Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Seizures and Brain Tumors
Transcript
SEIZURES Jane E. Binetti DNP MSN RN Seizure Disorders Paroxysmal electrical activity in the brain Usually symptomatic of other illnesses Not everyone with seizures have Epilepsy Can be caused by: Metabolic disorders: Electrolyte imbalances, hypoglycemia, hypoxia, ETOH, barbiturate withdrawal, dehydration, water intoxication Organ diseases Seizure Disorders Epilepsy In US >3 million people have it Spontaneous recurrence of seizures Males > females Highest new onset >60 More common in AA and disadvantaged Alzheimer's, stroke have higher risk Parent with Epilepsy Etiology/Pathophysiology Causes by age: 0 - 6 mo most commonly birth/congenital 2-20 can be birth injury, infection, trauma or genetics 20-30 – structural lesions: trauma, brain tumors, vascular disease >50, CVA, and mets to the brain ~30% of seizures are idiopathic! Genetics?? Predisposition?? Astrocytes?? What do you see? Several phases of seizures: Prodromal phase Aural phase Ictal phase Post ictal phase Classified as: Generalized or Partial Symptoms depend on type Generalized Seizures Involve both sides of the brain Loss of consciousness in seconds to minutes Tonic-Clonic Seizures “Gran Mal” seizure – loss of consciousness, stiffening then jerking Cyanosis Hypersalivation Incontinence Generalized Seizures Absence Seizures “Petit Mal” seizures Most common in preadolescent children Peak and wave pattern on EEG Brief staring episodes, or loss of consciousness Precipitated by flashing lights, hyperventilation Generalized Atypical Absence Seizures Brief warning prior, odd behavior during seizure Staring off, and confusion after Other Generalized Seizures Myoclonic Atonic Tonic Clonic Partial Seizures “partial focal seizures” Specific foci in the cortex Sx depend on focal area May evolve to a generalized tonic clonic seizure (secondary generalized) Tonic-Clonic seizures that begin with an aura are typically partial that evolve Todd’s paralysis – secondary generalized Transient post ictal residual weakness Other Partial Seizures Simple Partial Complex Partial Temporal lobe seizures Clouding or loss of consciousness, confusion Automatisms Psychosensory sx: Memory issues Vertigo, auditory and visual distortion, déjà vu Psychogenic seizures Complications Status Epilepticus Rapid recurrence Caused by any type Neurons burn out Subclinical seizures Sedation Epileptics mortality 2-3X greater SUDEP Diagnostics Accurate description and history EEG Within 24 hours of seizure Only small percentage of pts with disorders have abnormal EEG Magnetoencephalography CT, MRI r/o structural lesion Cerebral angiography, SPECT, MRS, PET Bloodwork Accurate classification is crucial Collaborative Care Most seizures are self limiting Pts note occurrence Medical care required if: First episode Bodily injury Prolonged or recurrent Tonic clonic most likely Therapy Cure is not possible, control is the goal 70% of pts controlled by medication Stabilize nerve cell membranes Best control with least side effects 1/3 of pts require combination therapy Serum levels checked and if seizures continue Compliance? Newer drugs, less testing Medications For Tonic/Clonic and Partial Seizures: Phenytoin (Dilantin) Carbamazepine (Tegretol) Phenobarbitol Divalproex (Depakote) Absence and Myoclonic Seizures: Ethosuximide (Zarontin) Divalproex (Depakote) Clonazepam (Klonopin) Other Medications Broad Spectrum for Multiple Seizure types: Gabapentin (Neurontin) Lamotrigine (Lamictal) Topiramate (Topamax) Tiagabine (Gabitril) Levetiracetam (Keppra) Zonisamide (Zonegran) Pregabalin (Lyrica) = add on Felbamate (Felbatol) Treatments regimens Status epilepticus needs IV meds Ativan (lorazepam) or Valium (diazepam) Short acting, for immediate use Long acting Dilantin(phenytoin), Phenobarb, Zarontin (ethosuximide), Lamictal (lamotrigine), Topamax (topiramate) Side effects typically involve CNS Can have rashes, dyscrasias, liver/kidney issues Phenytoin commonly causes gingival hyperplasia and hirsuitism Gingival Hyperplasia and Hirsutism Surgical Treatment Done to control seizures beyond medication Limbic or corpus callosum resection; hemispherectomy Requirements: Confirmed epilepsy Failed drug trial Type of seizures defined Other tx: Vagal Nerve stimulation Ketogenic diet Biofeedback ? What do you do? If your patient is seizing… Assess your patient! What preceded it? When did it occur? How long? Can you denote phases? Is there LOC, stiffening, lack of tone? Note post ictal behavior Do not restrain but ensure safety Protect the head and keep airway patent – suction! Pt/Family Education Educate about management: Compliance, Call 911 if seizure is unrelenting Realize difficulty with restrictions for pts Impact track seizures, f/u appts, side effects to job, Drivers License, stigma Medic Alert bracelets Support groups Nursing Diagnoses Ineffective Breathing Pattern Risk for Injury Ineffective Coping Ineffective Self-Health Management BRAIN TUMORS Jane E. Binetti DNP MSN RN Demographic Info Affect people of all ages, highest in middle age 20,000+ new cases in US yearly Deaths related to Brain Tumors ~13,000/yr 5 yr survival for primary Brain Tumor is ~ 36% Males > Females Caucasian have higher incidence of malignancy AA have higher incidence of benign tumors Brain is a common site of mets What is it? Mass of abnormal cells inside the cranium Cranium is a tight container – no room! Lesions and tumors occupy space Increase ICP Cause cerebral edema Impair blood flow-ischemia Types Brain tumors can be in the brain or spinal cord Primary tumors arise from brain Secondary tumors are metastatic Most common brain tumors are metastatic neoplasms Most common primary metastatic sites are Lung cancer Breast cancer Brain Tumors More than half of brain tumors are malignant Infiltrate and can’t be removed Even if benign, may not be able to be removed Primary brain tumors rarely metastasize outside CNS b/c: Meninges Blood brain barrier Unless treated brain tumors lead to death from tumor volume and IICP Classification of Tumors Primary brain tumors arise from different tissues: Gliomas make up 30+% of all brain tumors 80% of all malignant tumors Types of Gliomas: Glioblastoma - glial cells, typically malignant Astrocytomas - astrocytes, typically malignant Medulloblastoma - typically malignant and aggressive Oligodendroglioma - oligodendrocytes, typically benign More Classification of Tumors Meningiomas from meninges Typically Acoustic Neuromas from myelin sheath Can benign be malignant, most often benign Pituitary Adenomas from pituitary gland Typically benign What do you see? Symptoms will depend on location Headache is a common sx Constant, dull, throbbing Worse at night, insomnia Seizures with gliomas and mets Vomiting from IICP Cognitive dysfunction, memory, mood Muscle weakness, aphasia, temp alterations Hydrocephalus Areas of the Brain Motor activity Decision making, inhibition, motivation, word choice Broca’s area Intellect Calculation, perception, spelling, learned skills, gestures, touch, sensation Visual processing, color, shape, motion Motor speech Reading Memory Memory of facts, events, and language; Wernicke’s; hearing smell and taste Motor control, balance Diagnostics H and P Physical Exam, MRS, MRI, PET, CT, SPECT Angiography - blood flow to tumor Endocrine studies for pituitary Histological sample is reliable dx Stereotactic MIB-1 bx Collaborative Goals Goals are: Identify location and type of tumor Remove or minimize the mass and damage Manage the increased ICP Surgery reduces tumor size, ICP, and reduces symptoms, improves quality of life Open or stereotactic Types of Cranial Surgery Craniotomy Incision into any lobe of the cranium Burr holes and saws to create bone flap Allows for microscopes, drains, implants Stereotactic Frame is used, computer guided Biopsy, tumors, hematomas, ablation Reduced damage to collateral tissue Examples are cyber knife, gamma knife Crani and Stereotactic Collaborative Care Ventricular Shunts Hydrocephalus Catheter with one way valve with one end in lateral ventricle and the other in the jugular vein or the peritoneum Ventricular shunts ICP drained too fast causes headache Pt HOB raised gradually Shunt malfunction IICP – decreased LOC, vomiting, restlessness, HA, blurred vision Shunt revision Infection – high fever, headache, nuchal rigidity Antibiotics Shunt replacement Radiation Radiation Therapy Usually a follow up tx Concern is cerebral edema High dose steroids Stereotactic Radiation High dose radiation to specific site Used for failure of other treatment or locale Pt is typically awake Chemo Chemotherapy Limitations Blood-brain barrier Heterogeneity of tumors Resistance Malignancies can break down blood-brain barrier at tumor sites Types of chemo Nitrosoureas Implanted wafers Ommaya reservoirs Oral and Targeted therapy Temodar (temozolmide) first oral chemo to cross the blood brain barrier Does not interact with anti-seizure meds, steroids and anti-emetics Can cause myelosuppression Targeted therapy Avastin (bevacisumab) – targets endothelial growth factor for vasculature In spite of advancements, outcomes are poor What do you do? Pre-op Assess your patient! GCS – know their baseline Level of consciousness Motor abilities Balance, proprioception Sensory ability, pain response Bowel and bladder Signs of IICP What will you see with IICP Headache Changes in level of consciousness Ocular changes – oculomotor nerve Vomiting Diminished motor function Ataxia, hemiplegia, paralysis, decorticate and decerebrate What else will you do?? Pre-op teaching Do not encourage coughing or valsalva Anti microbial wash, prepare pt to be shaved Prepare pt and family for ICU post-op Address physical and emotional concerns Ensure spiritual support if requested You are not done yet! Post-op Care Assess your pt!!!!! Frequent VS and NS Check dressing Careful monitoring of ICP, F & E Nausea (post-op) and vomiting Careful pain control According to orders HOB at 30 degrees or less If no bone flap – protect the brain! Support patient and family Conscious or unconscious, engage your patient! Outcomes often uncertain Nursing Diagnoses Risk for Ineffective cerebral tissue perfusion Acute pain Self care deficits Anxiety Goals: Maintain normal ICP Maximize neuro functioning Control pain Long term planning Parting Thoughts
