Unit 1: Brain Tumors Flashcards
Primary Brain Tumors
- originate in the brain; brain cells, brain meninges, nerves, and glands
- range from slow growing, benign tumors to highly malignant, aggressive tumors
- can spread to the CNS in 3 locations: the brain tissue (parenchyma), the spinal cord, and the CSF = now called metastasis
Metastatic Tumors
- most common type of brain tumor
- commonly caused by lung, melanoma, renal, breast, and colorectal cancer
- spreads to the CNS
Brain Tumor Grades
> Grade 1:
-benign, slow growing, long term survival
> Grade II:
-relatively slow growing, can spread to nearby tissue, can come back as a higher grade tumor
> Grade III:
-malignant, actively reproduces abnormal cells, tends to come back as a higher grade tumor
> Grade IV:
-most malignant, rapid growth w/ formation of new blood vessels, easily spreads to nearby normal parts of the brain
Common Tumor Types
- Glioma
- Meningiomas
- Oligodendrogliomas
- Acoustic Neuromas
- Pituitary
Glioma
- originate in the cerebrum
- glial cells provide the physical structure of the brain and supports the endothelial cells of the blood-brain barrier (BBB)
- glial cells provide nutrients and ionic balance; involved in the repair and scarring process
- Gliomas develop along the curved areas of the brain, making frontal lobes more susceptible
Meningiomas
- arises in ages 40-70 years
- arise from the meninges (layers of the brain)
- usually benign
- can still cause devastating damage b/c they are space-occupying lesions that can increase ICP
- damage based on tumor size and location
Oligodendrogliomas
- arise from oligodendrocytes, or oligodendroglia, and their main functions are to provide support and insulation to axons in the CNS
- slow-growing
- generally do not spread to surrounding tissue
- arising from the fatty covering that protects nerves, they generally occur in the cerebrum
- found in middle-aged patients
Acoustic Neuromas
- “schwannomas”
- slow-growing, benign
- generally do not invade other tissue
- compression on other cranial nerves and tissue can manifest in severe complications of these
- originate from the protective covering around nerve fibers (CN VIII) at the anatomical location of the cerebellopontine angle
Pituitary Tumors
- found in anterior lobe of the pituitary
- benign
- clinical manifestations of pituitary adenomas are r/t hypersecretion of hormones by the pituitary gland
Clinical Manifestations of Brain Tumors
- r/t size and location in the brain
- dependent upon compression of associated structures
- may have S/S of increased ICP
Malignant Brain Tumors are associated with what?
swelling as the rapid growth damages brain tissue
What are Brain Tumors often referred to as?
space-occupying lesions that may cause increased ICP depending on rate of tumor growth and location
Presenting Clinical Manifestations of a Brain Mass: Locations and Symptoms associated
> Frontal motor cortex: motor weakness
Parietal sensory cortex: sensory loss
Left inferior frontal lobe (Broca’s area): speech (expressive)
Left temporal lobe (Wernicke’s area): speech (recessive)
Optic nerve: loss of vision in one eye
Optic chiasm: bitemporal field cuts
Optic tract, Occipital lobe: loss of visual field on the same side in both eyes
Pineal gland: loss of upward gaze, loss of light reflex
Brainstem: loss of cranial nerves on one side w/ loss of motor or sensory on contralateral side
Clinical Manifestations of Increased ICP
- papilledema (swelling of the optic nerve)
- headache
- nausea and vomiting
- decreased alertness
- cognitive impairment
- personality changes
- ataxia
- hemiparesis
- abnormal reflexes
- cranial nerve palsies
Medical Management
-Chemotherapy
-Radiation
>used in place or in conjunction w/ surgery depending on type and location of tumor
Chemotherapeutic Agents
- must have the ability to cross the blood-brain barrier
- nursing care= neuro assessment, standard care of the oncology pt receiving chemotherapy
- side effects: diarrhea, nausea, vomiting, weight loss, mucositis, hair loss, and fatigue
Radiation Therapy
- destroys both tumor and normal cells by damaging cellular DNA
- monitor for fatigue, reddening of the skin, headache, swelling, facial numbness, and any sensory or neurologic changes, visual changes
- CyberKnife is a type of radiation that more precisely targets the cancerous site, avoiding healthy brain tissue
Nursing Interventions for Complications of Radiation Therapy
- Fatigue nutritional supplements (i.e. boost, ensure)
- Skin utilization of sunscreens, sun-protectant coverings, and skin emollients
- Dexamethasone (Decadron) used to reduce swelling
- Ondansetron (Zofran) used to reduce nausea/vomiting
Surgical Management
- Brain Biopsy
- Craniotomy
Brain Biopsies
biopsies of brain masses to sample tissue within the mass so that the cells can be examined and a specific diagnoses can be made
-performed using radiological techniques that allow the neurosurgeon to map the location of the mass in multiple dimensions
Craniotomy
- most common for all types of brain tumors
- section of the skull is removed (bone flap) to provide access to the brain
- can be done to biopsy brain tissue or to excise (remove) a tumor
- if the entire tumor cannot be removed, the tumor is debulked, removing as much as the tumor as possible
Complications of Brain Tumors
- Increased Intracranial Pressure
- Bleeding
- Cerebral Edema
- Diabetes Insipidus
- SIADH
- Seizures
- Venous Thromboembolism
Complications: Increased ICP
-can hamper cerebral blood flow; causing decreased in cerebral perfusion pressure (CPP) and leading to secondary injury of the brain via cytotoxic and anoxic injury and herniation of the brain
Complications: Bleeding
- risk of intracranial bleeding post-op is variable and dependent on features of the tumor, location in the brain, proximity of the tumor to blood vessels, ad the surgical approach
- when changes in the neurological assessment are detected, healthcare team is alerted for further assessment and CT scan to determine whether there is a structural change such as bleeding
- can occur in the area where the tumor was resected
- can occur above or below the dural covering while blood vessels are manipulated during the surgical approach
Complications: Cerebral Edema
- Vasogenic edema: blood brain barrier becomes increasingly permeable
- most common after brain tumor resection; secondary to changes to the usually tightly controlled blood-brain barrier that becomes inflamed and more permeable in the area of the tumor and surgical resection
- serial neurological assessments to monitor a patients response to the surgical procedure, and deterioration of that assessment can be caused by cerebral edema
- edema can be located in and around the area where the tumor was resected
- edema can be located along the path taken by the surgeon to expose and resect the tumor
- Emergent TX: osmotic diuretics, hyperventilation, and HOB elevated 30-45 degrees
- Increase the dose of glucocorticoids; decrease the inflammatory process associated with damage in and around the tumor
Complications: Seizures
- may occur as a presenting sign of a brain tumor and episodically thereafter
- may occur post-operatively
- locations closer to the upper regions of the brain are at greater risk for seizure activity
- Immediate Tx: benzodiazepines to stop the seizure; antiepileptics to prevent reoccurrence
Complications: Venous Thromboembolism
- occurrence of a malignancy, surgical procedure, and immobility place pts w/ brain tumors at higher risk of VTE
- Prevention measures: mechanical VTE prevention devices (sequential compression devices), pharmacological (heparin subcutaneously)
Complications: Diabetes Insipidus/ SIADH
- at risk for DI manifested by large volume of dilute urine
- at risk for SIADH manifested by fluid overload and scant urine output
Nursing Management: Assessment + Analysis
- clinical manifestations observed in the patient w/ a brain tumor are r/t the location of the tumor, pressure on adjacent structures, and increased ICP
- change in LOC
- headache
- pupillary changes secondary to compression of CN III (oculomotor)
- vision changes
- seizure activity
- elevated BP w/ widening pulse pressure
- decreased HR
- nausea and vomiting
- numbness and tingling
Nursing Assessments
- Neurological Assessment
- Vital Signs
- Estimated blood loss
- Laboratory Studies (electrolytes)
- Intake and Output w/ specific gravity
- Pain
Assessments: Neurological Assessment
- LOC
- Orientation
- Motor Strength
- Sensation
- Cranial nerve assessment
Assessment: Estimated Blood Loss
- not large in craniotomy
- but, can be greater than expected
Assessment: Intake and Output
- who have undergone a craniotomy in which the pituitary gland has been manipulated
- risk for diabetes insipidus
- monitor urine specific gravity and osmolality, serum sodium and osmolality
Assessments: Electrolytes
(serum sodium and glucose)
- Serum sodium should be maintained within normal values; possibly on the higher end to prevent fluid moving into the cells potentially raising ICP
- Glucose monitored b/c dexamethasone may lead to elevated serum glucose levels
Assessments: Pain
- experience post-op pain associated w/ the incision and positioning of head and neck during surgery
- use of opioid medications w/ maintaining neurological assessments
- NSAIDs not preferred in post-op period b/c of concern for increase in bleeding risk
Diabetes Insipidus
- increased urinary output
- decreased urine specific gravity (<1.005)
- increased serum sodium concentration (>145)
- increase in serum osmolality (>280 mOsm/kg)
- urine osmolality (<200 mOsm/kg)
Nursing Actions
- Administer Glucocorticoids
- Replace urine loss and electrolytes
- HOB 30-45 degrees
- Administer Stool softeners (decrease straining)
- Administer antiepileptic medications
- Apply VTE prophylaxis
Nursing Actions: Administer Glucocorticoids as ordered
- to treat and prevent further cerebral edema
- dexamethasone: stabilize cell membranes to prevent the occurrence of cerebral edema; given post-op
Nursing Actions: Replace urine loss and electrolytes
-dehydration can lead to hemodynamic instability (hypotension, tachycardia, dysrhythmias), and decreased cerebral perfusion
Nursing Actions: Administer antiepileptic medications as ordered
-based on tumor location and hx or risk of seizure activity
Nursing Actions: Apply VTE prophylaxis
presence of cancer and tissue injury during surgery increases risk of VTE
-pharmacological prevention may not be implemented immediately after surgery b/c concern for bleeding risk but may be implemented further into hospital course
Nursing Teachings
- Tapering of steroids
- monitoring of glucose
- compliance with antiepileptic medications
- fall prevention
- hat or head covering as needed
- mouth care w/ chemotherapy
Teaching: Tapering of Steroids
- rapid withdrawal of glucocorticoids can cause adrenal crisis
- provide clear direction
Teaching: Monitoring of glucose
- can become hyperglycemic w/ steroid use and require home testing of glucose levels while receiving glucocorticoids
- temporary until medication is tapered off
Teaching: Compliance w/ antiepileptic medications
-some may require serum medication levels to ensure that they are maintained at a therapeutic level
Teaching: Fall Prevention
- b/c of previous or new motor weakness or visual deficits
- discuss fall or tripping hazards in hospital and home
Teaching: hat or head covering
- parts of the head may be shaved for surgery
- w/ chemotherapy pt is at risk for alopecia (blading)
- head coverings can decrease heat loss from the head
Teaching: Mouth care secondary to effects of chemotherapy and/or radiation therapy for brain tumor
- chemotherapeutic agents affect cells that divide quickly; makes pt at risk for sores in the mouth
- soft toothbrush and non-alcohol containing mouthwash decreases discomfort
Interventions after brain surgery
- no coughing
- no incentive spirometry
- turn q 2 hours
- when mobile, start walking
- interventions to help spread lungs other than causing pressure
