Pre-conditioning Activity

BRAIN-TU-MOR
The class will be divided into 3 groups. Each group will be named: Group 1 - Brain, Group 2 -
Tu, Group 3 - Mor. Everyone will sing a chant and in some parts of the chant, the host will point
to a group and that group has to shout their team name. The team will be out of the game if they
shout their team name even if the host did not point to their group, or if some members fail to
shout their team name although the host pointed at their group.

Script

- A brain tumor occupies space
within the skull, growing as a
spherical mass or diffusely
infiltrating tissue.
The anatomy of the brain is very complex, with
different parts responsible for different nervous
system functions.
A brain tumor is a growth of abnormal cells in the
brain or near it. Brain tumors can happen in the
brain tissue. Brain tumors also can happen near the
brain tissue. Nearby locations include nerves, the
pituitary gland, the pineal gland, and the
membranes that cover the surface of the brain.

- A variety of physiologic
changes result, causing any or
all of the following
pathophysiologic events:
(Hickey & Strayer, 2020):
● Increased intracranial
pressure (ICP) and
cerebral edema
All brain cancers are tumors, but not all brain tumors
are cancerous. Noncancerous brain tumors are
called benign brain tumors. Benign brain tumors
typically grow slowly, have distinct borders and
rarely spread. However, they can still be dangerous.
Malignant brain tumors, on the other hand, are
cancerous. They typically grow rapidly and invade
surrounding healthy brain structures.
As a brain tumor grows, it can physically occupy
space within the skull, putting pressure on the
surrounding brain tissue. This compression can
disrupt the normal flow of blood and cerebrospinal
fluid (CSF), leading to an increase in ICP. And
when CSF flow is blocked, it can accumulate in the
brain, causing cerebral edema.

● Seizure activity The tumor can physically press on or invade brain

tissue, disrupting the normal electrical activity of
neurons. This can lead to a sudden and
uncontrolled burst of electrical activity, which is what
a seizure is.
 ● Focal neurologic signs The severity of focal neurological signs caused by a
brain tumor will depend on the size, location, and
type of tumor. For example, a tumor in the motor
cortex could cause weakness or paralysis on one
side of the body, while a tumor in the visual cortex
could cause vision problems.
● Hydrocephalus
Hydrocephalus occurs when there is an imbalance
between the production and absorption of CSF. This
can happen if too much CSF is produced, if it is not
absorbed properly, or if the flow of CSF is blocked.

● Altered pituitary function Two specific examples of how brain tumors can alter
pituitary function include acromegaly – which is a
condition caused by an excess of growth hormone,
and it can lead to symptoms such as enlarged
hands and feet, a protruding jaw, and deepening of
the voice, or hypopituitarism — caused by a
- There are over 100 types of deficiency of one or more pituitary hormones
brain tumors with an estimated
78,000 new cases each year.
These include 25,000
malignant and 53,000
nonmalignant brain tumors.

- Brain tumors are classified

as primary or secondary.
Primary brain tumors
originate from cells within
the brain.
Tumors that develop in your brain are called
primary tumors. Tumors that spread to your brain
after forming in a different part of your body are
called secondary tumors, or metastatic brain
tumors.

Primary brain tumors

originate from cells within the
brain. In adults, most primary
brain tumors originate from glial
cells (cells that make up the
structure and support system
of the brain and spinal cord)
and are supratentorial (located
above the covering of the
cerebellum). Primary tumors
progress locally, rarely
metastasize outside the CNS,
 and have a 5-year survival rate
of 33.4%.

Secondary or metastatic
brain tumors develop from
structures outside the brain and
are twice as common as
primary brain tumors (AANN,
2016). Metastatic lesions to the
brain can occur from the lung,
breast, lower gastrointestinal
tract, pancreas, kidney, and
skin (melanomas) neoplasms.
Single or multiple metastases
may occur, and brain Brain metastases, also known as brain mets, are
metastases may be found at cancerous tumors that spread to the brain from
any time during the disease other parts of the body.
course, even at initial diagnosis
of the primary disease. Patient
survival rates from primary
brain cancers are improving,
however, the incidence of brain
metastases is increasing
(AANN, 2016).

TYPES OF BRAIN TUMORS

Gliomas. Gliomas are growths Glioblastoma is the most common type of malignant
of cells that look like glial cells. brain tumor.
The glial cells surround and
support nerve cells in the brain
tissue. Types of gliomas and
related brain tumors include
astrocytoma, glioblastoma,
oligodendroglioma and
ependymoma. Gliomas can be
benign, but most are malignant.

● Astrocytoma Astrocytomas are the most common type of glioma,

Astrocytoma is a cell accounting for about 70% of all gliomas, they can be
growth that begins in benign or malignant. Astrocytomas are graded on a
the brain or spinal cord. scale of I to IV, with I being the least aggressive and
IV being the most aggressive. The grade of an
The growth, known as a astrocytoma is determined by how quickly the tumor
tumor, begins in cells cells are growing, how they look under a
called astrocytes. microscope, and how much they have infiltrated the
 Astrocytes are nerve surrounding brain or spinal cord tissue.
cells that support and
link nerve cells in the
brain and spinal cord.
The symptoms vary
based on the tumor's
location. An
astrocytoma in the brain
can cause personality
changes, seizures,
headaches and nausea.
An astrocytoma in the
spinal cord can cause
weakness and disability
in the area affected by
the growing tumor.
● Glioblastoma is a form
Grade IV: Glioblastomas are the most aggressive
of cancer that begins as
type of astrocytoma and are considered malignant,
a cell growth in the brain so they are cancerous. They grow rapidly and can
or spinal cord. It spread to other parts of the brain and spinal cord.
spreads swiftly and has
the ability to penetrate
and destroy healthy
tissue. They form from
cells called astrocytes
that support nerve cells. As we age, our DNA accumulates damage, and this
It can happen at any damage can lead to mutations in genes that control
age. But it tends to cell growth. These mutations can eventually cause
occur more often in cells to become cancerous. This is likely why
older adults and more glioblastoma is more common in older adults.
often in men.
Men are more likely than women to have certain
Glioblastoma symptoms genetic mutations that increase the risk of
include headaches that developing glioblastoma. For example, men are
keep getting worse, more likely to have mutations in the PTEN gene,
nausea and vomiting, which is involved in regulating cell growth.
blurred or double vision,
and seizures.
● Oligodendroglioma is
Oligodendrogliomas are typically classified into two
a cell growth that begins grades: grade II and grade III. Grade II
in the brain. Tumors oligodendrogliomas are slow-growing and relatively
develop from the benign, while grade III oligodendrogliomas are more
proliferation or rapid aggressive and can spread to other parts of the
production of cells brain and spinal cord.
 known as
oligodendrocytes.
These cells produce a
chemical that protects
nerve cells and aids in
the transmission of
electrical signals across
the brain and spinal
cord.
● Ependymoma begins in
People with a family history of ependymoma have
the ependymal cells of
an increased risk of developing the disease.
the brain and spinal
cord, which line the Exposure to radiation, such as from X-rays or
passageways where the radiation therapy for other cancers, may increase
fluid that nourishes your the risk of developing ependymoma.
brain flows
(cerebrospinal fluid). It Ependymomas are typically treatable, but they can
recur after treatment.
can occur at any age,
however it is more
common in young
children. Headaches
and seizures are
common in children with
ependymoma. Adult
ependymoma is more
likely to originate in the
spinal cord and may
cause weakness in the
area of the body Again, astrocytoma, glioblastoma,
controlled by the nerves oligodendroglioma and ependymoma, are the types
of gliomas.
impacted by the tumor.

Choroid plexus tumors. This

So another type of brain tumor is the Choroid
cancer begins in the cells that
plexus tumor.
produce the fluid that surrounds
the brain and spinal cord which
is referred to as cerebrospinal
fluid. Choroid plexus tumors
are found in the ventricles,
which are fluid-filled chambers
in the brain. Tumors of the
choroid plexus can be benign
or malignant. The malignant
variant of this type of brain
tumor is known as choroid
plexus carcinoma. It is more
prevalent in children.

Embryonal tumors. There are several different types of embryonal

Embryonal tumors begin in
cells that are left over from fetal
development. The cells, called
embryonal cells, stay in the
brain after birth. Embryonal
tumors are malignant brain
tumors that happen most often
in babies and young children.
The most common type of
embryonal tumor is
medulloblastoma. It's usually
located in the lower back part of
the brain, called the
cerebellum.
tumors, each with its own characteristics and
treatment options. Some of the most common types
include:
Medulloblastoma: This is the most common type of
embryonal tumor, accounting for about 20% of all
childhood brain tumors. Medulloblastomas typically
arise in the cerebellum, the part of the brain that
controls balance and coordination.
Atypical teratoid rhabdoid tumor (AT/RT): This is a
rare and aggressive type of embryonal tumor that
can occur in the brain or spinal cord. AT/RTs are
characterized by their unusual appearance under a
microscope and their tendency to spread to other
parts of the body.

CNS embryonal tumors not otherwise classified

(NEC): This is a catch-all term for embryonal tumors
that do not fit into any other category. CNS NEC
tumors are a diverse group of tumors with a wide
range of characteristics and treatment outcomes.
Acoustic neuroma is a tumor
of the eighth cranial nerve that Acoustic neuroma accounts for 16% of brain tumors,
is noncancerous and develops with men and women equally affected, and occurs
on the main nerve leading from mostly in 40s-50s.
the inner ear to the brain. This
nerve is called the vestibular
nerve. Acoustic neuroma
pressure can cause hearing
loss, ringing in the ears, and
balance issues. Another name
for an acoustic neuroma is
vestibular schwannoma.

Meningiomas are brain tumors They arise from the meninges, which are the
that begin in the membranes protective layers that surround the brain and spinal
cord.
surrounding the brain and
spinal cord. These tumors are
typically benign, however they
can occasionally be cancerous.
Meningiomas are the most
 common type of benign brain
tumor.
Pituitary tumors account for
about 16% of all primary brain
tumors (AANN, 2016). They
can occur at any age but are
more common in older adults.
Women are affected more often
than men, particularly during
the childbearing years. Pituitary
tumors are rarely malignant but
cause symptoms as a result of
pressure on adjacent structures
or hormonal changes (Jang,
Oh, Lee, et al., 2020).
RISK FACTORS:
- Exposure to ionizing radiation
(AANN,2016)
- Genetic factors and Genetic
syndromes (AANN,2016)
- Head injury and Seizures
- Brain tumors happen when
cells in or near the brain get
changes in their DNA. A cell's
DNA holds the instructions that
tell the cell what to do. The
changes tell the cells to grow
quickly and continue living
when healthy cells would die as
part of their natural life cycle.
This makes a lot of extra cells
in the brain, leading to the
Pituitary tumors are growths that develop in the
pituitary gland, a small gland located at the base of
the brain. The pituitary gland is often referred to as
the "master gland" because it produces hormones
that control many important functions in the body,
including growth, metabolism, reproduction, and
stress response. There are two main types of
pituitary tumors:
Adenoma: This is the most common type of pituitary
tumor, and is usually benign (noncancerous) and
grows slowly.
Carcinoma: This is a rare type of pituitary tumor that
is cancerous.
Ionizing radiation is a type of radiation that has
enough energy to knock electrons off atoms, which
can create DNA damage. This DNA damage can
lead to mutations that can cause cancer, including
brain tumors.
There are several sources of ionizing radiation,
including:
Medical procedures: X-rays, CT scans, and
radiation therapy.
Occupational exposure: People who work in certain
occupations, such as nuclear power plant workers
and airline pilots, are exposed to higher levels of
ionizing radiation than the general population.
Head injury may cause inflammation and damage to
the brain, which could create an environment that is
more likely to allow cancer cells to grow.
 formation of a mass or lump.
This can interfere with normal
brain function by compressing
surrounding structures and
causing increased intracranial
pressure which may cause
symptoms such as headaches,
nausea, vomiting, and changes
in vision. Benign brain tumors
are non-cancerous and
generally grow slowly. They
tend to have a well-defined
border and do not invade
surrounding tissues. Malignant
brain tumors, on the other
hand, are cancerous and can
grow rapidly.

GERONTOLOGIC
CONSIDERATIONS

Generally, intracranial tumors can

produce personality changes,
confusion, speech dysfunction, or
disturbances of gait. The incidence of
all brain tumors increases with age
(Young et al., 2017). In older adult
patients, early signs and symptoms of
intracranial tumors can be easily
overlooked or incorrectly attributed to
cognitive and neurologic changes
associated with normal aging
(Eliopoulos, 2018). Neurologic signs
and symptoms in the older adult must
be carefully evaluated, because brain
metastases occur in patients with a
history of prior cancer. Regardless of
the age of the patient or the decision to
proceed or not with treatment, the
nurse provides supportive care.
Researchers have reported that the
degree of frailty influences clinical
outcomes of older adult patients
undergoing surgery for brain tumor
resection (Harland, Wang, Gunaydin,
et al., 2020). Patients identified as
moderately frail or frail are at increased
risk for a longer length of hospital stay
and tend to require discharge to a
long-term care facility rather than home
(Harland et al., 2020).

CLINICAL MANIFESTATIONS
● Increased intracranial pressure
● Headache
● Vomiting
● Visual disturbances
● Seizures
● Localized symptoms
O Sensory or motor
abnormalities
o Visual alterations
O Alterations in cognition or
language disturbances
(aphasia)
o Many tumors can be localized
by correlating the signs and
symptoms to specific areas in
the brain, as follows (Hickey
& Strayer, 2020)
❖ A tumor in the motor
cortex of the frontal
lobe produces Hemiparesis is a medical condition characterized by
hemiparesis and partial weakness or paralysis on one side of the body.
seizures on the opposite This also causes loss of coordination making it
side of the body or difficult to perform tasks that require fine motor
skills, such as writing or using utensils.
generalized seizures.
❖ A frontal lobe tumor A frontal lobe tumor is a growth that develops in the
may also produce frontal lobe, the anterior portion of the brain. The
changes in emotional Broca's area, located in the left frontal lobe, is
state and behavior, as responsible for producing speech. Damage to this
well as an apathetic area can cause difficulty speaking or understanding
mental attitude. speech.

Apathetic mental attitude means a lack of interest,

enthusiasm, or concern about what is happening
around you.
❖ A parietal lobe tumor
Damage to the parietal lobe can cause problems
may cause decreased
with processing sensory information, such as touch,
sensation on the temperature, and pain. This may lead to numbness,
 opposite side of the tingling, or pain in the affected area.
body or generalized
seizures.
❖ A temporal lobe tumor Damage to the temporal lobe can cause problems
may cause seizures as with hearing, such as tinnitus (ringing in the ears) or
hearing loss. It can also cause problems with
well as psychological
speech, such as aphasia. Aphasia is a condition that
disorders.
makes it difficult to understand or produce language.
❖ An occipital lobe An occipital lobe tumor is a growth that develops in
tumor produces visual the occipital lobe, the part of the brain that is
manifestations: responsible for processing visual information.
contralateral
homonymous
hemianopia (visual loss
in half of the visual field
on the opposite side of
the tumor) and visual
hallucinations.
A cerebellar tumor is a growth that develops in the
❖ A cerebellar tumor cerebellum, the part of the brain that is responsible
causes dizziness; an for coordinating movement, balance, and posture.
ataxic or staggering gait
with a tendency to fall
toward the side of the
lesion; marked muscle
incoordination; and
nystagmus, usually in
the horizontal direction.
❖ A cerebellopontine
angle tumor usually
originates in the sheath
of the acoustic nerve
and gives rise to a
characteristic sequence
of symptoms. Tinnitus
and vertigo appear first,
soon followed by
progressive nerve
deafness. Numbness
and tingling of the face
and tongue occur. Later,
weakness or paralysis
of the face develops.
Finally, because the
enlarging tumor presses
on the cerebellum,
abnormalities in motor
 function may be
present.
❖ Brainstem tumors may A brainstem tumor, also known as a brain stem
be associated with tumor or a pontomedullary tumor, is a growth that
cranial nerve deficits develops in the brainstem, the part of the brain that
connects the upper brain to the spinal cord.
along with complex
motor and sensory
Patients may experience loss of sensation on one
function impairments. side of the body, and spasticity — a condition
characterized by stiff muscles and involuntary
contractions.
ASSESSMENT:
● History of illness
● The manner and time frame in
which the symptoms evolved
● Occupation As what was discussed earlier, one risk factor of
brain tumor is exposure to ionizing radiation. And
people who work in certain occupations, such as
nuclear power plant workers and airline pilots, are
exposed to higher levels of ionizing radiation than
the general population.
DIAGNOSTIC FINDINGS:
● CT scan (Computed
Tomography): Gives specific
information concerning the
number, size, and density of the
lesions, and the extent of
secondary cerebral edema.
● MRI (Magnetic Resonance
Imaging): Detects particularly
smaller lesions, and tumors in
the brainstem and pituitary
regions, where bone is thick.
● Computer- assisted stereotactic
(three-dimensional) biopsy: Is
used to diagnose deep- seated
brain tumors.
- Involves the use of
three-dimensional frame
that allows very precise
localization of the tumor.

● Brain mapping technology By creating detailed maps of the brain, this

● PET (Positron Emission technology can help doctors to identify tumors more
accurately, plan surgeries more effectively, and
Tomography): Is used to
monitor treatment progress.
supplement MRI. On PET
scans, low-grade tumors are
 associate with
hypometabolism, and
high-grade tumors show
hypermetabolism.( Achrol,
Rennert, Ander, et al.,2019)
● Electroencephalogram: Detects
abnormal brain waves in
regions occupied by or adjacent
to tumor: it is used to evaluate
temporal lobe seizures and to
assist in ruling out other
disorders.
● Cytologic studies of the CSF:
To detect malignant cells.

MEDICAL MANAGEMENT
● Surgical
o Biopsy tissue to
establish a definitive
diagnosis
o Craniotomy used in
patients with
meningiomas,
acoustic neuromas,
cystic astrocytomas,
colloid cysts,
congenital tumors
such as dermoid
cyst and some of
the granulomas
o Patients with
malignant gliomas
relief for ICP,
removal of any
necrotic tissue and
reduction in the bulk
of tumor because
complete removal of
the tumor are not
possible
o Transsphenoidal
microsurgical
removal for pituitary
adenomas, and the
remainder that
cannot be removed
 are treated by
radiation (Hickey &
Strayer, 2020)

● Radiation therapy - decreases

the incidence of recurrence of
incompletely resected tumors
o Gamma radiation
delivered via an
external beam to the
tumor in multiple
fractions
o Brachytherapy
(surgical
implantation of
radiation sources to
deliver high doses at
short distance) is an
option for some
types depending on
the location of the
tumor. Usually used
as an adjunct to
conventional
radiation therapy or
as a rescue
measure for
recurrent disease
o Radioisotopes such
as iodine 131 are
used to minimize
effects on
surrounding the
brain tissue
o Stereotactic
procedures may be
performed using a
linear accelerator or
gamma knife to
perform
radiosurgery (Hickey
& Strayer, 2020).
These procedures
allow treatment of
deep, inaccessible
tumors, often in a
 single session.
Precise localization
of the tumor is
accomplished by the
stereotactic
approach and by
minute
measurements and
precise positioning
of the patient.
● Chemotherapy
o Malignant glioma is
usually treated with
6 weeks of oral
temozolomide
during radiation
therapy, followed by
6 to 12 months of
oral temozolomide.
o Low-grade gliomas
may be treated with
6 months of oral
temozolomide
alone.
o Temozolomide is an
oral chemotherapy
that crosses the
blood–brain barrier
(McFaline-Figueroa
& Lee, 2018).
o Autologous bone
marrow
transplantation is
used in some
patients who will
receive
chemotherapy or
radiation therapy. A
fraction of the
patient’s bone
marrow is aspirated,
usually from the iliac
crest, and stored.
o The marrow is then
reinfused
intravenously after
 treatment is
completed.
● Pharmacologic therapy
o Corticosteroids such
as dexamethasone
reduces
inflammation and
edema around
tumors and relieves
headache and
alterations in level of
consciousness.
o Osmotic diuretics
(e.g., mannitol and
hypertonic saline) to
decrease fluid
content of the brain
which leads to
decrease in ICP
o Anticonvulsant
medications to treat
and control seizures
(Comerford &
Durkin, 2020)

NURSING MANAGEMENT
● Assess the characteristics of
headache if present.
● Upright positioning and
administering pain medications
may be useful. Evaluate the
effectiveness of the pain
management interventions.
● Patient’s significant others (SO)
must be educated for the
possibility of seizure attacks
and adherence to prophylactic
anticonvulsant medications, if
prescribed.
As nurses, our priority is to alleviate patient’s pain.
So we assess the patient’s level of pain using pain
scales and other assessment tools.
SO’s must be taught how to recognize seizure signs
and symptoms, such as such as sudden changes in
behavior, loss of consciousness, or unusual
movements; and how to respond to it — this
includes ensuring the patient's safety by removing
potential hazards, maintaining a calm and
reassuring presence, and avoiding unnecessary
movements or stimulation.

Anticonvulsants can also be used to treat seizures

that are already occurring. They can be used as
monotherapy (a single medication) or in combination
with other AEDs.
Examples of anticonvulsant medications used for
brain tumors: Levetiracetam (Keppra), Lamotrigine
 (Lamictal), and Carbamazepine (Tegretol).
● Note that there may be an
increased risk for aspiration as
a result of cranial nerve
dysfunction.
● Consider medications for You can give antihistamines, such as
dimenhydrinate (Dramamine) and meclizine
nausea and vomiting
(Bonine).
● Evaluate gag reflex and ability
to swallow, preoperatively. With
diminished gag reflex, educate
the patient to direct food and It is important to avoid foods that are hard to chew
fluids toward the unaffected or swallow, such as raw fruits and vegetables, nuts,
side, upright positioning, and tough meats. These foods can increase the risk
semi-soft diet, and having of choking or aspiration.
suction readily available.
● Perform neurologic checks (e.g. Neurological checks can help detect early signs of
assessing mental status, level neurological deficits caused by the brain tumor or its
of consciousness, pupillary treatment. This early detection allows for prompt
response, gait, etc.), monitor intervention and management of these deficits.
vital signs, nursing
interventions to prevent rapid
increase in ICP, and reorient
the patient when necessary to
person, time, and place.
● The use of corticosteroids to Corticosteroids are a powerful class of drugs that
control headache and can provide significant relief from headaches and
neurologic symptoms requires neurological symptoms in brain tumor patients.
astute nursing assessment and However, their use requires astute nursing
intervention. assessment and intervention due to their potential
side effects and the need for careful monitoring of
patient response.

● Patients with changes in

cognition caused by their lesion
require frequent reorientation
and the use of orienting devices
(e.g., personal possessions,
photographs, lists, a clock),
supervision of and assistance
with self-care, and ongoing
monitoring and intervention for
prevention of injury.
● Monitor and protect patients
with seizure tendencies from You can create a safe environment by removing
sharp objects, furniture with sharp corners, and
injury.
other potential hazards from the patient's
surroundings, padding sharp edges of furniture with
 soft materials, installing grab bars in hallways and
bathrooms to provide support during seizures, and
● With muscle weakness, using non-slip mats in the bathroom to prevent falls.
approach collaboratively with
physical and occupational
therapists.
● Assess for sensory
disturbances and protect any
area of numbness from injuries.
● Evaluate for speech problems.
If present, educate patients to
use alternative forms of
communication (e.g. gestures,
writing, sign language, speech
generating device, etc.).
● Conserve energy for fatigue
from therapy and promote rest. By conserving energy, patients can maintain a
sense of normalcy, independence, and overall
well-being throughout their treatment and recovery
journey.