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Brain Tumors

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Overview

  1. Tumors in the brain disrupt normal brain functioning
    1. Area of the brain
      1. Frontal
        1. Controls Motor movement, thought, reasoning, bowel and bladder
        2. Called the “silent area of the brain”
          1. Tumors growing here show less symptoms initially
      2. Temporal
        1. Controls memory, hearing, and speech
      3. Parietal
        1. Controls memory, reasoning, and spacial recognition
      4. Occipital
        1. Controls vision and reading
      5. Cerebellum
        1. Controls coordination and balance
      6. Brainstem/ Pons/ Medulla
        1. Controls breathing, heart rate, consciousness
      7. Ventricles
        1. Allows for movement of cerebral spinal fluid (CSF) which nourishes and protects the brain
      8. Meninges
        1. Membranes covering the brain and spinal cord
      9. Blood-brain barrier
        1. Restricts passage of substances to the brain
        2. Also limits what medications will reach the brain
  2. Tumors in the brain lead to an increase in intracranial pressure
    1. Normal ICP 5-15 mmHg, impacted by brain tissue, blood, and CSF
    2. The pressure inside the skull increases as a tumor grows and can also increase if a tumor blocks the flow of CSF
    3. An increase in ICP can cause brain tissue death
  3. Brain tumors grow from different cells of the brain tissue
    1. Neurons- Nerve cells
      1. A tumor from these cells is called neuronal
    2. Glial cells- supporting cells of the brain
      1. A tumor from glial cells is called a glioma and further classified by the type of supporting cell it comes from
        1. Astrocytes- transport nutrients
          1. A tumor from these cells is called astrocytoma
          2. A fast-growing, grade 4 astrocytoma is called glioblastoma
        2. Oligodendrocytes- insulates nerve fibers
          1. A tumor from these cells is called oligodendroglioma
        3. Ependymal cells- lines the ventricles and secrete CSF
          1. Cancer in these cells is called ependymoma
    3. Tumors in the meninges are called meningioma
    4. Lymphoma can also form in the brain called CNS lymphoma

Nursing Points

General

  1. Brain tumors are most commonly from metastasis or spread from cancers of another origin
  2. Tumors that originate in the brain are called primary brain tumors
    1. Primary brain tumors usually don’t spread to other parts of the body but can spread across the brain
    2. Benign- slow-growing, clear margins
    3. Malignant- fast-growing, grow into surrounding tissue
  3. Incidence
    1. Can occur at any age
    2. Commonage of onset depends on tumor type
  4. Risk Factors
    1. Radiation treatment to the head
    2. Weakened immune system
      1. HIV linked to CNS lymphoma
    3. Genetic disorders
      1. Neurofibromatosis
      2. Li-Fraumeni syndrome
      3. Turcot syndrome

Assessment

  1. General symptoms from ↑ ICP
    1. Headache
    2. Nausea
    3. Vomiting
    4. Altered level of consciousness
    5. Seizures
  2. Focal symptoms related to tumor location in the brain
    1. Sensory changes
      1. Hearing
      2. Vision
    2. Personality changes
    3. Weakness
    4. Ataxia = impaired balance and coordination

Therapeutic Management

  1. Decrease ICP
    1. Steroids work quickly
      1. Dexamethasone IVP drug of choice
    2. Ventricular Shunt
      1. A surgical procedure to drain CSF
    3. Rarely given Mannitol
      1. Risk of rebound increase ICP
  2. Remove or shrink the tumor
    1. Craniotomy- the goal is to remove the entire tumor
      1. Tumor excised in surgery
      2. Sometimes due to location, tumors cannot be surgically removed
    2. Radiation treatment
      1. External Beam radiation
      2. Radioactive implants
    3. Chemotherapy
      1. Must cross the blood-brain barrier or be delivered directly to CNS
        1. Ommaya reservoir is a port inserted in the ventricles to give chemo directly
        2. Intrathecal chemo is given by oncologists via lumbar puncture
        3. Chemotherapy wafers can be placed in OR after tumor removed- this delivers chemo directly to the area
    4. Targeted therapy
      1. Prevents angiogenesis so tumors cannot get blood supply

Nursing Concepts

  1. Cellular regulation
    1. Tumors formed from masses of abnormal cells that grow out of control
  2. Cognition
    1. AMS/ impaired memory from tumors
  3. Intracranial regulation
    1. Alterations in ICP
  4.  Coping
    1. Terrifying diagnosis because it can lead to severe disability or death

Patient Education

  1. Treatment specific
    1. Side effects of chemo and radiation
      1. Immunosuppression
      2. Risk of bleeding
      3. Hair loss
      4. Fatigue
      5. Nausea
    2. Post-op instructions
      1. In hospital for 5-6 days after craniotomy
  2. Recognize symptoms of recurrence
    1. Headaches
      1. Change in headache characteristics
      2. New persistent headache
    2. Vision changes
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Nursing Care Plan for Brain Tumors

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Video Transcript

Hi guys, today we are talking about brain tumors. So let’s start off by reviewing some of the functions of the brain. Obviously the brain does so much for us, right? And it’s divided into these different lobes and these lobes specifically control different functions of the body, right? So the frontal lobe has a big piece in controlling our motor movement and also, also our thought among other things, right? But those are big ones. The parietal lobe has a lot to do with memory and also reasoning. The occipital lobe has a lot to do with vision and along with that reading, temporal lobe: hearing is a big one and the temporal lobe. And again, there are other functions of these lobes, but these are some of the big ones. And then we kind of group the brainstem pons and medulla oblongata. So right here, and this is sort of the life center, right? So this controls our heart rate breathing, And then the cerebellum is a big factor in coordination. And why is that important when we’re talking about brain tumors and that has a lot to do with what side effects we’re going to see in the patients with tumors in these different areas. So a simple example, if we have a big tumor in the temporal lobe, that person might have a lot of, deficits with their hearing or over here or in the middle lobe here, we might have a lot of changes in vision. So the location of the tumor is going to impact what symptoms we see. And then of course there’s other functions of the brain and other parts of the brain. This image shows kind of our ventricles. It’s a little bit hard to see, but if you remember, the ventricles are, these, the sections in the brain where CSF or so we roll spinal fluid can flow through and that’s important to nourish and protect the brain. And then we also have the meninges, the layers. The three layers that again, protect the brain and then between the brain and the, central nervous system and the rest of the body. A big thing we need to remember is the blood brain barrier. And if you recall that really limits or restricts the passage of different substances to the brain. So that’s important because, it makes it difficult to treat tumors in the brain, certain substances, Including meds and chemo. they sometimes cannot pass the blood brain barrier. So we’ll talk about that a little bit more in other sections. Brain tumor types, there are tons of different types of brain tumors based off of the cells that form them. So we’re going to review some of them here. If the tumor is formed in the nerve cells, it’s called a neuronal tumor. If it’s formed in the supporting cells, it’s called a glioma and there’s different types of gliomas. That’s what this picture is of the different types of cells supporting cells. And they’re going to all these tumors are going to act a little bit different. That’s why it’s important to distinguish between them. Okay. So types of gliomas, we have astrocytes and they deliver nutrients. So if those are impacted nutrients, won’t be delivered to the nerve cells. These are these green cells here. If we have tumors that arise from these cells, they’re called an astrocytoma. 

If it’s slow growing, and if it’s fast growing, it would be called a glioblastoma. You can check out the outline. Those words are written in there for you. Another glioma would be if it’s in the, oligodendrocytes, and those are these blue cells right here, and they insulate nerve fibers. If there’s a cancer in there, it’s called a oligodendroglioma. I know guys stick with me. These are tough words. I just want you to recognize them a little bit. If you hear him, you don’t need to know everything I say. And then we have the ependymal can’t even say him at then ependymoma. Those are these red cells here, and these produce CSF. So if those are impacted, we’re going to have a change to our CSF, whether it’s a huge release of it or decrease, right. Okay. So the important thing here is that the different cells, cancers, or tumors arising from the different cell types are going to basically act differently.  Another one would be a meningioma and that’s if a tumor forms in the meninges or we also have CNS lymphoma, and that’s obviously if a lymphoma spreads or forms in the central nervous system. And then metastasis is a big thing with brain tumors. Oftentimes the most common brain tumors are from metastasis, from another cancer. If it has not spread from another cancer, then it would be called a primary brain tumor. And that’s what I have right here. So that’s when that forms within the brain, right as the primary site. So are we talking about cancer or tumors here? I know I’ve been using those terms interchangeably, but it’s important to note that we usually talk about any tumors or cancer within the brain as tumors, because they perform a little bit different than other cancers.

They don’t usually spread beyond the brain tissues. So if we’re talking about a benign tumor, it’s just slow growing. If it’s a metastatic tumor, it’s fast-growing into the surrounding tissues within the brain. Cause they very, very rarely would spread outside of the brain. And we talk about them as tumors because it, whether they’re benign or metastatic, they’re both very dangerous and treated in mostly the same way. What are the risk factors for brain tumors?  Age really isn’t one. I’m just saying it could be any age, even children getting brain tumors. It’s actually the second, most common cancer in children, but there are risk factors: prior radiation treatment is one of them. So whether you were treated for cancer in the past, or if you had radiation to your brain for something else, they used to use radiation for a lot of different things that, we don’t really use it for anymore, but you might see that in the,  in different generations. 

And it has been linked to certain genetic disorders. These are also written in the outline, guys, check them out because I’m not going to write them out there. Other long words, neurofibromatosis, Li-Fraumeni and Turcot syndromes, and those are linked to several different cancers. And then a weakened immune system, especially HIV has been linked very heavily to the CNS lymphoma. Okay. Intracranial pressure is important to mention when we’re talking about brain cancer because we know, we have pretty limited space within our cranial volt, right? That’s what I drew here. That’s a big brain for this person. This is our brain, right? Okay. There’s not a whole lot of room. There is just not a whole lot of room in this area for any change in pressure. Normal intracranial pressure is between five and 15 and our body can change that a little bit. 

It’s impacted by CSF and blood flow and also brain tissue. If it increases, if it keeps going up that can equal brain tissue death. And as a tumor is growing within this very limited cavity, it can increase ICP. And that needs to be addressed immediately. That can cause brain tissue, death. So symptoms of intracranial pressure:  nausea, vomiting, altered level of consciousness and seizure activity. So those would be just general signs of increased ICP and brain tumors. Now we also have the focal symptoms related to the area of the brain that is impacted. I talked a little bit about this at the beginning of the lesson. So sensory changes if we’re impacting these lobes that have to do with hearing and vision, right? We’ll have sensory changes, personality changes, especially with that frontal lobe, possibly the parietal lobe weakness and ataxia that would have a lot to do here with the cerebellum. 

So ataxia, that’s kind of a fancy nurse word, right? Ataxia is impaired balance and coordination. And I mentioned before, the cerebellum is huge in this involvement. So these people slowly progressed to having a loss of their motor function or a change. I’ll never forget. I had a patient come into a clinic once I had been seeing him frequently and suddenly his gait, the way he walked, was just a little bit different. And the oncologist came over to see and the oncologist said, touch your finger to your nose. And he was able to do that. And then the oncologist said, touch your finger to this pencil I’m holding out. And he just couldn’t quite get it. He wasn’t coordinated enough to do that. And that was a sign oncologist right away knew that the patient had metastasis to the brain treatment.
We need to decrease that intracranial pressure. 
If that’s high immediately, that can be done with steroids. We give dexamethasone IV and it works quick guys. It’s surprising how much they improve with steroids cause that decreases inflammation or some patients will have a shunt. And that’s what this picture is of. So this is draining fluid from the ventricles down this shunt, to decrease the intracranial pressure. Surgeries- craniotomy,  to remove the tumor. Uh, sometimes it can not be removed and we have to use radiation and chemotherapy. Radiation is very effective against brain tumors. I’ve seen a lot of patients do really well with radiation treatment, even if the goal is not to cure, but just to improve symptoms, it does work pretty well. And then chemotherapy: Remember we have to cross that blood-brain barrier. So there are certain chemos that can cross it given in the vasculature. 

But oftentimes we give chemo directly to the CNS that can be done through a shunt. It’s called an Omar, or I’m sorry, a port it’s called an Ommaya reservoir. It’s actually, it stays in the head once it’s been surgically placed. And once it’s there, surgeons can, or oncologists can give chemotherapy directly into this reservoir. And then it goes to the ventricles. Also, the chemo can be given via a lumbar puncture directly to the CNS. Okay. So education for our patients: we need to talk about the side effects of the treatments that they’re going through. We need to talk about postop considerations and then the risk of recurrence. We need them to watch out for headaches, which is often a sign of recurrence or things like vision changes. Any of the symptoms of the cancer nursing concepts cellular regulation went out of whack, right? Cognition and intracranial regulation because our brain is impacted. We might have big changes to those key points here, takeaways, brain tumors, whether it’s benign or malignant, it can still be very dangerous, increased intracranial pressure needs to be treated immediately. Steroids are often the first line, the blood-brain makes treating with chemo difficult. And the location of the tumor is going to determine the symptoms that we see. All right, that’s all I have guys. We love you. Go out and be your best self today. And as always happy nursing.

 

 

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