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Client’s Health Problem and Background Information:
M.W. is a fifty-nine year old African American female with previous medical history of brain tumor and related surgeries from years past. She is admitted to a major City community hospital because she has been having seizures and falling frequently at the boarding home in which she resides. A series of medical diagnostic tests performed while in the hospital confirms that she presently has an enlarged sella turica and lacunar infarct in basal ganglia with soft tissue nodular area within a questionable pituitary mass. M.W. also has a history of bipolar disorder.
Brain tumors occur as a proliferation or abnormal growth of cells normally found within the central nervous system. Secondary tumors develop from malignant cells from other tumors outside the central nervous system that metabolize to the brain. Tumor expands in an irregular fashion to eventually cause damage or compression to normal brain tissue. This leads to some areas of cell death where normal tissue should be present and some areas of mass cell growth where cell tissue should be much less dense. Cerebral edema, increased intracranial pressure, focal neurological deficits, obstruction of the flow of cerebrospinal fluid, pituitary dysfunction, and related dysfunction of hormones, all or some may occur. Pituitary tumors frequently cause endocrine dysfunctions, therefore creating the domino effect to related body systems and functions. Exact causes and risks for tumors are currently under scientific investigation. Some areas of research currently include genetic changes, heredity, errors in fetal development, ionizing radiation, electromagnetic fields, environmental hazards, diet, viruses, injury, and trauma.
Clinical symptoms and manifestations of brain tumors generally include any of the following: severe headaches (especially bad upon awakening in the morning), nausea and vomiting, visual symptoms, seizures, changes in mentation, changes in personality, swelling of the optic disk, memory loss and cognitive impairment. Location of tumor is relevant and may produce additional symptoms with different degrees of disability. For example, cerebral tumors may also produce symptoms consistent with hemiparesis, hemiplegia, hyperkinesias, hyperesthesia, paresthesia, decreased tactile discrimination, aphasia, and changes in personality or behavior.
To appropriately diagnose brain disorders, health practitioners perform a medical history, neurological assessment, physical examination, computed tomography (CT) scan, magnetic resonance imaging (MRI), and skull films. The CT scan and MRI identify size, location, and extent of any abnormalities. MRI is usually first, followed by CT scan. Cerebral angiography, electroencephalography (EEG), lumbar puncture, myleogram, brain scan, and positron emission tomography (PET) all provide additional support and specific information about size, shape, location, characteristics, and blood flow to or about the tumor in question. Laboratory tests evaluate endocrine function, renal status, and electrolyte status.
Interventions include drug treatment, radiologic and radiosurgical procedures, surgical interventions, positioning after surgery, dressing care, monitoring of lab values, and ventilation for clients in need of that support. MRI, CT scans, magnetic resonance angiography, and angiography with the gamma knife procedures are combined to get at deep seated lesions and problem areas. Chemotherapy and radiation therapy are also used for many occurrences.
M.W. presented with the following symptoms at time of care:
Diagnosis of enlarged sella turica with questionable pituitary mass and lacunar infarct with basal ganglia soft tissue nodular area within was confirmed by test reports as described above. M.W. had developed a pattern of seizures and dizziness which ultimately led to several falls at home prior to hospitalization. She has previous history of bipolar disorder. Lab tests confirmed presence of an active urinary tract infection. A recent EEG showed the slowing and irritability in the left frontal region consistent with structural disorder with epileptogenic potential (possibility of seizure activity confirmed). When I first met M.W., she presented as alert and oriented to self, place, time about two out of three criteria, varying a little throughout the course of day. Stomach was soft and non tender, bowel sounds were present in all four quadrants. Breath sounds were clear, heart rate steady and within normal range per minute. M.W. was awake, conscious, able to sit-up, stand, transfer, and move around from bed to commode to chair and as needed in her hospital room area. M.W. had a bit of the shakes when in motion and complained of weakness. Her appetite was declined the first day that I met her. M.W.’s skin was mostly warm, dry, intact, except for some slight pitting on her lower extremities. Pulses were present in all four extremities and she could easily move her arms and legs against gravity. An IV site on the back of her left hand used for medication access as needed showed no signs of infection. Her temperature was ninety-eight point six degrees Fahrenheit, blood pressure: one hundred thirty six over sixty-two, respirations: twenty, and apical pulse: seventy-four. M.W. was a little groggy, but awake and aware when examined.
M.W.’s lab results confirmed the following systematic concerns:
Potassium a few points below acceptable range; Glucose was a few points higher than standards, BUN low, Creatinine low, Red Blood Cells low, Hemoglobin low, Hematocrit low, MCH just below threshold, Albumin just below threshold, blood culture confirmed Escherichia coli, and urine tests confirmed both Escherichia coli and Enterococcus faecalis.
Treatment for M.W. involves some more testing, frequent monitoring of physical and mental conditions, frequent vital signs, assistance with activities of daily living, resting periods, and medications. Altace is to help maintain blood pressure, Heparin injection and Aspirin to anticoagulate blood platelets that may pool with long non-mobile rest periods, Cogentin to treat Parkinsonian like symptoms, Haldol to treat psychotic conditions, Depakote to treat mood and bipolar disorders, Zyprexia to treat psychosis and depression, Lachydrin lotion for treatment of lower extremities, amoxicillin for treatment of bacterial infections, and K-Dur to treat mineral and electrolyte deficiencies.
Nursing Research Regarding Backrest Positioning to Reduce ICP and CPP:
In the American Journal of Critical Care, regarding Neurological Critical Care, the “Effect of Backrest Position on Intracranial and Cerebral Perfusion Pressures in Traumatically Brain-Injured Adults” is discussed. This became of interest to me because positioning is a key concern when caring for a brain damaged patient. The journal article’s author, Chris Winkleman, RN, PhD, CCRN, discusses the difference between background backrest positioning of the thirty degree angle elevation, as compared to the zero degree flat angle. The article’s study participants were between eighteen to forty-five years of age. Although the ages studied were younger than my patient, there appears to be good indication that the same principles and proven results would be consistent with other age groups as well, including my patient. The article supported some strong evidence, making it a serious consideration to use when treating M.W.
Conclusions of the study indicated that the elevated position, “resulted in significant and clinically important improvements in both intracranial (ICP) and cerebral perfusion pressures (CPP).” Also noted was the fact that, “None of the subjects experienced adverse clinical changes in either intracranial pressure or cerebral perfusion pressure with either backrest position.” “The results strengthen the research foundation for raising the backrest position for adults, eighteen to forty-five years old, who have nonvascular, nonpenetrating, severe brain injury.” (American Journal of Critical Care. 2000;9:373-382)
In addition to the Abstract, the article provided information on the author’s Background and Literature Review, The Objectives, Methods (Design), The Subjects, Study Protocol, Data Analysis, Results, Discussion, Conclusion, and References. Several charts were used to illustrate points.
In the final conclusion, “A backrest elevation of thirty degrees promotes therapeutic levels of intracranial pressure and cerebral perfusion pressure in young adults with closed, nonvascular head injury. A flat backrest resulted in significant and clinically detrimental increases in ICP, and did not maximize CPP in the sample studied.” “Gravitational outflow of cerebrospinal fluid and venous blood from the cranial vault can decrease ICP and prevent secondary brain injury. An increasing body of evidence indicates that backrest elevation is in the patients’ best interest. In patients with severe, nonpenetrating, nonvascular injury, elevating the head above the level of the heart reduces ICP and does not compromise CPP.”
I like to utilize the Internet for research. The article discussed above was located while looking through several articles on the Internet about treating brain damaged patients. It appears to be very relevant and provides good information on an inexpensive, easily accomplished, therapeutic intervention. The Internet is an excellent reference for both basic and complex treatment plans for most forms of disease or medical condition. I had no problem gaining access to the information that I was searching.
Positioning is one of the most common tasks performed in Nursing and is part of routine monitoring. Patients are often found placing themselves in weird and unsafe positions, especially those with mentation deficits. They frequently need to be adjusted and moved back into a more acceptable position, especially those prone to extended periods of bed rest. But, is it safe to elevate the head of a brain damaged patient? This is a very relevant question to explore. As the article suggests, proper positioning can be more than an issue of comfort and safety. It is important enough that proper positioning can actually help to improve conditions and decrease intracranial pressure.
M.W has the ability to sit-up for extended periods of time and occasionally moves about the room. The conclusion from reading the article described above helps to support the idea that positioning the patient’s head above the level of her heart is absolutely the right thing to do and will in fact promote more therapeutic conditions. For those of us that work or visit health care settings frequently, how often do we see clients flat on their backs? The implication with this article is that even in severely brain damaged patients, the laws of gravity are still one of the best therapeutic measures, because even slight elevations as little as thirty degrees, can substantially help to decrease intracranial pressures, reduce the possibility of further brain damage, decrease the risk of adverse effects such as headaches, and generally make the patient more comfortable. While the positive therapeutic effects are easy to observe from a talkative ambulatory patient that can say, “This feels better”. It is important to know that this is also an effective strategy for the non-communicative patient as well.
For Further Reading, Please Refer To:
Deglin, J.H. & Vallerandi, A.H. (2003). Davis drug guide for nurses. (8th).
(pp. 44-48, 66-70, 94-98, 316-320, 461-468, 743-747, 836-840, 915-919, 1040-1044). Philadelphia: F.A. Davis Company.
Gulenick, M., Meyers, J., Klopp, A., Gradisher, D., Galenes, S., & Knoll, M. (2003). Nursing care plans. Nursing diagnosis and intervention. (5th) (pp. 523-530). St. Louis: Mosby
Ignativicus, D. D. & Workman, M.L. (2002). Medical surgical nursing. (pp. 631-632, 1000-1006). Philadelphia: W. B. Saunders Company.
Winkelman, C. (2000). Neurological critical care: Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults. American Journal of Critical Care, Vol. 9, No. 6, pp. 373-382. Retrieved 03-31-2004 from http://www.aacn.org/AACN/...
Originally Written 04/26/2004. Submitted 10/19/2005
Copyright 1998, 2005, By Bob Singer, BS, NHA, PCHA, Author.
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