Lisa Randall, RN, MSN, ACNS-BCRNSG 2432

• Classify brain tumors according to type and location

• Discuss unique characteristics of primary and metastatic brain tumors

• Recognize common signs and symptoms• Discuss nursing care re: management of S/S and

treatment interventions

• Incidence of primary brain tumors(benign or malignant) 12.8/100,000• 10%–15% of cancer patients developbrain metastases

• Primary – unknown• Genetic – hereditary• Metastatic

o 35% - lungo 20% - breasto 10% - kidneyo 5% - gastrointestinal tract

• Often unknown• Under investigation:

o Genetic changeso Heredityo Errors in fetal developmento Ionizing radiationo Electromagnetic fields (including cellular phones)o Environmental hazards (including diet)o Viruseso Injury or immunosuppression

• Tissue of origin• Location• Primary or secondary (metastatic)• Grading

• Microscopic appearance• Growth rate• Different for other types of CA• For CNS, per WHO:

o GX Grade cannot be assessed (Undetermined)o G1 Well-differentiated (Low grade) o G2 Moderately differentiated (Intermediate grade) o G3 Poorly differentiated (High grade) o G4 Undifferentiated (High grade)

• Depends on location, size, and type of tumor• Neurological deficit 68%

o 45% motor weaknesso Mental status changes

• HA 54%• Seizures 26%

• Generalo Cerebral edemao Increased intracranial pressureo Focal neurologic deficitso Obstruction of flow of CSFo Pituitary dysfunctiono Papilledema (if swelling around optic disk)

• Cerebral Tumorso Headacheo Vomiting unrelated to food intakeo Changes in visual fields and acuityo Hemiparesis or hemiplegiao Hypokinesiao Decreased tactile discriminationo Seizures o Changes in personality or behavior

• Brainstem tumorso Hearing loss (acoustic neuroma)o Facial pain and weaknesso Dysphagia, decreased gag reflexo Nystagmuso Hoarsenesso Ataxia (loss of muscle coordination) and dysarthria (speech

muscle disorder) (cerebellar tumors)

• Cerebellar tumorso Disturbances in coordination and equilibrium

• Pituitary tumorso Endocrine dysfunctiono Visual deficitso Headache

• Frontal Lobeo Inappropriate behavioro Personality changeso Inability to concentrateo Impaired judgmento Memory losso Headacheo Expressive aphasiao Motor dysfunctions

• Parietal lobeo Sensory deficits

Paresthesia Loss of 2 pt discrimination Visual field deficits

• Temporal lobeo Psychomotor seizures – temporal lobe-judgment,

behavior, hallucinations, visceral symptoms, no convulsions, but loss of consciousness

• Occipital lobeo Visual disturbances

• Gliomaso Astrocytoma (Grades I & II)o Anaplastic Astrocytomao Glioblastoma Multiforme

• Oligodendroglioma • Ependymomas• Medulloblastoma• CNS Lymphoma

• Grade I• Non-infiltrating

• Grade II• Infiltrating • Slow growing

• Grade III• Infiltrating• Aggressive

• Grade IV• Highly infiltrative• Rapidly growing• Areas of necrosis

• Grades II-IV• Mixed astro/glio

• Slow growing• Benign• HCP/ICP• Surgery, RT, Chemo

• Small cell embryonal neoplasms

• Malignant• HCP/ICP

• Primary CNS lymphoma• B lymphocytes• Increased ICP• Brain destruction

• Meningioma• Metastatic• Acoustic neuromas (Schwannoma)• Pituitary adenoma• Neurofibroma

• Usually benign• Slow growing• Well circumscribed• Easily excisable

• Peritumoral edema• Necrotic center

• Benign• Schwannoma cells• CN VIII

• Benign• Anterior pituitary• Endocrine dysfxn

• Cystic tumor• Hypothalamic-pituitary axis dysfunction

• Radiological Imagingo Computed Tomography scan (CT scan) with/without

contrasto Magnetic Resonance Imaging (MRI) with/without

contrasto Plain filmso Myelographyo Positron Emission Tomography scan (PET scan)

• LP/CSF analysis• Pathology

• Resection • Craniotomy• Stereotaxis Surgery• Biopsy• Transsphenoidal

http://youtu.be/d95K3unaNCs

• Drug therapy – Palliative o Done for symptom treatment and to prevent

complications NSAIDs Analgesics – Vicodin, Lortab, MS Contin Steroids (Decadron, medrols, prednisone) Anti-seizure medications (phenytoin) Dilantin &

Cerebyx Histamine blockers Anti-emetics Muscle relaxers (for spasms) Mannitol for ICP –New Hypertonic saline

• Pre-op care• Post-op care• Patient teaching

o Activityo Wound careo Dieto Medso F/U

• Neuro assessment • Vital signs• H & P• Teaching

o Diagnostic test infoo Pre & Post-op careo ICUo Dressings, edema, bruising, hair removalo Sensations if done partially awakeo Emotional supporto Avoid false hope

• Anxiety• Risk for infection• Risk for injury: seizures • Pain (Acute) • Impaired cognitive ability• Impaired physical mobility• Altered nutrition: less than body requirements• Urinary retention• Risk for constipation• Disturbed self-esteem

• Increased ICP• Hematoma• Hypovolemic shock• Hydrocephalus• Atelectasis• Pulmonary edema• Meningitis• Fluid and electrolyte

imbalances (ADH)

• Wound infection• Seizures• CSF leak• Edema

• Follow-up appointments and procedures• Medications• Exercise• Diet

o Patient may need referral to dietician to help with diet planning while undergoing chemotherapy

• Seizures o Are a risk for 1 or more years following surgery

• If expecting long term changes, coordinate discharge planning with appropriate members of health care team

• Damages DNA of rapidly dividing cells• 4000–6000 Gy total dose• Duration of 4–8 weeks• Brachytherapy• Stereotactic radiosurgery

• Side Effectso Skin burns, hair loss, fatigue, local swelling

• Patient teaching o Do not erase markingso Steroidso S/S of cerebral edema

• Radiation necrosis

• Slows cell growth• Cytotoxic drugs

o CCNU, BCNU, PCV, Cisplatin, Etoposide, Vincristine, Temozolomide (Temodar)

• Gliadel wafers• Ommaya Reservoir

• Side effectso Oral mucositis, bone marrow suppression,

fatigue, hair loss, nausea/vomiting, anxiety, peripheral neuropathy

• Patient teachingo Meds/MVo Nutrition/hydration/activityo Avoid pregnancyo Resources

• Ineffective Tissue Perfusion• Ineffective Airway Clearance• Impaired Communication• Decreased Intracranial Adaptive Capacity• Activity Intolerance• Disturbed Sensory disturbance• Acute Confusion

Subjective data? Interventions? Goals? Evaluation?

A patient is being directly admitted to the medical-surgical unit for evaluation of a brain mass seen in the frontal lobe on a diagnostic CT scan. Which of the following signs and symptoms would the patient most likely present with?

a. Personality changesb. Visual field cutsc. Difficulty hearingd. Difficulty swallowing

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibitsa. A positive Brudzinski’s sign b. A negative Kernig’s sign c. Absence of nuchal rigidity d. A Glascow Coma Scale score of 15

• AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St.

• Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida.