SAMARTH NURSING COLLEGE,

DERVAN

SUBJECT: MEDICAL SURGICAL

NURSING

SEMINAR
ON
BRAIN TUMOR

SUBMITTED TO, SUBMITTED BY,

Mr. Arunkumar.V.N Ms. Priyanka Deorukhkar
Associate Professor First Year M.Sc. Nursing
Medical Surgical Nursing Samarth Nursing College,
Samarth Nursing College, Dervan.
Dervan.

SUBMITTED ON,
15/05/2021
 BRAIN TUMOR

INTRODUCTION:
A Brain Tumor is a collection or mass of abnormal cells in brain. Skull
which encloses the brain is very rigid, any growth inside this restricted place can cause
problems.
When these tumors grow inside the brain it increases intracranial pressure
which can cause brain damage and may be even life threatening. When most normal
cells grow old and get damaged’ they die and new cells take their place. Sometimes this
process goes wrong. New cells form when body doesn’t need them and old or damaged
don’t die as they should. The buildup the extra often forms a mass of tissue called a
growth or Tumor.

ANATOMY AND PHYSIOLOGY:

The brain is an amazing three-pound organ that controls all functions of the
body, interprets information from the outside world, and embodies the essence of the
mind and soul. Intelligence, creativity, emotion and memory are a few of the many
things governed by the brain. Protected within the skull, the brain is composed of the
cerebrum, cerebellum and brainstem.
The brain receives information through our five senses: sight, smell, touch, taste
and hearing- often many at one time. It assembles the messages in a way that has
meaning for us and can store that information in our memory. The brain controls our
thoughts, memory of the arms and legs and the function of many organs within our
body.
The central nervous system (CNS) is composed of the brain and spinal cord. The
peripheral nervous system (PNS) is composed of spinal nerves that branch from the
spinal cord and cranial nerves that branch from the brain.
 Brain:
The brain is composed of the cerebrum, cerebellum and brainstem.
1. Cerebrum:
Cerebrum is the largest part of the brain and is composed of right and
left hemispheres. It performs higher functions like interpreting touch, vision
and hearing as well as speech, reasoning, emotions, learning and fine control
of movement.

2. Cerebellum:
Cerebellum is located under the cerebrum. Its function is to coordinate
muscle movements, maintain posture and balance.

3. Brainstem:
Brainstem acts as a relay center connecting cerebrum and cerebellum
to the spinal cord. It performs many automatic functions such as breathing,
heart rate, body temperature, wake and sleep cycle, digestion, sneezing,
coughing, vomiting and swallowing.

 Right brain - Left brain:

The cerebrum is divided into two halves; the right and left hemispheres.
They are joined by a bundle of fibers called the corpus callosum that transmits
messages from one side to the other. Each hemisphere controls the opposite
side of the body. If a stoke occurs on the right side of the brain, your left arm or
leg may be weak or paralyzed.
Not all functions of hemispheres are shared. In general, the left
hemisphere controls speech, comprehension, arithmetic and writing. The right
hemisphere controls creativity, spatial ability, artistic and musical skills. The
left hemisphere is dominant in hand use and language in about 92% people.

 Lobes of the brain:

The cerebral hemispheres have distinct fissures, which divides brain into
lobes. Each hemisphere has 4 lobes; frontal, temporal, parietal and occipital.
 1. Frontal lobe:
I. Personality, behavior, emotions
II. Judgment, planning problem solving
III. Speech- speaking and writing (Broca’s area)
IV. Body movement (motor strip)
V. Intelligence, concentration, self-awareness

2. Parietal lobe:
I. Interprets language, words
II. Sense of touch, pain, temperature (sensory strip)
III. Interprets signals from vision, hearing, motor, sensory and
memory
IV. Spatial and visual perception

3. Occipital lobe:
I. Interprets vision (color, light, movement)

4. Temporal lobe:
I. Understanding language (Wernicke’s area)
II. Memory
III. Hearing
IV. Sequencing and organization

 Ventricles and cerebrospinal fluid:

The brain has hollow fluid-filled cavities called ventricles. Inside the
ventricles is a ribbon-like structure called the choroid plexus that makes clear
colorless cerebrospinal fluid (CSF). CSF flows within and around the brain and
spinal cord to help cushion it from injury. This circulating fluid is constantly
being absorbed and replenished.
There are two ventricles deep within the cerebral hemispheres called
the lateral ventricles. They both connect with the third ventricle through a
separate opening called the foramen of Monro. The third ventricle connects
with the fourth ventricle through a long narrow tube called the aqueduct of
Sylvius. Fromm the fourth ventricle CSF flows into the subarachnoid space
where it bathes and cushions the brain. CSF is recycled (or absorbed) by
special structures in the superior sagittal sinus called arachnoid villi.
The balance is maintained between the amount of CSF that is
absorbed and the amount that is produced. A disruption or blockage in the
system can cause a buildup of CSF, which can cause enlargement of ventricles
(hydrocephalus) or cause a collection of fluid in the spinal cord
(syringomyelia).

DEFINITION:
 1. Brain tumor is a cancerous or non-cancerous mass or growth of
abnormal cells in the brain.
2. A benign or malignant growth in the brain. Primary brain tumors
initially form in brain tissue. Secondary brain tumors are cancers that
have spread (metastasized) to the brain tissue from tissue elsewhere in
the body.

INCIDENCE AND PREVELANCE:

Today, nearly 700,000 people in the United States are living with primary brain
tumor, and approximately 23,890 adults (13,590 males and 10,300 females) will be
diagnosed with primary brain tumor.
About 3,540 children under the age of 15 will also be diagnosed with brain and CNS
tumor this year.
In India ranges from around 5 to 10 cases per 1,00,000 population.
The largest percentage of childhood tumor i.e. 17% located in frontal, parietal and
occipital lobe followed by cerebellum (16%) and brain stem (11%)

RISK FACTORS:
A risk factor is something that may increase the chance of getting a disease.
Studies have found the followings risk factors for brain tumors;
1.Ionizing Radiations: Especially from higher dose x-rays and other sources can cause
cell damage that leads to a tumor. Most common types are meningioma or glioma.
2. Family History: It is rare for brain tumors to run in a family. Only a very few numbers
of families have several members with brain tumors.

SIGNS AND SYMPOMS:

1. The symptoms of a brain tumor depend on tumor size, type and location.
2. Symptoms may be cause when a tumor presses on the nerve or harms the part of
the brain.
3. Most common symptoms of brain tumors are;
 Headaches (usually worse in the morning)
 Nausea and vomiting
 Changes in speech, vision or hearing
 Problems balancing or walking
 Changes in mood, personality or ability to concentrate
 Problem with memory
  Muscle jerking or twitching (seizures or convulsions)
 Numbness or tingling in the arms or legs
 Papilledema (swelling of optic nerve)

4. Specific Signs and symptoms;

Few clinical features are related to functional areas of the brain thus have a
specific localizing value in medically diagnosing a brain tumor;
 Frontal lobe- Hemiparesis, Seizures, Aphasia and Gait difficulty with growth
of tumor there may be personality changes like Disinhibition, irritability,
impaired judgement and lack of initiation.
 Parietal lobe- Contralateral sensory loss and hemiparesis, Homonymous
visual deficits or neglect, agnosia, apraxia and visual disorders. If dominant
parietal lobe is involved aphasia may be present. If non-dominant Parietal
lobe is involved contralateral neglect and decreased awareness of
impairments can commonly be found.
 Occipital lobe- Dysfunction of the eye movement and homonymous
hemianopsia. If parietooccipital junction is involved, visual agnosia and
agraphia are often present. Bilateral tumor may cause cortical blindness.
 Temporal lobe-
i. Anterior lesion- Clinically silent until they become very large and
causing seizers.
ii. Lateral side- Auditory and perceptual changes.
iii. Medial side- Changes in cognitive integration, long term memory,
learning and emotions may be seen.
iv. Dominant temporal lobe- Aphasia.
v. Left temporal lobe lesion- Anomia, agraphia, acalculia, Wernicke
aphasia (Fluent, nonsensical speech).
vi. Bitemporal involvement- It is rare and causes memory deficits and
possible dementia.
 Cerebellum-
i. Lesion of midline- Truncal and gait ataxia.
ii. Lesion of Hemispheres- Uni. Appendicular ataxia mostly in UE.
iii. Lesion of either Hemisphere- Ipsilateral dysmetria,
dysdiadochokinesia and intentional tremor.
iv. Lesion in cerebellopontine angle- hearing loss, headache, ataxia,
dizziness, tinnitus and facial palsy may occur.
 Brain stem- Gait disturbance, diplopia, focal weakness, headache, vomiting,
facial numbness and weakness and personality changes.
 Pituitary gland-
i. Lateral extension- 3rd and 4th cranial nerve diplopia, 5th nerve
(Ipsilateral facial numbness), Internal carotid artery occlusion
(Cerebral Infarction).
ii. Upward extension- Compresses optic chiasma and hypothalamus.
iii. Downward extension- Compresses sphenoid sinus.
PATHOPHYSIOLOGY:
 (Monrokellies Hypothesis)
Fast Growing Tumor

Increased ICP
Compensatory mechanism
Reduction in volume of blood and CSF
 Initial compensatory mechanism-

Displacement of CSF in to spinal cord and subarachnoid space

Impairment of venous drainage

Venous congestion and papilledema

 Secondary Compensatory Mechanism-

Reduction in blood volume

Hypoxia

Ischemia

Tumor growth

Compression of veins

Decreased absorption of CSF Increased capillary permeability

Cerebral edema
 Last Stage of Compensation-
Increased ICP

Displacement of brain tissue

 Death

DIAGNOSIS EVALUATION:
1. Clinical Diagnosis-
 History collection.
 Neurological examination- Testing of reflexes and assess visual, cognitive,
sensory and motor function.
 Physical examination (especially eyes examination).

2. Radiological Diagnosis-
 Tumor imaging are classified into 3 categories;
i. Static imaging - (CT Scan, MRI)
a) CT Scan:
-It was the first brain imaging technique to allow determination of
tumor size.
-Contrast enhancement helps to identify isodense tumor from
surrounding parenchyma, hypodense, lesions in edematous areas
and optimal sites for tumor biopsy.
b) MRI:
-Contrast enhancement with gadolinium sharpens the definition of
lesion.
-MRI enhanced with gadolinium can distinguish between edema and
tumor.

ii. Dynamic imaging – (PET, SPECT, MRS, Functional MRI)

a) PET Scan:
-It is non-invasive and uses cyclotron and specific isotopes to obtain
information about mechanism and physiology of the tumor and
surrounding tissue.
-It uses radioactive markers to measure glucose metabolism which
is useful to determine the grade of primary tumor. It also helps in
study of metabolic effect of chemotherapy, radiation therapy and
steroids on the tumor.
-It is expensive and less reliable in patient with heavy dose of
chemotherapy.

b) SPECT:
 -It is functional imaging technique evolved from PET scan and uses
isotopes w/o cyclotron to assess cerebral blood flow and
determining tumor location.
-It is used to identify high-& low-grade tumor to differentiate
between tumor recurrence and radiation necrosis.
-It is used pre-op with static imaging to localize highest metabolic
area of tumor for biopsy.
c) Magnetic Resonance Spectroscopy:
-It is non-invasive technique used in conjunction with static MRI to
measure the metabolism of brain tumors.
-It has been proved to differentiate successfully normal brain from
malignant tumor and recurrent tumor from radiation necrosis.
-It also has been used to document early treatment response and
provide information regarding histological grade of astrocytoma.
d) Functional Magnetic Resonance Imagining:
-It uses a conventional MRI scanner fitted with echo planar
technology to map cerebral blood flow at the capillary level.
-Its intended purpose is to provide information regarding the
diffusion of contrast into tumor, resulting in better resolution of
tumor and edema.
-It can also be used to identify the motor, sensory and language
areas of the brain or the functional eloquent cortex.

iii. Computer Integration Imaging –

- Modern computer technology allows for the two- and three-
dimensional reconstruction of identical planes in cranial space by
combining tumor images from different modalities, including CT,
MRI, PET and SPECT.
- Computed integration imaging involves the simultaneous display
of images from different techniques in a single imaging system that
is transposed to a reference stereotactic frame.
- This development has resulted in significant advances in
stereotactic biopsy, interstitial radiotherapy and laser-guided
stereotactic resection.
- It provides a safer, more accurate method of tissue acquisition and
biopsy.
3. Biopsy-
 Surgical biopsy is performed to obtain tumor tissue as part of tumor resection or
as a separate diagnostic procedure.
 Stereotactic biopsy is a computer-directed needle biopsy. When guided by
advanced imaging tools, stereotactic biopsy yields the lowest surgical morbidity
and highest degree of diagnostic information.
 This technique is frequently used with deep-seated tumors in functionally
important or inaccessible areas of the brain in order to preserve function.
4. Laboratory diagnosis-
 Laboratory testing is often used to further assess focal deficits during the
diagnosis and management of brain tumors.
 Perimetry is the measurement of visual fields used when evaluating tumors near
the optic chiasm.
 Electroencephalography (EEG) is used to monitor brain activity and detect
seizures but has limited value during screening because EEG findings are often
normal in clients with brain tumors.
 Lumbar puncture is used to analyze CSF, which is useful in the diagnosis and
detection of dissemination of certain brain tumors.
 Audiometry and vestibular testing are useful for diagnosing tumors in the
cerebellopontine angle.
 Endocrine testing is used to examine endocrine abnormalities with tumors in the
pituitary gland and hypothalamus.

TREATMENT:
1. Medical and surgical management:
 The ultimate goal of tumor management is to improve quality of life and
extend survival by improving body function and structures.
 Treatment techniques are determined by histological type, location, grade
and size of tumor, age of onset; and medical history of the patient.
 Four types of treatment are discussed:
i. Traditional Surgery.
ii. Chemotherapy.
iii. Radiation Therapy.
iv. Stereotactic Radiosurgery.

I. Traditional Surgery:
 Maximal tumor resection with the least amount of damage to neural
or supporting structures.
 The purposes of surgery in the management of brain tumors
include the following;
a) Biopsy to establish the diagnosis.
b) Partial resection to decrease the tumor mass to be
treated by other methods.
c) Complete resection of the tumor.
d) Provision of access for adjuvant treatment
techniques.

a) Biopsies are performed through open, needle and stereotactic

needle techniques.
 Open biopsies involve exposure of the tumor followed by
removal of a sample through surgical excision.
  Needle biopsies involve insertion a needle into the tumor
through a hole in the skull and the excision of the tissue
sample drawn through the needle.
 Stereotactic needle biopsies use computers and MRI or CT
scanning equipment to assist in directing the needle into the
tumor.
b) Partial & Complete Resections are accomplished through
craniotomy.
 Craniotomy involves removal of a portion of the skull and
separation of the dura mater to expose the tumor.
 Stereotactic craniotomy uses technology to guide
neurosurgeon during the procedure.
 Awake craniotomy allows for intra-op brain mapping.
- Preoperative Management: During surgery, precautions are taken
to prevent an increase in edema or ICP.
 Mannitol (aposiopetic) and hyperventilation is used to
decrease ICP,
 Steroid use is continued and antibiotics administered to
prevent infection.
- Postoperative Management: Patients are observed in an intensive
care unit for at least 24 hrs for possible intracranial bleeding or
seizures. Blood pressure is monitored continuously.
Post-op these patients are more prone to DVT but due to
the risk of intracranial bleeding, a coagulant cannot be given so
Compression stockings are used prophylactically.
Steroids are tapered in 5-10 days post-op.

II. Chemotherapy:

 It can be used independently or as an adjuvant to surgery or

radiation.
 Chemotherapy can be administered in a number of different
ways.
 Most agents are given intravenously through a peripheral
intravenous line or through a catheter such as a peripherally
inserted central catheter (PICC).
 Chemotherapy drugs impede cellular replication of the
tumor cells, interfering with their ability to copy
deoxyribonucleic acid (DNA) and reproduce.
 Methotrexate (Highly neuro-toxic) is administered with
Leucovorin (Antidote)
 Temozolomide is orally available chemotherapeutic agent
for the treatment of Gliomas.
 The antiangiogenetic monoclonal antibody. Avastin
(bevacizumab) improved the progression – free survival and
 the tumor images on MRIs of patients with glioblastoma. The
drug targets vascular endothelial growth factor (VEGF) and
is administered intravenously.

III. Radiation Therapy:

 It can be used alone or in conjunction with surgery or
chemotherapy to treat malignant brain tumors.
 It is typically chosen as a treatment option for tumors that
are too large or inaccessible for surgical resection and to
eradicate residual neoplastic cells after a surgical debulking.
 Radiotherapy consists of the delivery of high-powered
photons with energies in a much greater range than that of
standard x-rays, as an external beam directly at the tumor
site.
 Hyper fractionated radiation therapy is believed to increase
the efficacy and decrease the long-term side effects of
radiation.
 Conformal radiation delivery is the Peacock system. This
method attempts to deliver a uniform amount of radiation to
the tumor and minimize irradiation of healthy brain tissue.
 Radiosurgery involves relatively high-dose hypo
fractionated radiation beams directed at small tumor areas
through the use of computer imaging. This type of treatment
includes the Gamma Knife, linear accelerators and the
cyberknife.

IV. Stereotactic Radiosurgery:

 Stereotactic radiosurgery is defined as delivery of a high
dose of ionizing radiation, in a single fraction, to a small,
precisely defined volume of tissue.
 The high-energy accelerators involved with stereotactic
radiosurgery improve the physical effect of radiation by
allowing energy to travel more precisely in a straight line
and penetrate deeper before dissipating.
 The goal of stereotactic radiosurgery is to arrest tumor
growth.
 Stereotactic radiosurgery is used to treat benign and
malignant tumors, vascular malformations and functional
disorders. The primary modes of administration for
stereotactic radiosurgery include the Gamma Knife, linear
accelerators and the cyberknife.
 2. Supportive Care:
 A brain tumor and its treatment can lead to other health problems.
You may receive supportive care to prevent or control these
problems.
 You can have supportive care before, during and after cancer
treatment.
 It can improve your comfort and quality of life during treatment.

 Health care team help you with following problem;
- Swelling of the brain
- Seizures
- Fluid buildup in the skull
- Sadness and other feeling

3. Rehabilitation:
 Rehabilitation can be a very important part of treatment plan. The
goals of rehabilitation depend on your needs and how the tumor has
affected your ability to carry out daily activities.
 Several types of therapists can help;
- Physical therapists
- Speech therapists
- Occupational therapists
- Physical Medicine Specialist
 Rehabilitation is a key component and the management of the client
with a brain tumor.
 With advances in technology and treatment intervention, survival
rates of people with cancer have improved.
 Ultimate goal for rehabilitation is by preventing complications,
maximizing function and providing support, rehabilitation
specialists ultimately improve the client’s quality of life.

NURSING MANAGEMENT:
 Nursing Diagnosis:
1. Impaired tissue perfusion related to cerebral edema
2. Acute pain related to cerebral edema and increased ICP
3. Self-care deficit related to neuromuscular dysfunction
4. Anxiety
5. Risk for altered cerebral tissue perfusion
6. Ineffective individual coping
7. Risk for altered thought process
  Providing Preoperative Care:
A. The nurse assesses:
- Weakness, Muscle wasting, Spasticity, Sensory changes, Bowel and Bladder
dysfunction, Potential respiratory problems, assessing the patient after surgery, the
patient is monitored for deterioration in neurologic status

B. Frequent neurologic checks are carried out, with emphasis on movement,

strength, and sensation of the upper and lower extremities.

C. Managing Pain:
- Pain is the hallmark of spinal metastasis.
- Patients with sensory root involvement or vertebral collapse may suffer
excruciating pain, which requires effective pain management.

D. The bed is usually kept flat initially. The nurse turns the patient as a unit,
keeping shoulders and hips aligned and the back straight.The side lying position is
usually the most comfortable, because this position imposes the least pressure on the
surgical site Placement of a pillow between the knees of the patient in a side lying
position helps to prevent extreme knee flexion

E. Monitoring and Managing Potential Complication Cervical area the nurse

monitors the patient for asymmetric chest movement, abdominal breathing, and
abnormal breath sounds. For a high cervical lesion, the endotracheal tube remains in
place until adequate respiratory function is ensured.

F. The patient is encouraged to perform deep breathing and coughing exercises.

 CONCLUSION
After this seminar I conclude that, Brain tumor is a cancerous or
non-cancerous mass or growth of abnormal cells in the brain. Headaches
(usually worse in the morning), nausea and vomiting, changes in speech,
vision or hearing, problems balancing or walking these are some of the
important signs and symptoms of brain tumor.
Brain tumor (benign) can be cured completely by surgical
excision, while for malignant tumors survival can be prolonged by chemo
and radiotherapy after surgery. Early diagnosis and treatment are the
keystone for brain tumor.
 SUMMARY
In this seminar we have discussed about anatomy and physiology of brain,
definition of brain tumor, incidence, causes, signs of symptoms, pathophysiology of
brain tumor. Diagnostic evaluation in that clinical diagnosis and radiological diagnosis,
medical, surgical and nursing management of brain tumor.
 BIBLIOGRAPHY

 Textbook on Neurosurgical Nursing, I Clement, Jaypee publications, page no;

493,495,496.

 Brunner and Suddarth’s, textbook of Medical Surgical Nursing, volume-2, edition-

13th , Wolters Kluwer publication, page no. 2052-2058.

 Javed Ansari, Comprehensive Medical Surgical Nursing, Peevee publication, part-

A, page no- 275-280.

 Gates and Fink, Oncology Nursing Secretes, Jaypee brothers, page no-135-141.
 Usha Ravindran Nair, Jaypee brothers, page no- 364-368.

 www.myoclinic.org

 www.healthline.com

 www.medicinenet.com