N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide ©2017 Achieve Test Prep Page 101 of 204 o Vital signs: temperature, pulse (watch for bradycardia), and blood pressure (note pulse pressure, the distance between the two numbers) o Hand grips and leg strength o Check pupils o Assess speech • Inquire about health history, history of head injuries, and history of cancer • Review laboratory and radiological reports: o Lumbar puncture: Lab performs cytology on CSF for pathology of disease o Brain biopsy: Can identify if tumor is malignant or benign and origin o CT/MRI/PET scans: Used to locate tumor and check size o EEG: Checks electrical activity of brain o Cerebral angiogram: Checks vascular and blood supply to brain tissue and areas of compression Nursing diagnosis for brain tumor: • Pain related to headache, secondary to cerebral edema • Risk for injury related due to decreased level of consciousness • Altered tissue perfusion related to vascular compression, secondary to cerebral edema • Altered nutritional status related to nausea and vomiting, secondary to increased ICP • Knowledge deficit regarding diagnosis, treatment regimen, and management of symptoms Nursing interventions for brain tumor: • Continuously monitor vital signs for signs of ICP; watch for wide pulse pressure and bradycardia and report these symptoms to neurosurgeon immediately • Monitor neurological status for changes: restless or agitated • Prepare patient for diagnostic testing such as biopsy and lumbar puncture • Prepare patient for surgical intervention to relieve ICP: Burr holes or tumor resection • Discourage any coughing after surgery or biopsy to keep ICP fromincreasing • Monitor respiratory status and airway patency • Avoid hip flexion and deep suctioning as it raises ICP • Maintain sterility near cranial openings to prevent infection • Give medications per MD order: o Pain medications: Monitor carefully for side effects of depressed respiration, level of consciousness, and nausea as these can mimic increased ICP o Corticosteroids: Given for their anti-inflammatory effects to reduce ICP o Respiratory assessment