Managing Patients with Brain Tumors - 3 Nursing CEs

Author: Kristi Hudson RN MSN CCRN

Written: January 2, 2007

Updated: September 25, 2009

Course Description

This course is designed to give an overview of the patient with a brain tumor. Focus will be placed on the classifications of brain tumors as well as the pathophysiology. Signs and symptoms as well as diagnosis for brain tumors will also be presented. Medical treatment and commonly used chemotherapy drugs will also be discussed. Nursing management pre/post-op, during radiation and chemotherapy therapy will also be presented. A list of both physical and emotional nursing diagnoses for the patient with a brain tumor will be final focus of this course.

Course Objectives

Upon completion of this course the student will be able to:

• Differentiate different classes of brain tumors.
• Describe the pathophysiology of a brain tumor.
• State 3 common side effects of a brain tumor.
• Discuss medical treatment options for the patient with a brain tumor including radiation, chemotherapy and surgical intervention.
• Describe the key components of nursing management for the patient with a brain tumor.
• List 3 nursing physical and emotional nursing diagnoses for the patient with a brain tumor.

Overview of Brain Tumors:

The diagnosis of a brain tumor can start a long course of uncertainty for patients and family members. Patients with brain tumors are often experience a level of neurological and cognitive deterioration coupled with the fear of being diagnosed with a possibly deadly condition. This requires care of the patient and family to be administered with additional sensitivity and compassion. Although the cause of most nervous system tumors remains unknown, it is thought that some of the following are contributing factors:

• Inherent Genetic Syndromes – Neurofibromatosis type I and II, Tuberous Sclerosis, and von Hippel-Lindau Disease.
• Congenital Based – Epidermoid, Dermoid, Teratoid and Craniopharyngiomas.
• Environmental Agents thought to Cause Brain Tumors – Ionizing and Radiation agents.

Classification of Brain Tumors:

Classification of a brain tumor is based primarily on historical pathology and characteristics of the tumor itself. The following is a list of the major classifications of brain tumors:

• Gliomas
  • Astrocytic tumors
  • Ependymomal tumors
  • Oligodendroglial tumors
  • Medulloblastoma
• Meningiomas
• Pituitary Adenomas
• Neruinoma (schwannoma, acoustic neuronma)
• Craniopharyngioma (dermoid, epidermoid, teratoma)
• Angiomas
• Sarcomas
• Miscellaneous (pinealoma, chordoma, granuloma, lymphoma)

Pathophysiology of Brain Tumors:

The pathophysiology of most brain tumors is viewed on both a molecular level as well as the effect that the tumor has on surrounding brain tissue (both directly and indirectly).

Molecular considerations include the following:

• The fact that brain tumors arise in association with multiple specific structural molecular genetic alterations (i.e. mutations).
• These mutations can cause the cell to proliferate inappropriately which results in malignancy.
• There are two types of genetic molecular alterations that trigger the changes seen in cellular behavior and these are:
  • Complete cessation or partial decrease in cellular activities which physiologically restrains growth (these genes are known as “tumor suppressor genes).
  • Inappropriate activation of genes that are known to enhance cellular proliferation (these genes are known as “proto-onco-genes”).

The effects of a “Space Occupying Lesion” within the brain:

• Through compression of cerebral tissue, tumors directly affect the brain. Brain tumors usually grow as spherical masses until they encounter a more rigid structure such as bone or the falx cerebri which requires the tumor to change course.
• Neoplastic cells can grow diffusely and causes multiple cells to infiltrate tissue spaces without forming a defined mass.
• These tumors enlarge due to cell proliferation, necrosis, fluid accumulation, hemorrhage or accumulation of degenerative by-products within the mass.
• The clinical effects of a tumor depend on type, location and rate of growth. For example:
  • Meningiomas are slow growing and can become quite large before the patient experiences any symptoms.
  • Glioblastomas are fast growing and almost immediately causes the patient to develop symptoms of increased intracranial pressure (ICP).

Signs and Symptoms of Brain Tumors:

The location and size of a tumor determines for the most part, the signs and symptoms the patient will experience. General signs and symptoms of a brain tumor include:

• Headache (this is an early sign).
• Nausea and Vomiting (may be a sign of increased ICP).
• Changes in level of consciousness (initial signs may be subtle).
• Seizures (a new onset of seizures should prompt and immediate search for the underlying cause).

Focal signs and symptoms:

Focal findings are often present and assist the healthcare provider in localizing the tumor. The following are focal signs and symptoms as they relate to a specific section of the brain.

Anterior Frontal Lobe (higher level functioning/personality deficits):

• Short/Long term memory loss
• Difficulty problem solving, concentrating and calculating
• Slowness of reaction time and abstraction
• Behavioral changes
• Emotional lability
• Flat affect
• Lack of initiative/spontaneity
• Loss of self restraint
• Loss of social behavior

Posterior Frontal Lobe (Broca’s Area):

• Fluent speech deficits
• Difficulty with word finding
• Motor weakness
• Focal seizure activity

Parietal Lobe (Sensory discrimination, vision, language and body orientation):

• Deficits in sensation
• Inability to recognize common objects/numbers/letters
• Neglect syndrome (such as being unaware of ½ of the body)
• Loss of left-right discrimination

Temporal Lobe (Wernicke’s area is located in the dominant temporal lobe):

• Psychomotor deficits
• Weakness
• Seizures
• Visual field deficits
• Memory deficits
• Hallucinations
• Automatism
• Amnesia

Occipital Lobe (tumors in this area are infrequent):

• Visual deficits
• Homonymous
• Quadrantanopia (loss of vision in ¼ of the visual field)
• Visual hallucinations
• Inability to recognize common objects

Pituitary/Hypothalamus Region (these areas are closely related by area and endocrine function):

• Visual deficits
• Extra-occular muscle paralysis
• Headache
• Endocrine dysfunction
• Cushing’s Syndrome
• Giantism
• Acromegaly
• Hypopituitarism

Lateral and Third Ventricles (patients with small tumors in this region will likely be asymptomatic):

• Obstructive CSF disorders
• Headache
• Nausea and vomiting
• Rapidly increased ICP

Brain Stem (brain stem tumors produce multiple symptoms):

• Cranial nerve deficits (swallowing, articulation, gag, vision etc.)
• Motor deficits (ataxia, lack of coordination,)
• Sensory deficits
• Nystagmus (vertigo, nausea, vomiting)
• Obstructive hydrocephalus
• Sudden death

Mid Brain (neoplasm’s of the mid brain are rare):

• Visual deficits and defects (paralyzed upward gaze, ptosis and diminished light reflex).

Fourth Ventricle (Obstructive flow of CSF):

• Headache
• Nausea and vomiting
• Nuchal rigidity
• Compression of the cardiopulmonary center (can cause sudden death)
• Increased ICP

Cerebellum (usual signs of increased ICP):

• Ataxia (incoordination)
• Nystagmus
• Vertigo
• Obstruction of CSF
• Headache
• Nausea and vomiting
• Changes in vital signs

Diagnosis of Brain Tumors:

The clinical manifestations as noted above span a wide range of signs and symptoms. After attaining a complete medical history and neurological assessment; diagnosis of a brain tumor can be confirmed with the following tests:

• Computed Tomography (CT) – with and without gadolinium contrast is the procedure of choice for imaging all types of brain tumors.
• Magnetic Resonance Imaging (MRI) – recommended for high sensitivity and location of small tumors as well as those located near a bone especially in the posterior fossa, pituitary fossa, internal auditory canal and floor of the middle cranial fossa.
• For tumor located around the optic region, careful mapping of the visual fields should be done by an ophthalmologist.  
• Endocrine studies (blood, urine, hormone levels) are helpful for suspected tumors in the pituitary and hypothalamus regions.

Medical Treatment of Brain Tumors:

The three recommended methods of medical management for brain tumors are surgical intervention, radiation and chemotherapy. The determining factors for choosing to correct intervention include the type and grade of the tumor, the tumor location and size, surgical accessibility, presenting signs and symptoms and the general condition of the patient. The final decision is one that must include the patient in the decision making process.

Surgical Intervention – surgical intervention is the most common approach to treatment for a brain tumor. In most cases a surgical biopsy if first preformed to assure an accurate diagnosis of a brain tumor. Examination of the tissue can help determine the histological grade and hence help determine which treatment option will be most effective. Surgical removal of a tumor includes a complete or partial removal of the tumor depending on location, accessibility and the risk of injuring surrounding tissue.

Radiation Therapy – radiation is the second most common treatment for a brain tumor. The objective of radiation therapy is to destroy the tumor cells without injuring the surrounding tissue. The following radiation options are the cornerstone for brain tumor treatment:

• Standard Radiation Therapy (standard fractional external beam radiation therapy uses x-rays or gamma rays to destroy tumor cells).
• Hyperfractionation (a prescribed dose of radiation given in a “timed” course)
• Stereotactic Radiosurgery (this is a system that used focused radiation with a sophisticated planning system in a single dose).
• Gamma Knife – (this procedure is used for AVMs and deep and difficult to access tumors. It focuses on being able to use large doses of radiation while minimizing damage to surrounding tissue).
• Interstitial Brachytherapy (this is where radioactive seeds are planted in the tumor bed).
• Stereotactic Radiotherapy (this combines stereotactic focused radiation with multiple fraction or daily small doses of radiation).

Responses to Radiation Therapy – Failure to completely annihilate malignant cells can be a problem. Because hypoxic cells (found in brain tumors) are three times more resistant to radiation then normal well oxygenated cells, not all patients respond well to radiation therapy. Side effects from radiation therapy can also be a problem for patients. Depending on the size and location of the brain tumor common side effects from radiation therapy include:

• Loss of pituitary function
• Diminished intellectual function
• Hydrocephalus
• Cerebral necrosis (less common)

Chemotherapy – chemotherapy is most commonly used in combination with either surgical intervention and/or radiation. Chemotherapeutic drugs work by interfering with the transmission of genetic information that is necessary for tumor cells to grow or replicate. The following table describes commonly used chemotherapeutic drugs used to treat brain tumors:

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