Brain and spinal cord malignant tumors account for 1.4% of all cancers and 2.4% of all cancer-related deaths. Because of the difficulty with pathological discrimination and absence ofmetastasis, the clinical staging method is not used to describe brain cancer. Rather, tumors are classified as low grade or high grade. Although there are a wide variety of histologic types (Table 3), a small number of tumor types account for most morbidity and mortality. Average survival time for persons with a low-grade astrocytoma is 6 to 8 years; the average survival time for a person with a glioblastoma is 12 months.
Most brain tumors are not associated with any risk factors. Evidence suggests that therapeutic radiation for other purposes (e.g., leukemia) may predispose one to later development of a brain tumor. Brain tumors are also more common in the immunosuppressed population.
Nursing care plan assessment and physical examination
Symptoms produced by tumors vary by cell type and location and may cause generalized or focal symptoms. Although clearly every case of headache or dizziness is not a sign of brain tumor, it must always be considered. Any of the following indicate the possibility of a brain tumor: headache, progressive neurological deficit, convulsions (focal or generalized), increased intracranial pressure (ICP), and organic mental changes.
The generalized symptoms are usually caused by increased ICP from the tumor, obstruction of the cerebrospinal fluid (CSF) pathways, or cerebral edema. Headache and vomiting are the most common first symptoms of increased ICP. Typically, headache is worse in the morning and may waken the patient from sleep. The patient or significant others may also report personality changes (irritability initially, progressing to apathy and forgetfulness), increased fatigue, decreased endurance, visual disturbances, and a tendency toward social withdrawal. Generalized seizures are the presenting symptoms in 15% of adults and 30% of children. Focal signs and symptoms result from local pressure or damage to limited parts of the brain and depend on the area of the brain affected. Tumors in the dominant hemisphere produce communication difficulties (aphasia); tumors near an optic tract will produce changes in visual fields. A lesion in the temporal lobe may lead to temporal lobe seizures that are exhibited by unexplained olfactory sensations, visual auras, or psychomotor seizures, all of which may be misdiagnosed as psychological problems or mental illness.
Inspect the child suspected of a brain tumor before the sutures are closed; there may be head enlargement or bulging of the fontanelles from increased ICP. In rare cases, an adult with meningioma may have skull bulging. The appearance of the optic disc may change; if the tumor compresses the optic nerve, it will remain flat or atrophy. If ICP is increased, papilledema is possible. Perform a thorough neurological examination to identify changes in vision, hearing, sensation, and movement. A tumor may exert local pressure causing apraxia (inability to use objects), paresthesia (numbness and tingling), paresis (partial or incomplete paralysis), or hyperreflexia.
Assess for the presence of irritability and personality changes. Changes in a person’s mental status and ability to perform various roles are extremely disturbing to patients and significant others. Families and patients often display profound grief, extreme anxiety, and disbelief upon receiving the diagnosis of a brain tumor.
Nursing care plan primary nursing diagnosis: Decreased intracranial adaptive capacity.
Nursing care plan intervention and treatment
The type of treatment used for brain cancer depends on the type of tumor. The primary modes of treatment include surgery, radiotherapy, and pharmacologic therapy.
Surgery remains the primary treatment modality. A craniotomy is done to remove larger tumors. This involves making a surgical opening in the cranium to remove the tumor and inspect various areas of the brain; reconstruction is required. Stereotactic surgery involves insertion of a needle through a small opening in the skull to “suction out” the small tumor. The goals of surgery are (1) total removal of the tumor, (2) subtotal removal to relieve symptoms, or (3) procedures to protect the brain from damage, for example, placement of a shunt to relieve hydrocephalus. Other modalities are used in combination. After the surgery, the patient needs careful monitoring for increased ICP. Notify the surgeon if the bone flap becomes elevated, which is a sign of increased ICP. The physician usually manages cerebral swelling and elevated ICP with fluid restriction (usually 1500 mL or less in 24 hours), steroids, shunt placement, and osmotic diuretics such as mannitol.
For tumors that are not accessible to surgical removal, radiation may be used. Locally contained tumors receive direct beam radiation focused on the lesion. For multiple lesions, especially metastatic brain lesions, whole-brain radiation therapy (WBRT) is used. Radiation is usually not used in children younger than 2 years of age because of the long-term effects—panhypopituitarism, developmental delay, and secondary tumors.
The first priority is to ensure that the airway is patent. Keep equipment to manage the airway (endotracheal tube, laryngoscope, nasal and oral airway) within easy access of the patient. Make sure that working endotracheal suction is at the bedside. Note that an obstructed airway and increased levels of carbon dioxide contribute to increased ICP in patients with a space-occupying lesion. Keep the patient comfortable but not oversedated. If the patient is awake, encourage him or her to avoid Valsalva’s maneuver and isometric muscle contractions when moving or sitting up in bed to limit the risk of increased ICP. Perform serial neurological assessment to watch for sudden changes in mental status. To reduce ICP and optimize lung expansion, place the patient in semi-Fowler position. Keep the head in good alignment with the body to prevent compression on the veins that allow for venous drainage of the head. Avoid hip flexion. Assist the patient to turn in bed and perform coughing, deep breathing, and leg exercises every 2 hours to prevent skin breakdown, as well as pulmonary and vascular stasis. As soon as allowed, help the patient get out of bed and ambulate in hallways three to four times each day. If the patient has sensory or motor deficits, work with the rehabilitation team to encourage activities of daily living and increased independence.
Patients who have been newly diagnosed with brain cancer are often in emotional shock, especially when the disease is diagnosed in the advanced stages or is inoperable. Encourage the patient and family to verbalize their feelings surrounding the diagnosis and impending death.
Assist family members in identifying the extent of home care that is realistically required by the patient. Arrange for visits by a home health agency. Suggest supportive counseling (hospice, grief counselor), and if necessary, make the initial contact. Local units of the American Cancer Society offer assistance with home care supplies and support groups for patients and families. Also refer patients to the American Brain Tumor Association, the Brain Tumor Society, and the National Brain Tumor Foundation. Instruct the patient to use the pain scale effectively and to request pain medication before the pain escalates to an intolerable level. Consider switching as-needed pain medication to an around-the-clock dosing schedule to keep pain under control.
Nursing care plan discharge and home health care guidelines
Consult with occupational and physical therapists to develop an appropriate rehabilitation plan, if one is needed. Discuss aids for self-care and mobilization such as wheelchairs, bathroom rails, and speech aids and where and how they can be obtained. Evaluate the home situation before discharge to determine if wheelchair access is available if it is necessary. Teach the patient and family strategies to avoid exposure to infection. If the patient develops an infection or notes increased bleeding, teach the patient to notify the primary healthcare provider immediately. Teach the patient and significant others the early signs of tumor recurrence so that they can notify the primary healthcare provider if they occur. Instruct the patient on care of the skin in the external radiation field. Stress the need to maintain a schedule for follow-up visits as recommended by the physician.
Explain the purpose, action, dosage, desired effects, and side effects of all medications prescribed by the physician.