Preoperative Education

Preoperative education for the patient with a high-grade CNS malignancy is a unique challenge to nurses. Management of this patient population involves multiple treatment modalities and requires ongoing vigilance of a multidisciplinary team to detect and treat newly diagnosed and recurrent tumors. Multiple studies have indicated that preoperative education significantly reduces pre- and postoperative anxiety. Certainly, with the addition of a potential malignant diagnosis, and the often rapid succession of events from diagnosis to surgery, patient and family education is a cornerstone in this population.

Preoperative education can broadly cover the entire surgical experience of the patient. Patients need to be educated on their individual surgical procedure, medication use and potential side effects, necessary neurodiagnostic testing (preoperative and over the continuum), and education regarding how to identify and prevent the more common postoperative complications such as deep vein thrombosis (DVT) and wound infection. A detailed history and a physical examination are the basis of every patient evaluation, and will aid in decisionmaking before surgical intervention. Many institutions use Critical Pathways to delineate the inpatient and outpatient care required during the perioperative period (6). Outpatient visits are necessary to medically optimize patients prior to surgery and to provide crucial patient education by the nursing staff. The patient should be provided with both verbal and written information pertinent to their diagnosis, procedure, and plan of care.

It is important to have a complete medication list from the patient including not only prescription drugs but OTC medications, vitamins, "as needed" drugs, as well as herbal supplements and preparations. The medication list should be reviewed at every visit with the patient and changes made as necessary. Aspirin and aspirin containing preparations, anticoagulants, nonsteroidal anti-inflammatories (NSAIDs), and vitamins, minerals, and herbal medications should be stopped prior to surgery. The length of cessation varies from physician to physician and individual institutional policies. Anesthesiologists are conducting research to determine exactly how certain herbals interact with certain anesthetics. They are finding that certain herbal medicines may prolong the effects of anesthesia; other medications may increase the risks of bleeding or raise blood pressure (7). Certain oral hypoglycemics also need to be discontinued at some point prior to surgery, depending on the individual drug, and can be identified during the review of medications. Patients and their families need to be educated on what medications to stop prior to surgery, as well as what medications are necessary to take the morning of their procedure, despite their nothing to eat or drink after midnight status.

A battery of tests is routinely ordered preoperatively and throughout the patient's course oftreatment. In addition to routine preoperative laboratory studies, it is important to remember to monitor anticonvulsant levels and make necessary adjustments accordingly. Multiple neurodiagnostic tests may be ordered for the patient with a HGG. It is important the patient be educated on the rationale for these studies, which include:

• Cerebral angiograpy: Invasive method of visualizing cerebral vascular structures.

• Cerebrospinal Fluid (CSF) flow scan: Used to evaluate CSF flow abnormalities, particularly in patients with leptomeningeal disease or tumors within the ventricular system (8).

• Computed Tomography (CT): Helpful in evaluating soft tissue, edema, bony lesions, calcifications, or hemorrhage. If a contrast agent is used, it is usually iodine-based and patients who are allergic to iodine should inform their health care providers before undergoing a CT scan with contrast.

• Electroencephalogram (EEG): Used to document seizure activity, seizure focus and focal slowing of brain waves.

• Functional MRI (fMRI): Detects physiological changes during physical and cognitive activity; may be used for evaluation of language, sensory, and motor function.

• Lumbar puncture/spinal tap: Helpful in diagnosing of leptomeningeal involvement.

• Magnetic resonance angiography (MRA): Noninvasive method of visualizing vascular structures.

• Magnetic resonance imaging (MRI): Shows structure in three planes, with and without contrast (gadolinium). MRI is the examination of choice for primary brain tumors.

• Magnetic resonance spectroscopy (MRS): Measures the level of metabolites, ratio of choline to creatine to help differentiate necrosis or scarring from malignancy. The level of metabolites in tumors is different from that of normal brain tissue; the presence of lactate may suggest a higher grade tumor.

• Magnetic resonance venogram (MRV): Noninvasive method of visualizing venous structures and patency of cerebral sinuses.

• Positron emission tomography scan F-18 fluorodeoxyglucose (FDG): Measures tissue metabolism; currently the most effective method to differentiate treatment related necrosis or scarring (hypometabolic) vs tumor (hypermetabolic). Aggressive tumors generally have a higher rate of metabolism and therefore a higher uptake of FDG.

• Stereotactic MRI and CT: Studies done preoperatively for surgical localization purposes to provide computer-assisted, three-dimensional surgical guidance.

• Thallium 201 single-photon emission computed tomography (SPECT): May help differentiate tumor versus radiation necrosis.

• WADA: Cerebral angiography with addition of neurologist present testing for definitive language and memory dominance.

One of the nurse's main responsibilities during this diagnostic period is to provide information about the necessary tests, however, the emotional impact of the possibility of a brain tumor or its recurrence can cause extreme stress. The impact of the diagnosis is dependent on the extent the patient is able to understand the information and how it will affect their life. It is important to develop individualized teaching plans that are flexible and can adapt to the patient's broad range of physical and emotional needs.

Education about postoperative concerns should begin preoperatively. Numerous complications and problems can develop after a craniotomy. The nurse is responsible for monitoring the patient for the development of complications and implementing preventative measures when possible (9). Within the medical community, DVT is a well-recognized problem in persons with brain cancer (10). Postoperatively, routine lower extremity ultrasounds should be ordered to assess for DVT. Consideration should be given to preoperatively screen high-risk patients. Routine postoperative instruction includes diligent education regarding daily wound inspection and wound care. Special attention needs to be given to the patient and family regarding signs and symptoms of infection, or CSF leak, and instructions to call the office immediately if questions or concerns arise. Permanents, dyes, or hair bleaching should be avoided for at least 4 wk. Patients should be knowledgeable regarding postoperative swelling and preventative factors such as sleeping with the head elevated on pillows and keeping active and out of bed during the day. Heavy lifting (anything over twenty pounds) should be avoided for about 6 wk, gradually increasing, as tolerated thereafter. Teach the patient to avoid activity that requires bending at the waist and demonstrate proper body mechanics by bending at the knees. It should be mentioned to avoid any activity requiring them to hold their breath, such as the Valsalva maneuver. Encourage ambulation, with walking being the exercise of choice, and caution patients to use the railing when climbing stairs. Patients should not drive or return to work until their physician releases them. Educate the patient that headaches are to be expected, but if they persist or increase despite pain medication, they should notify their doctor's office. Prescription pain medication should only be taken as needed, usually in the first few days postoperatively, and OTC medication, such as acetaminophen (1000 mg), may be taken for minor pain. It is important to educate the patient that narcotic pain medication is constipating and the use of laxatives and stool softeners is safe to control constipation. Make sure the patient and their family has the physician's office and emergency phone numbers.

It is important to include not only the patient in the education process, but their family and support system as well, as cognitive deficits are common in this patient population. Encourage family members to accompany the patient to appointments to assist in information gathering and to provide the necessary emotional support. It is a unique challenge of the neurosurgical oncology nurse to prepare the patient for the surgical process. The dynamic nature of the disease as well as the patient's perspective and knowledge of their diagnosis provides many opportunities for education in this patient population.

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