Question

Case Scenario for CNS-Brain Cancer

This is a case of a 45-year-old female, smoker, non-diabetic, non-hypertensive who was

having on and off headache for 5 months prior to consult (April, 2015), this is associated

with nausea and vomiting. The headache was becoming recurrent until August of 2015

she decided to consult her doctor. Aside from nausea and vomiting, symptoms include

weakness of the left side of the body and numbness and tingling sensation. Apparently,

complete neurological examination was done and it was unremarkable. A CT scan was

done on Sept 30, 2015 with the following findings:

A contrast-enhanced brain MRI demonstrated a 3 × 3 cm right fronto-parietal resection

cavity surrounded by a 5 × 4 cm area of heterogeneous contrast enhancement extending to the right corona radiata and periventricular white matter with associated

cerebral edema (Fig. 1). The mass was not technically resectable due to location and

biopsy was consistent with GBM (Glioblastoma multiforme), wild-type isocitrate

dehydrogenase and unmethylated O6-methylguanine DNA methyltransferase (MGMT),

with an MIB-1 index of 50% (Fig. 2).

Fig. 1

T1-weighted brain MRI with contrast at the time of diagnosis of radiation-induced

glioblastoma multiforme.

Fig.2Radiation-induced glioblastoma multiforme demonstrating increased cellularity with

marked nuclear atypia, necrosis, and vascular endothelialization.

On January 25th of 2016, the patient underwent surgical therapy, including fronto

parietal craniotomy, with total resection of the tumor. On February 7th of 2016, a

histopathology examination, confirmed a diagnosis of the GBM IV stage.

In February 2017, approximately 13 months after her brain tumor surgery, Patient

Carlota had a follow-up diagnostic work-up, no brain tumor recurrence was found. Due

to the absence of tumor, no radiotherapy was considered, and “watchful waiting” was

recommended including brain imaging studies (CT or MRI) to be repeated every 3

months. Due to the lack of the patient's consent, no chemotherapy was implemented.

During the irradiation period, Patient Carlota had the first seizure episode, and was

started on antiepileptic therapy (Depakine 200 mg a day). she continued this therapy for

the rest of her life. After the radiotherapy, diagnostic follow-up examinations were

conducted every 3 months.

At the beginning of March 2018, tumor recurrence was found, and the tumor was

localized in an upper part of the tumor bed, within the previously irradiated area (its size

was 3.7 cm × 2.6 cm × 2.3 cm). Surprisingly, Patient Carlota had not experienced any

symptoms, and her physical and neurological examinations were unremarkable.

On March 13th of 2019, stereotactic radiotherapy was done, using a single dose of 8 Gy

applied to the area of recurrent tumor was performed. Unfortunately, on follow up

examination, on July 6th of 2018, further progression of the GBM was found, due to the

tumor expansion, resulting in cerebral edema, herniation, and multi-organ failure.

Guide questions:

1. What are the significant assessment findings that you have noted on the case?

2. Based on the case given above, Identify the risk factors related to the case.

3. Trace the pathophysiology of the condition and course of the disease mentioned

on the case. (Connect the signs and symptoms, laboratory and diagnostic

procedures as well as the prioritized problem/ nursing diagnosis)

4. What are your nursing responsibilities related to the laboratory and diagnostic

examination including the procedures and medications?

5. What are the treatments and procedures performed during the course of

hospitalization?

6. Enumerate appropriate discharge plan and health teaching for your patient?

7. Identify at least three (2) priority nursing problems and formulate 2 nursing care

plans with appropriate objective and evaluation of care.( with Scientific Rationale

on the Nursing Diagnosis and Rationale on the Interventions)

Answer 1

1. This is 45 year old female had headache often for the past 5 months and associated vomiting and nausea till April 2015 and headache becomes recurrent till august 2015 she had weakness of the left side of the body and numbness and tingling sensation . Therefore MRI was done to diagnose the causes the symptoms of the patient. It showed Glioblastoma multiforme

MRI showed 3× 3right fronto parietal resection cavity surrounded by a heterogeneous contrast enhancement extending to the right corona radiate and periventricular white matter with associated cerebral edema

Radiation induced glioblastoma mulitiforma showed the increased cellularity with marked nuclear atypia, Necrosis, vascular endothelialization. then she underwent frontoparietal  craniotomy

after undergoing surgery , she underwent follow up procedure for identifying any recurrent cancer. After that, she developed recurrence of tumor in her brain for that she underwent stereotactic radiotherapy after a year of diagnosis of recurrent tumor using a single dose of 8 gray causes.unfortunately she developed glioblastoma, cerebral edema, herniation, and multiorgan failure

2. Normally the causes of the glioblastoma multiforme is unknown and other risk factors for glioblastoma multiforme is inherited DNA changes, high dose ionizing radiation exposure, head injury, viruses.

           But she had glioblastoma multiforme as a result of radiation exposure

3. Pathophysiology of glioblastoma multiforme

                          Due to etiological factor such as long standing exposure to ionizing radiation

                                

                               There numbers of cells are increased and divided abnormally

                          This abnormal cell infiltrates in to the brain cells

                   This results in compression of the brain because of increasing size of the tumor

                 Enlarged tumor cause compression of brain alter the balance of the CSF, brain, cerebral blood circulation

                  Initially compensatory mechanism tried to overcome this alternation by either decreasing CSF volume, decreasing cerebral blood flow

It produces signs and symptoms of increased intracranial pressure after these compensatory mechanisms fail to overcome, tumor enlargement causes cerebral edema as a result of compression of the brain structure and occlusion of blood supply

             Patient develops nausea, vomiting, headache, left side weakness of body as a result of compression of right side of the brain structure. Headache is not commonly present and present in the morning and it is aggravated by the changes in positioning, straining and result of tumor enlargement

4. Nursing responsibilities

1. Explain the patient every procedure and get consent from the patient

2. Clear the doubts of the patient and procedure

3. Explain information clearly and slowly

4. Monitor vital signs of the patient

5. Protect the patient because of the effects of tumor on the brain structures

6. Monitor for any neurological deficits

7. Orient the patient to every procedure, time and place

8. Keep the tray ready to treat the seizure if it occurs

5. Management of glioblastoma multiforme

          The main treatment for glioblastoma multiforme is surgery followed by the radiation and chemotherapy normally for all patient s

She underwent surgery called fronto parietal craniotomy with total resection of the tumor after that she had undergone regular follow up and it didn’t show any tumor and radiotherapy was not implemented. Patient has not given consent to chemotherapy therefore chemotherapy has not been given to her. During the irradiation period, patient develops seizure; thereby antiepileptic drugs are given to her. She continued this antiepileptic medication and she underwent radiation therapy followed by she was suggested to undergo the follow up diagnostic test every 3 months.

6. Teaching plan and discharge instruction

1. Advise the patient contact health care provider if incase of any signs and symptoms of neuro vascular changes

2. Advise to continue antiepileptic medication continuously

3. Educate the patient contact hospital if he developed seizure frequently and laster than 5 minutes

4. Advise to contact hospital incase injuries occur during seizure

5. Encourage the patient rest and avoid more activities

6. Advise patient to consume good nutrition and adequate amount of fluid

7. Advise to contact and perform exercise as per instruction said by physiotherapist, occupational therapist

8. Explain the patient to undergo counseling therapy for any stressor if she has

9. Advise to avoid activities near swimming pool, fire, harmful instruments

nursing diagnosis and intervention for glioblastoma multiforme

Nursing diagnosis	Goal	Nursing interventions	Rationale	Evaluation
Ineffective cerebral tissue perfusion related to brain cancer as evidenced by verbal report of headache	To improve cerebral tissue perfusion	Assess the cerebral tissue perfusion Advise the patient to avoid straining activities Elevate the head of the bed Monitor level of consciousness often Advise the patient to breath out while turning Provide safe environment for the patient	It helps to analyze the plan of care Straining activities may increase intracranial pressure It increase venous drainage It helps to analyze brain activities It decrease intracranial pressure Stimuli increase intracranial pressure and also irritates brain tissue	Cerebral perfusion will be improved
Acute pain related to increased cerebral edema as evidenced by verbal report of headache	To reduce pain	Assess the pain level of the patient Provide relaxation therapy Provide safe and quiet environment Support the patient in case of anxiety Advise to reduce activities    Explain try to avoid sneezing, coughing	It helps to analyze the care It relax mind and safe sleep and reduce pain It reduces stimuli that irritates the brain and cause headache It reduces fear and reduces vasoconstriction It helps to decrease intracranial pressure It increases headache as a result of increased intracranial pressure	Her pain will be releived
Self care deficient related to compression of brain on motor center of activity as evidenced by left side weakness of the body	To improve Self care	Assess the self care of the patient Provide things within a reachable patient side Provide a ball to the patient for squeezing hands Encourage the family to assist in daily activities Encourage the patient to use a dairy to note activities to be done	It helps to plan of care It helps the patient access to the care To improve muscle function of hand It helps to the patient to access o the care It helps to cope with disabilities and improve self care as much as possible	Herself care will be improved