Lisa Randall, RN, MSN, ACNS-BC RNSG 2432

1. Lisa Randall, RN, MSN, ACNS-BC RNSG 2432

2. 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

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

4. Primary – unknown • Genetic – hereditary • Metastatic • 35% - lung • 20% - breast • 10% - kidney • 5% - gastrointestinal tract

5. Often unknown • Under investigation: • Genetic changes • Heredity • Errors in fetal development • Ionizing radiation • Electromagnetic fields (including cellular phones) • Environmental hazards (including diet) • Viruses • Injury or immunosuppression

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

7. Microscopic appearance • Growth rate • Different for other types of CA • For CNS, per WHO: • GX Grade cannot be assessed (Undetermined) • G1 Well-differentiated (Low grade) • G2 Moderately differentiated (Intermediate grade) • G3 Poorly differentiated (High grade) • G4 Undifferentiated (High grade)

8. Depends on location, size, and type of tumor • Neurological deficit 68% • 45% motor weakness • Mental status changes • HA 54% • Seizures 26%

9. General • Cerebral edema • Increased intracranial pressure • Focal neurologic deficits • Obstruction of flow of CSF • Pituitary dysfunction • Papilledema (if swelling around optic disk)

10. Cerebral Tumors • Headache • Vomiting unrelated to food intake • Changes in visual fields and acuity • Hemiparesis or hemiplegia • Hypokinesia • Decreased tactile discrimination • Seizures • Changes in personality or behavior

11. Brainstem tumors • Hearing loss (acoustic neuroma) • Facial pain and weakness • Dysphagia, decreased gag reflex • Nystagmus • Hoarseness • Ataxia (loss of muscle coordination) and dysarthria (speech muscle disorder) (cerebellar tumors)

13. Cerebellar tumors • Disturbances in coordination and equilibrium • Pituitary tumors • Endocrine • dysfunction • Visual deficits • Headache

14. Frontal Lobe • Inappropriate behavior • Personality changes • Inability to concentrate • Impaired judgment • Memory loss • Headache • Expressive aphasia • Motor dysfunctions

15. Parietal lobe • Sensory deficits • Paresthesia • Loss of 2 pt discrimination • Visual field deficits • Temporal lobe • Psychomotor seizures – temporal lobe-judgment, behavior, hallucinations, visceral symptoms, no convulsions, but loss of consciousness • Occipital lobe • Visual disturbances

17. Gliomas • Astrocytoma (Grades I & II) • Anaplastic Astrocytoma • Glioblastoma Multiforme • Oligodendroglioma • Ependymomas • Medulloblastoma • CNS Lymphoma

18. Grade I • Non-infiltrating

19. Grade II Infiltrating Slow growing

20. Grade III • Infiltrating • Aggressive

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

22. Grades II-IV Mixed astro/glio

23. Slow growing Benign HCP/ICP Surgery, RT, Chemo

24. Small cell embryonal neoplasms Malignant HCP/ICP

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

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

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

28. Peritumoral edema Necrotic center

29. Benign • Schwannoma cells • CN VIII

30. Benign • Anterior pituitary • Endocrine dysfxn

31. Cystic tumor • Hypothalamic-pituitary axis dysfunction

33. Radiological Imaging • Computed Tomography scan (CT scan) with/without contrast • Magnetic Resonance Imaging (MRI) with/without contrast • Plain films • Myelography • Positron Emission Tomography scan (PET scan) • LP/CSF analysis • Pathology

34. Resection Craniotomy Stereotaxis Surgery Biopsy Transsphenoidal http://youtu.be/d95K3unaNCs

35. Drug therapy – Palliative • 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

36. Pre-op care • Post-op care • Patient teaching • Activity • Wound care • Diet • Meds • F/U

37. Neuro assessment • Vital signs • H & P • Teaching • Diagnostic test info • Pre & Post-op care • ICU • Dressings, edema, bruising, hair removal • Sensations if done partially awake • Emotional support • Avoid false hope

38. 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

39. Wound infection • Seizures • CSF leak • Edema • Increased ICP • Hematoma • Hypovolemic shock • Hydrocephalus • Atelectasis • Pulmonary edema • Meningitis • Fluid and electrolyte imbalances (ADH)

40. Follow-up appointments and procedures • Medications • Exercise • Diet • Patient may need referral to dietician to help with diet planning while undergoing chemotherapy • Seizures • 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

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

42. Side Effects • Skin burns, hair loss, fatigue, local swelling • Patient teaching • Do not erase markings • Steroids • S/S of cerebral edema • Radiation necrosis

43. Slows cell growth • Cytotoxic drugs • CCNU, BCNU, PCV, Cisplatin, Etoposide, Vincristine, Temozolomide (Temodar) • Gliadel wafers • Ommaya Reservoir

44. Side effects • Oral mucositis, bone marrow suppression, fatigue, hair loss, nausea/vomiting, anxiety, peripheral neuropathy • Patient teaching • Meds/MV • Nutrition/hydration/activity • Avoid pregnancy • Resources

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

46. Subjective data? • Interventions? • Goals? • Evaluation?

47. 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? • Personality changes • Visual field cuts • Difficulty hearing • Difficulty swallowing

48. 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 exhibits a. A positive Brudzinski’s sign b. A negative Kernig’s sign c. Absence of nuchal rigidity d. A Glascow Coma Scale score of 15

50. AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St. • Greenberg, Mark. (2006). Handbook of • Neurosurgery. Greenberg Graphics, • Tampa, Florida.