Chapter 65 Management of Patients with Oncologic or Degenerative Neurologic Disorders

1. Chapter 65 Management of Patients with Oncologic or Degenerative Neurologic Disorders

2. Pathophysiologic Results of Neurologic Oncologic Disorders • Manifestations depend upon the tissues infiltrated and compressed by the neoplasm • Pathophysiologic events may include: • Increase ICP • Seizures • Hydrocephalus • Altered pituitary function

3. Oncologic Tumors • Brain tumors • Benign or malignant • Classification is based upon location and histological characteristics • Types of primary tumors • Gliomas (arises from glial cells) • Meningiomas • Acoustic neuromas (tumor of the eighth cranial nerve) • Pituitary adenomas • Angiomas—masses of abnormal blood vessels • Metastatic tumors

4. Brain Tumors • Symptoms are dependent upon the location and size of the lesion and the compression of associated structures • Manifestations: • Localized or generalized neurologic symptoms • Symptoms of increased ICP • Headache • Vomiting • Visual disturbances • Hormonal effects with pituitary adenoma • Loss of hearing, tinnitus, and vertigo with acoustic neuroma

5. Diagnostic Evaluation • Neurologic examination • CT scan • MRI • Cytological study of cerebral spinal fluid • Biopsy

6. Medical Management • Specific treatment depends upon the type, location, and accessibility of the tumor • Surgery • Goal is removal of tumor without increasing neurologic symptoms or to relieve symptoms by decompression • Radiation therapy • External beam radiation • Brachytherapy • Chemotherapy

7. Spinal Cord Tumors • Classified according to their anatomic relation to the spinal cord • Intramedullary: within the cord • Extramedullary: extradural; outside the dural membrane • Manifestations include pain, weakness, and loss of motor function, loss of reflexes, loss of sensation • Treatment depends upon type of tumor and location • Surgical removal • Measures to relieve compression: dexamethasone combined with radiation

8. Parkinson’s Disease • Associated with decreased levels of dopamine due to destruction of cells in the substantia nigra in the basal ganglia; this effects the neurotransmission of impulses • Manifestations: tremor, rigidity, bradykinesia, postural instability, depression and other psychiatric changes, dementia, sleep disturbances, • Medical management • Pharmacologic treatment • Surgical procedures • Other therapies

9. Pathophysiology of Parkinson’s Disease

10. Treatment • Levodopa • Anticholinergics • Amantadine hydrochloride (antiviral) • Monoamine Oxidase Inhibitors (inhibit dopamine breakdown)

11. Nursing diagnosis • Impaired physical mobility related to muscle rigidity and motor weakness • Self-care deficits (feeding, dressing, hygiene, and toileting) related to tremor and motor disturbance • Constipation related to medication and reduced activity • Imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing • Impaired verbal communication related to decreased speech volume, slowness of speech, inability to move facial muscles • Ineffective coping related to depression and dysfunction due to disease progression

12. Alzheimer's Disease • The most common cause of dementia • A chronic, progressive, degenerative brain disorder that effects 4.5 million people in the United States • Research suggests oxidative stress plays a role in the pathophysiology of this disease

13. Degenerative Disk Disease • Most back problems are related to disk disease. • Degenerative changes occur with aging or are the result of previous trauma. • In herniation of the intervertebral disk (ruptured disk), the nucleus of the disk protrudes into the annulus (the fibrous ring around the disk), with subsequent nerve compression. • Continued pressure may produce degenerative changes in the nerves with resultant changes in sensation and motor responses.

14. Normal Spinal Vertebral and Ruptured Vertebral Disk

15. Clinical Manifestations • A herniated disk with accompanying pain may occur in any portion of the spine: cervical, thoracic (rare), or lumbar. • The clinical manifestations depend on the location, the rate of development (acute or chronic), and the effect on the surrounding structures. • Low back pain with muscle spasms, followed by radiation of the pain into one hip and down into the leg (sciatica). • Paresthesia

16. Management • Treatment is usually conservative—rest and medications. • Surgery may be required. • Discectomy: removal of herniated or extruded fragments of intervertebral disk • Laminectomy: removal of the bone between the spinal process and facet pedicle junction to expose the neural elements in the spinal canal; this relieve compression of the cord and roots • Hemilaminectomy: removal of part of the lamina and part of the posterior arch of the vertebra • Partial laminectomyor laminotomy: creation of a hole in the lamina of a vertebra

17. Nursing Process: The Care of the Patient with Cervical Diskectomy—Assessment • 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 • Patient education

18. Nursing Process: The Care of the Patient with Cervical Diskectomy—Diagnoses • Acute pain related to the surgical procedure • Impaired physical mobility related to the postoperative surgical regimen • Deficient knowledge about the postoperative course and home care management

19. Nursing Process: The Care of the Patient with Cervical Diskectomy—Collaborative Problems/Potential Complications • Hematoma at the surgical site, resulting in cord compression and neurologic deficit • Recurrent or persistent pain after surgery

20. Nursing Process: The Care of the Patient with Cervical Diskectomy—Nursing Interventions • Relieving pain • Improving mobility • Monitoring and managing potential complications • Promoting home and community-based care