the pathophysiology, signs & symptoms, and diagnostic tests associated with brain injury & tumorsExplain the therapeutic interventions and nursing care associated with the care of patients with brain injury & tumors.
2Traumatic Brain Injury Etiology & Pathophysiology The results of TBI range from undetectable to persistent vegetative stateCauses: hemorrhage, contusion, laceration, cellular damageMVA, falls, sports injuries, violence
3Traumatic Brain Injury Etiology & Pathophysiology Classifications of Injuries Define each term (page 1148) 1) Closed Head Injury (nonpenetrating injury) 2) Open head injury (penetrating injury) 3) Acceleration injury 4) Deceleration injury
4Traumatic Brain Injury Etiology & Pathophysiology Define & Describe the following brain Injuries (use page 1148 for help)Concussion:Contusion:
5Brain Injuries: Hematomas Subdural HematomasBleeding is between the dura and arachnoid spaceMay be acute or chronicAcute: symptoms onset within 24 hoursBleeding is most often venousS&S increase in severity as hematoma enlargesOlder adults and alcoholics more prone because of changes in brain tissue
6Brain Injuries: Hematomas Subdural Hematoma S&SsForgetfulness, lethargy, irritability, HAIf hematoma persists or increases in size hemiparesis, pupillary changes, altered levels of consciousnessS&S may be abrupt or gradual depending on the extent of injury and amount of bleeding
7Brain Injuries: Hematomas Epidural HematomaCollection of blood between the dura mater and the skullUsually arterial in nature quicker onset of SXs: seizures, hemiparesis, LOC changes complete unresponsivenessIf ICP is not controlled rapidly permanent brain tissue damage or deathDevelops dilated pupil & paralyzed EOMs on side of hematoma
8Brain Injuries: Hematomas Epidural Hematoma: DiagnosisCT scan: patient usually has multiple injuriesNeurophysiological testing: performed when PT stable; identifies problems with memory, judgment, learning, & comprehension. Rehabilitation strategies are then planned.
9Brain Injuries: Hematomas Therapeutic MeasuresGoal: control of ICP; often require ICP monitoring devices and drainage of CSFOsmotic diuretics: mannitol (Osmitrol) utilize osmosis to pull fluid from tissue into the intravascular space eliminated.Hyperventilation via mechanical ventilator cerebral vasoconstriction less blood flow to head lowered ICP (now controversial)
10Brain Injuries: Hematomas Therapeutic Measures Barbiturate coma: induces therapeutic coma decreased metabolic needs; requires complete care and mechanical ventilation.
11TBI: Complications Brain Herniation Displacement of brain tissue out of its normal locationDisplacement causes lack of function and pressure on other structures.Herniation of brain tissue through the foreman magnum is common and occurs when ICP is not controlled
12TBI: ComplicationsDiabetes insipidus: edema or injury affects the pituitary gland or hypothalamus inadequate release of antidiuretic hormone polyuria & polydipsia Hydrocephalus: Cerebral edema interferes with the circulation of CSF. This may require the insertion of a ventriculoperitoneal shunt drains CSF from the brain to the peritoneum lowered ICP
13TBI: ComplicationsPost-Traumatic Syndrome: Patients report vague symptoms of headache, fatigue, depression, difficulty concentrating, & memory impairment.These symptoms often interfere with work, school and relationships.Neuropsychological testing establishes need for cognitive rehabilitation
14Cognitive & Personality Changes TBI: ComplicationsCognitive & Personality ChangesShort-term memory impairment: limits ability to learn new information, ability to function, & to make judgmentsEmotional Liability: loss of inhibitions. Behavior may become violent, profane, or bizarre disintegration of relationshipsMotor & speech impairments
15TBI: Nursing ProcessData Collection & Assessment: ICP monitoring (review box 48.1, p. 1137), Glasgow coma scale, pupil responses, muscle strength, vital signs.Once patient is stable, neurological damage is assessed: physical/cognitive deficits, neuropsychological testing, rehabilitation needs, referral to appropriate services.
16TBI: Nursing Process: Nursing Diagnosis Risk for ineffective cerebral tissue perfusion related to increased ICPAssess S&S of Increased ICP: posturing, Glasgow coma scale, responses to pain tactile stimuli, LOCReview Measures to prevent increased intracranial preasure (table 48.4, p. 1141)
17TBI: Nursing Process: Nursing Diagnosis Ineffective airway clearance related to reduced cough reflex and decreased LOCRespiratory assessmentsUse discretion: suctioning increases ICPKeep HOB elevated, reduce risk of aspirating oral secretionsTurn frequently to mobilize respiratory secretions and prevent complications of immobility
18Brain Tumors Pathophysiology & Etiology 80 to 90% of brain tumors are primaryTumors infiltrate and invade brain tissueCause is unknownPrimary brain tumors rarely metastasizeBenign tumors may be fatal
19Brain Tumors Pathophysiology & Etiology Common Tumor TypesIntra-axial VS. Extra-axial tumors (Classifications)MeningiomaGlioblastoma multiformeAstrocytomaAcoustic Neuroma
20Brain Tumors Pathophysiology & Etiology Intra-axial TumorsNeoplasms that arise from cells within the cerebrum, cerebellum, or brain stem
21Brain Tumors Pathophysiology & Etiology Meningioma (Extra-axial)Slow growing neoplasms arising for the meningesOccur most commonly in adultsExtra-axial tumor
22Brain Tumors & Intracranial Surgery Pathophysiology & Etiology Glioblastoma (Intra-axial)A malignant and rapidly growing tumor of the cerebrum or spinal cord
23Brain Tumors & Intracranial Surgery Pathophysiology & Etiology Astrocytoma (Extra-axial) Composed of astrocytes & characterized by slow growth and invasion into surrounding structures Complete surgical resection is possible during the early development of it. Astrocyte: a large star-shaped neurological cell with many branches that is found in certain nervous system tissues. Astrocytes
24Brain Tumors & Intracranial Surgery Pathophysiology & Etiology Acoustic NeuromaA benign unilateral or bilateral tumor arising from the vestibulocochlear (VIII) cranial nerve that grows within the auditory canal.Depending on the size of the neoplasm, tinnitus, hearing loss, headache, facial numbness, papilledema, dizziness, and unsteady gait may occur.
25Brain Tumors Signs & Symptoms S&S are related to the location of the tumorCommon symptoms: motor & sensory deficits, visual changes, seizures, headaches, hemiparesisPituitary gland involvement symptoms:
26Brain Tumors Diagnostic Testing MRI: clearest imagesAngiogram: performed when neoplasm lies in close proximity to major blood vesselsIf pituitary gland involvement is suspected, serum hormone levels are evaluated
27Brain Tumors Therapeutic Interventions Medical TreatmentControl symptomsICP and cerebral edemaSeizuresPain controlSurgical TreatmentRemoval of tumor, or of as much of the tumor as possible.
28Brain Tumors Therapeutic Interventions Radiation TherapyStandard treatmentBrachytherapy: a means of delivering radiation directly to a tumor.Stereotaxic radiosurgery: small amounts of radiation are directed at a tumor from different angles.
29Brain Tumors Therapeutic Interventions ChemotherapyStandard chemotherapeutic agents do not cross the blood-brain barrierNew procedures are aimed at delivering chemotherapeutic directly to the brain tumor .Many new procedures being investigatedi.e.: Gene therapy
30Brain Tumors Therapeutic Interventions Difficult to distinguish between symptoms of a brain tumor and complications of treatment.May experience hemiparesis or aphasia following surgery or treatmentPatient gradually becomes comatose with untreatable brain tumors.Nursing care of the patient with a brain tumor is similar to the patient with brain injury.Review p : Nursing Care for the Patient with a Brain Tumor or Injury
31Intracranial Surgery Purpose: to remove a mass or lesion Lesions include: hematomas, neoplasms, diseased brain tissue, arteriovenous malformations, seisure foci, removal of foreign body, or removal of infectious debris/material.
32Intracranial Surgery Procedure Types Burr holes: holes drilled into the skull to drain or irrigate materialsCraniotomy: surgical opening into the skullCraniectomy: removal of part of a cranial boneCranioplasty: repair of cranial bone or the placement of prosthetic bone to repair a cranial defect.Bone flap: refers to the piece of bone that was removed during a craniectomy
33Intracranial Surgery Surgical goal: removal of all of the tumor. Debulking: removal of as much of a tumor mass as possibleAppropriateness of intracranial surgery is dependent upon location of lesion and patient’s condition
34Intracranial Surgery Preoperative Care Routine pre-surgical work ups and evaluationsComplete neurological & cognitive baseline functionManagement of anxiety & fearPatient & family education:Prepare patient and family for ICU environmentMany brain surgeries can last for up to 12 hoursHair is shavedFacial & periorbital edema
35Intracranial Surgery Nursing Process Frequent neurological & routine post-operative assessmentsChanges need to be reported promptlyPlanning depends on the deficits and functional level of the clientPlanning requires an interdisciplinary approach
36Nursing Process: Nursing Diagnoses Intracranial SurgeryNursing Process: Nursing DiagnosesRisk for ineffective cerebral tissue perfusion related to edema at the operative siteRisk for infection related to surgical procedure
37Nursing Process: Nursing Diagnoses Intracranial SurgeryNursing Process: Nursing DiagnosesIII. Knowledge deficit related to treatment regimens
38Brain Tumors & Intracranial Surgery Review QuestionsWhat is the goal of chemotherapy when it is given for an inoperable brain tumor?State two examples of extra-axial tumors that effect neurological functionDescribe a glioblastomaDescribe a craniectomy and a bone flap
39Brain Tumors & Intracranial Surgery Review Questions5) Your patient has had a craniectomy and you note there is a wet mark next to his ear. How do you determine if this wet mark was caused by a CSF leak?6) Why are seizure precautions implemented for a client with a brain tumor?7) List interventions you may offer to help a post-operative craniectomy patient cope with a shaved head.
40TBI Injury Review Questions List measures that can be implemented to prevent increased intracranial pressureList signs and symptoms related to increased intracranial pressureCompare and contrast subdural and epidural hematomas.