Brain Tumors and Traumatic Brain Injuries: Diagnosis, Symptoms, and Treatment, Exams of Neurology

Download Brain Tumors and Traumatic Brain Injuries: Diagnosis, Symptoms, and Treatment and more Exams Neurology in PDF only on Docsity! BRAIN TUMOR CASE STUDY EXAM LATEST 2024 UPDATE GUARANTEED SUCCESS 1. Brain Tumor Case Study F.N. is a 57-yr WF/ housewife, happily married with grown children and 2 new grandchildren. F.N. made an appointment with her optometrist to explore a progressive OS (left eye) visual loss over a 9-month period. Her eye exam was essentially normal, and the optometrist referred her to a neurologist. After work-up, a 2.5-cm brain mass was found, and surgery was scheduled. PMH HTN on long-acting metoprolol (Toprol XL) 100 mg daily. PSH tonsillectomy and adenoidectomy (T&A) as a child, cholecystectomy, and a total abdominal hysterectomy (TAH) at age 42. She also takes a conjugated estrogen (Premarin) 0.625 mg daily. 1. Name one test that can be done to evaluate for brain tumor. Both and MRI and a CAT scan with and without contrast can help show a brain tumor. 2. Using the term benign when discussing brain tumors is somewhat misleading. Why? A complete cure is not always possible with a brain tumor and it is still a space-occupying lesion that may not be surgically accessible. The benign tumor may continue to grow and cause increased ICP, neurological deficits, herniation, and possible death. 3. Onset of neurologic symptoms is usually insidious, and patients exhibit symptoms in relation to the area of the brain where the tumor is located. List 6 general symptoms associated with many brain tumors. General symptoms include headache, N/V, weakness, impaired gait, speech deficits, vision changes, lethargy, memory loss, personality or behavioral changes, hearing changes, dizziness, facial weakness, of generalized seizures. 4. Corticosteroids, such as dexamethasone (Decadron), prednisone (Deltasone), or methylprednisolone (Solu-Medrol), are commonly prescribed when a tumor is diagnosed and the presence of increase intracranial pressure (ICP) is demonstrated. The drugs are administered preoperatively and postoperatively and in conjunction with radiation and chemotherapy. Why is dexamethasone prescribed, and why should it not be abruptly stopped? Dexamethasone (Decadron) is a long-acting steroid that suppresses immune function. It is given in increased ICP to decrease cerebral edema and reverse symptoms. Abrupt withdrawal can cause adrenal crisis. 5. Other common supportive medications include anticonvulsants, diuretics (including osmotic diuretics), H2 blockers, analgesics, antiemetics, and antidepressants. Indicate why each is used. ◦ Anticonvulsants are used to prevent seizures ◦ Diuretics decrease cerebral edema and ICP - MANNITOL ◦ H2 Blockers prevent or treat ulcers and are usually given with corticosteroids (-TIDINE) ◦ Analgesics control headaches and other pain ◦ Antiemetics are given to control nausea ◦ Antidepressants are given to combat depression 6. Once the diagnosis is made, the patient and family must be involved in the plan for treatment. Treatment depends on the type, grade, and location of the tumor and can include surgery, radiation, chemotherapy, or any combination of these. The patient also has the right to refuse treatment. Identify 4 other factors the medical team, patient, and family would consider in devising a treatment plan. The size of the tumor, prognosis or where the tumor is located, patient’s level of pain, general condition of the patient, surgical accessibility, and presenting S&S. 7. Describe common responses to a diagnosis of a brain tumor. ◦ Extreme stress and anxiety ◦ Profound life changes ◦ Altered self-concept ◦ Responses of anger, denial, sadness, and fear ◦ Grieving ◦ Altered role performance ◦ Social isolation 8. F.N. draws up a living will and health care power of attorney after she hears the diagnosis. She also sits down with her family and makes her wishes known. Why is this important for F.N. in particular and for everyone in general? A brain tumor is a potentially life-threatening disease that may result in great loses of even death. F.N. will be able to make her own life decisions while she is healthy and express her wishes to her family and medical team. 9. You enter F.N.’s room to take VS, and she says, “What if I come out of surgery and I’m different? Or what if I die? My grandbabies will never know me.” You hear the concern in her voice and want to provide realistic reassurance about expected outcomes. Suggest several ways that F.N. can communicate with her loved ones in the event that her surgery is unsuccessful. ◦ She could write letters to her love ones ◦ She could videotape a special message ◦ You can arrange a family meeting to discuss family issues and wrap things up 10. F.N. has the surgery and is admitted to ICU postoperatively. She does very well and remains neurologically intact (neurologic checks every hour). Her BP is slightly elevated (147/68 mm Hg); the rest of her VS are normal; she has 2 PIVs, TED (thromboembolic deterrent) hose, O2 at 4 L by nasal cannula (NC), and a Foley. Postoperatively, F.N.’s potassium (K) is 2.7 mmol/L, and CBG is 202 mg/dl. Describe possible reasons why these 2 laboratory values are abnormal, and identify what treatment will be ordered to correct each. The hypokalemia 2/2 NG loss or dieresis which is induced to decrease cerebral edema. Mannitol causes extreme diuresis that can decrease the K level. F.N needs K replacement. The glucose could be elevated due to steroids, the stress of surgery, or IV fluids. It will be necessary to monitor CBG and give IV insulin to titrate the glucose down. An ischemic stroke like this patient experienced was not due to a ruptured brain vessel but due to a lack of normal blood flow in the cardiovascular system. Following diagnosis, Mrs. Gonzalez is set up to receive IV recombinant tissue plasminogen activator (rtPA); the nurse is to administer a bolus dose and then Mrs. Kennedy will receive the rest of the dose over the course of the next hour. 7. Explain how rtPA works to manage ischemic stroke. tPA works by affecting the clotting factors and other components involved with the clot that is most likely was the cause for the ischemic attack. Tissue plasminogen activator (tPA) is already a common protein in the lining of blood vessel which help break down clots. 8. What is the criteria for receiving rtPA? Less than 3.5 hr onset of initial symptom, (-) Hx of bleeding (-) HTN 9. Based on the mechanism of action (MOA), what factors would prevent Mrs. Kennedy from being a candidate for receiving rtPA as treatment? If she had any bleeding disorders, ulcers, on blood thinners, or uncontrolled HTN then these are some things that would prevent her from being a candidate for this treatment. 10. What s/s indicate a (+) outcome that the rtPA has been effective as treatment for Mrs. Kennedy’s stroke? Her BP should decrease from her baseline taken upon coming to the hospital and there should be no signs of cardiovascular complications including chest pain and tachycardia. HTN should decrease from her baseline taken upon coming to the hospital and there should be no signs of cardiovascular complications including chest pain and tachycardia. 11. What s/s would indicate that further treatment is necessary? If has a TIA or complains of chest pain, then it may mean the patient needs more treatment or needs to be tested further. Furthermore, if she begins to have weakness in other parts of her body and not just the one side then it could mean there is still poor blood flow and should be addressed. CS1. An 85-yr WF w/ PMH HTN, DM, CKD, CHF, and hypothyroidism is admitted with status post ground level fall (blunt injury). She is brought into the ED on a non-rebreather via EMS. Upon initial exam you find that the patient has a small laceration over her right eye, but no obvious signs of skull fracture or penetrating injuries. 2. Based on this presentation the information presented on the patient and traumatic brain injuries, what type of mechanism of injury (MOI) does she have? A. Blunt (2/2 post ground level fall) B. Penetrating C. Blast When you assess the patient, you find that she has a Glasgow Coma Scale (GCS) of 13 (E3, V4, M6) with no focal neurological deficits. The patient has a 3mm laceration over her right eye. 3. She has a Glasgow Coma Scale (GCS) of 13 (E3, V4, M6) with no focal neurological deficits. Which classification of brain injury does she have? A. Mild 13-15 B. Moderate 9-12 C. Severe 3-8 The patient was diagnosed with basilar skull fracture (primary head injury) and is now complaining of a headache and is impulsive, attempting to get out of bed despite being told multiple times that she needs to have someone assist her when getting out of bed because of her risk of falling. She is oriented to person and place, but not to time or situation continuing to ask to get up to let her dog out and complains that it, “smells like rubbing alcohol in here”. When you ask her to please sit down, she smiles and gets back in bed. 4. Your patient has a GCS of 13 and unable to stick out her tongue. What is the most likely basilar skull fracture associated with this deficit? A. Anterior (70% case, CN I injury, Raccoon eyes & rhinorrhea) B. Middle (weak vault, CN II injury, Battle signs & otorrhea) C. Posterior (uncommon, CN IX, X, XI, XII injury, clivus or occipital bone fx) CS2. Which of the following patients is most likely to survive a penetrating head injury? A. An 85-yr female was at the park walking her dog and was stabbed several times in multiple areas of her head. She was found 4-hr later lethargic with unequal pupils and minimal movement. B. A 26-yr male suffered a self-inflicted gunshot wound to the face last night and was found by his family this morning breathing, but not opening his eyes despite aggressive attempts to awaken him. (less likely to survive) C. A 42-yr man about 1 hour ago, had a witnessed ground level fall landing on a steel rake that penetrated the left side of his head. He is awake and following commands. CS3. The patient is a 35-yr HF in the Neuro ICU status post motor vehicle crash (MVC). She suffers from the following injuries: traumatic right temporal intracerebral hemorrhage (ICH), a traumatic subarachnoid hemorrhage (SAH), right 3-6 rib fractures, and a right radial fracture that has been reduced and splinted. Your patient’s VS this morning are as follows: Temp 98°F, HR 116 bpm, BP 88/54 mmHg, RR 18 breaths/minute, Pulse ox 97% on 2 Liters/minute nasal cannula (NC). The patient has no PMH ◦ GU: no signs of trauma; no discharge or lesion present ◦ Integumentary: Scattered ecchymosis on limbs and trunk; no open wounds ◦ Neurologic: Eyes open to noxious stimuli, no verbal response, withdraws to pain in upper extremities and flexes to pain in lower extremities ◦ CN: Pupils equal and brisk, corneal reflex and VOR intact, grimace to pain equal bilaterally, gag intact ◦ Motor: withdraws to pain in upper/lower extremities ◦ Sensory: Responds to painful stimuli in all four extremities ◦ Cerebellar: Patient unable to cooperate with exam ◦ Reflexes: normal reflexes in all 4 extremities 3. What is the GCS Score for this patient? Eyes open to noxious stimuli, no verbal response, withdraws to pain in upper extremities and flexes to pain in lower extremities a. 3 b. 5 c. 7 (2E, 1V, 4M) After your assessment is completed, that patient develops generalized convulsive activity concerning for a generalized tonic-clonic seizure. The provider orders 4 mg of lorazepam (Ativan- benzo/BZDs) and 1000 mg of levetiracetam (Keppra, anti- SZ). The patient’s airway is at risk during the seizure and the patient is emergently intubated (ETT) by the provider. Because the seizure activity is not completely ceased by the initial medications, a propofol (Diprivan, general anesthesia) infusion is started. Visible seizure activity ceases after initiation. A CT brain is ordered by the provider to assess the type of injury sustained in the MVC and different advanced neurologic monitoring modalities are being considered. The CT scan is completed and the patient is accepted by the Neuro ICU team. The patient is brought up to the ICU and a handoff of care is given at bedside between the ED and ICU nurses. The radiology CT brain report states a right frontal intraparenchymal hemorrhage (IPH) with posterior occipital contusion. Vasogenic edema and midline shift is seen. The patient is started on hypertonic saline (3%) for the edema. The decision is made with the medical team to place a ventriculostomy for ICP monitoring and CSF drainage. Due to her INR of 3.1 she was reversed prior to placement of ventriculostomy. After placement of the drain, continuous EEG is placed. 4. What is the best description of the injury described by the CT report (right frontal intraparenchymal hemorrhage (IPH) with posterior occipital contusion)? a. Right frontal IPH represents coup, and occipital contusion represents contrecoup b. Occipital contusion represents coup, and right frontal IPH represents contrecoup 5. What is the purpose of implementing continuous EEG monitoring for this patient? a. Monitor for cerebral edema b. Capture electrical impulses from neuroglial cells c. Assess for subclinical seizures (Because of the patient’s previous seizure, EEG is placed to monitor for subclinical seizure activity. The Propofol infusion can be titrated based upon the EEG results). d. Monitor vital signs 6. The ICP is 18 recorded on the monitor for the external ventricular drain (EVD). While suctioning, the ICP increases to 26 while coughing. The ICP returns to 18 two minutes after coughing completed. What is the best nursing intervention? A. Drain extra CSF to prevent further ICP spikes B. Notify the MD for need for mannitol to rapidly decrease ICP C. Nothing, these transient increases in ICP are normal Many normal activities can increase ICP, such as coughing, bearing down, or repositioning. It is important for the nurse to monitor that the patient’s ICP returns to baseline immediately following interventions. Sustained increases in ICP > 5 minutes are cause for further intervention. 7. Which of the following treatments are used for intracranial hypertension? a. Mannitol ( ↓ cerebral edema), vasopressin, hypertonic saline ( ↓ cerebral edema), propofol b. Hypertonic saline, hypothermia ( ↓ cerebral metabolism), mannitol c. Propofol, lorazepam, magnesium, hypertonic saline d. Hypertonic saline, phenylephrine, phenytoin 8. Basic treatment for brain injury includes: a. ABCs, head of bed elevation, fever management, trend of neurologic assessment b. Hypothermia, hypercarbia, hypoxia c. Administer D50, hypocapnia, paralysis d. 100% oxygen delivery, head of bed 15, fever management, trend of neurologic status 9. The patient exhibits HTN, bradycardia, & irregular respirations. This patient exhibits which of the following: a. Uncal herniation b. Cushing’s triad c. Horner’s syndrome d. Cingulate herniation An 80-yr female patient who was brought to the ICU following a MVC. PMH atrial fibrillation on Warfarin, DM, CKD and CHF. Throughout her ICU stay she has been intubated for respiratory distress, had an ICP monitor placed to manage her intracranial pressures and an insulin drip to manage her diabetes. She has been stable hemodynamically and neurologically for 24 hours and it is now time to consider her transfer to a step-down unit. Her functional abilities both mentally and physically need to be evaluated at this time, if they have not already, by PT and OT. A thorough evaluation of the patient’s post-acute care needs will then need to be coordinated with the Case Manager to arrange for the patients ongoing rehabilitation and recovery (SNF). 5. Post-concussion syndrome 21-yr college WF w/ no PMH was seen at ED after she hit her head against the door frame when she tried to get in the car. (+) parietal HA as constant, sore in nature, 4/10, not associated with N/V/confusion/vision changes or neck pain. (-) CT brain for hemorrhage. Pt was D/C from ED with instruction such as lie down in a dark room, avoid anything requiring strenuous thought, returning to ED with worsening symptoms such as worsening HA, N/V, dizziness, agitation/ irritability, etc. Pt was instructed to not to drive home by herself due to concussion. Pt did not go to school afterwards, still have headache, unable to focus, fatigue, feeling depressed, photophobia, and phonophobia. It lasts for 1-week and gradually resolved. Surgery can also be done to transplant fetal neural tissue into the basal ganglia, this can help provide DA producing cells. 9. Because L.C. is reporting that his gait is more unsteady, there is an increased risk for falls. Which suggestion could you offer to diminish this risk? a. Only use a wheelchair to get around. b. Stand as upright as possible and use a walker. c. Keep the feet close together while ambulating. d. Consciously think about walking over imaginary lines on the floor. 10. What are three nutritional interventions that should be implemented for L.C.? • Increases fiber (fruits and vegetables) intake can help with constipation and boost vitamins and minerals in the body • Increase water intake, limiting caffeine and alcohol consumption, ensuring L.C is well hydrated can help combat muscle cramps • Eating dark leafy green vegetables which are high in can help reduce the number of free radicals in the body and possibly slow the progression of PD. Parkinsonism, a disorder of the basal ganglia, is characterized by destruction of the nigrostriatal pathway, with a subsequent reduction in striatal concentrations of dopamine. This results in an imbalance between the inhibition and excitation. The disorder is manifested by resting tremor, increased muscle tonus and rigidity, slowness of movement, gait disturbances, and impaired autonomic postural responses. The disease usually is slowly progressive over several decades. The tremor often begins in one or both hands and then becomes generalized. Postural changes and gait disturbances continue to become more pronounced, resulting in significant disability. Critical Thinking Questions: 1. Define meningitis? What are the different types? Which one is common? Meningitis is an inflammation of the meninges surrounding your brain and spinal cord. The different types are viral and bacterial meningitis: Hib meningitis-caused by H. influenza type b (Hib) bacteria, Meningococcal meningitis-caused by Neisseria meningitides bacteria, Pneumococcal meningitis-caused by streptococcus pneumoniae bacteria. 2. What are the risk factors for meningitis for this client? Risk factors for meningitis for this client is skipping vaccinations. Viral meningitis occurs in children < age 5. Bacterial meningitis is common in < age 20. Living in a community setting (college students, military bases, children in boarding school). Pregnancy and compromised immune system (AIDs, diabetes, immunosuppressant). 3. Which clinical manifestations are essential for the nurse to note at this time? “bad” headache pain, nausea, vomiting & neck tightening. 4. What additional assessment data should the nurse obtain? Background information and how long symptoms has presented. Monitor neurological status and vital signs for decompensation. 5. What diagnostic findings differentiate meningitis from encephalitis? (+) Brudzinki and Kernig’s sign. 6. What classes of medications would most likely be prescribed for a client with acute bacterial meningitis and identify 2 nursing implications for each medication listed (e.g., Verify allergies, assess renal and hepatic function (if risk for toxic effects on these systems)? IV/PO abx, monitor for allergies and assess the type of organism. Corticosteroids monitor for BP, weight and ABG’s. 7. Explain essential nursing interventions pre/post- lumbar puncture. Monitor fluid leakage, color, consistency, smell. Monitor for signs of infection. Cleansing skin before procedure. Sterile technique is needed. Educate patient to stay still for procedure and minimize movement. Administer pain medication prior to procedure if unable to tolerate. 8. Identify priority nursing diagnoses for this client. Disturbed sensory perception related to cerebral edema or increased intracranial pressure as evidence by altered sensorium. Acute pain related to meningeal irritation as evidenced by headache and neck stiffness. 9. Identify nursing interventions according to priority. Maintain patency of airway. Monitor neurological status of patient. Monitor vital signs and oxygenation. Administer pain medication for pain control. Glasgow coma scale to measure motor, verbal and sensory cues related to LOC. Acute pain related to meningeal irritation as evidenced by headache and neck stiffness. 10.How would you, as the nurse, evaluate the effectiveness of your nursing interventions? Pain level decrease, symptoms subside by (-) HA. Lab results/culture WNL. Pupillary response and (-) Brudzinki and Kernig’s sign. 11. If the initial interventions were not effective, what addition interventions would you implement? Pain management consult, administer oxygen for low saturations. Notify provider if worsening signs of symptoms. Prescribe antibiotics to decrease infection 7. Intracranial Regulation - Hydrocephalus You admit L.M., a 2-month-old girl with a history of hydrocephalus and ventriculoperitoneal (VP) shunt placement 1 month earlier. Her parents report that she has been more irritable than usual and for the past 3 days has fed poorly and has had emesis five or six times every day. 1. Explain the pathophysiology of hydrocephalus and cerebrospinal fluid (CSF) imbalance. Hydrocephalus happens when there is too much CSF in the brain. This happens when the ventricles fail to absorb enough CSF. The ventricles make and absorb the CSF but when they cannot absorb the proper amount an abundance is left over and hydrocephalus begins to happen. 2. Explain how the placement of a VP shunt helps the patient. Hydrocephalus is the accumulation of CSF in the ventricles of the brain. When A VP shunt is put in place it facilitates drainage of the CSF out of the ventricles and into the peritoneal compartment when it can now be absorbed. This will decrease intracranial pressure in the brain by preventing the buildup of CSF. 3. You get L.M. settled on the unit and promptly perform her admission assessment. Your assessment includes the following findings. Select the abnormal findings and state a possible rationale for each. System Assessment and Vital Signs Identify what is abnormal State Rationale Weight 4.5 kg Neurologic • Irritable, awake, and fussy; difficult to console • FOC: 44 cm, “increased 2 cm from measurement yesterday” per mother • Anterior fontanel slightly bulging • Unable to palpate posterior fontanel The patient has increased ICP. Due to slightly bugling anterior fontanel, being fussy, increased FOC, and being unable to palpate the posterior fontanel.