NURSING PROCESS: THE PATIENT WITH CEREBRAL METASTASES OR INCURABLE BRAIN TUMOR
The nursing assessment includes a baseline neurologic examina-tion and focuses on how the patient is functioning, moving, and walking; adapting to weakness or paralysis and to visual and speech loss; and dealing with seizures. Assessment addresses symptoms that cause distress to the patient, including pain, respiratory problems, bowel and bladder disorders, sleep disturbances, and impairment of skin integrity, fluid balance, and temperature reg-ulation. Tumor invasion, compression, or obstruction may cause these disorders.
Nutritional status is assessed because cachexia (weak and ema-ciated condition) is common in patients with metastases. The nurse explores changes associated with poor nutritional status (anorexia, pain, weight loss, altered metabolism, muscle weakness, malabsorption, and diarrhea) and asks the patient about altered taste sensations that may be secondary to dysphagia, weakness, and depression and about distortions and impaired sense of smell (anosmia).
The nurse takes a dietary history to assess food intake, intol-erance, and preferences. Calculation of body mass index can con-firm the loss of subcutaneous fat and lean body mass. Biochemical measurements (albumin, transferrin, total lympho-cyte count, creatinine index, and urinary tests) are reviewed to as-sess the degree of malnutrition, impaired cellular immunity, and electrolyte balance. A dietitian assists in determining the caloric needs of the patient.
The nurse works with other members of the health care team to assess the impact of the illness on the family in terms of home care, altered relationships, financial problems, time pressures, and family problems. This information is important in helping family members cope with the diagnosis and changes associated with it.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Self-care deficit (feeding, bathing, and toileting) related to loss or impairment of motor and sensory function and de-creased cognitive abilities
· Imbalanced nutrition, less than body requirements, related to cachexia due to treatment and tumor effects, decreased nutritional intake, and malabsorption
· Anxiety related to fear of dying, uncertainty, change in ap-pearance, altered lifestyle
· Interrupted family processes related to anticipatory grief and the burdens imposed by the care of the person with a terminal illness
Other nursing diagnoses of the patient with cerebral metas-tases may include acute pain related to tumor compression; im-paired gas exchange related to dyspnea; constipation related to decreased fluid and dietary intake and medications; impaired uri-nary elimination related to reduced fluid intake, vomiting, and reactions to medications; sleep pattern disturbances related to dis-comfort and fear of dying; impairment of skin integrity related to cachexia, poor tissue perfusion, and decreased mobility; deficient fluid volume related to fever, vomiting, and low fluid intake; and ineffective thermoregulation related to hypothalamic involve-ment, fever, and chills.
The goals for the patient may include compensating for self-care deficits, improving nutrition, reducing anxiety, enhancing fam-ily coping skills, and absence of complications.
The patient may have difficulty participating in goal setting as the tumor metastasizes and affects cognitive function. It is important to encourage the family to keep the patient as independent as pos-sible for as long as possible. Increasing assistance with self-care ac-tivities is required. Because the patient with cerebral metastasis and the family live with uncertainty, they are encouraged to plan for each day and to make the most of each day. The tasks and challenges are to assist the patient to find useful coping mecha-nisms, adaptations, and compensations in solving problems that arise. This helps patients maintain some sense of control. An in-dividualized exercise program helps maintain strength, endurance, and range of motion. Eventually, referral for home or hospice care may be necessary.
Patients with nausea, vomiting, diarrhea, breathlessness, and pain are rarely interested in eating (Wilkes, 2000). These symptoms are managed or controlled through assessment, planning, and care. The nurse teaches the family how to position the patient for comfort during meals. Meals are planned for the times the pa-tient is rested and in less distress from pain or the effects of treatment.
The patient needs to be clean, comfortable, and free of pain for meals, in an environment that is as attractive as possible. Oral hygiene before meals helps to improve intake. Offensive sights, sounds, and odors are eliminated. Creative strategies may be re-quired to make food more palatable, provide enough fluids, and increase opportunities for socialization during meals. The family may be asked to keep a daily weight chart and to record the quan-tity of food eaten to determine the daily calorie count. Dietary supplements, if acceptable to the patient, can be provided to meet increased caloric needs. If the patient is not interested in most usual foods, those foods preferred by the patient should be of-fered. When the patient shows marked deterioration as a result of tumor growth and effects, some other form of nutritional support (eg, tube feeding, parenteral nutrition) may be indicated if con-sistent with the patient’s end-of-life preferences. Nursing inter-ventions include assessing the patency of the central and IV line or feeding tube, monitoring the insertion site for infection, check-ing the infusion rate, monitoring intake and output, and chang-ing the IV tubing and dressing. Family members are instructed in these techniques if they will be providing care at home. Par-enteral nutrition can also be provided at home if indicated.
The patient’s quality of life may guide the selection, initiation, and maintenance of nutritional support. The nurse and family should not place too much emphasis on eating or on discussions about food as the patient may not desire aggressive nutritional in-tervention. The subsequent course of action must be congruent with the wishes and choices of the patient and family.
Patients with cerebral metastases may be restless, with changing moods that may include intense depression, euphoria, paranoia, and severe anxiety. The response of patients to terminal illness re-flects their pattern of reaction to other crisis situations. Serious illness imposes additional strains that often bring other unre-solved problems to light. The patient’s own coping strategies can help deal with anxious and depressed feelings. Caregivers need to be sensitive to the patient’s concerns and fears.
Patients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to understand the disease and its treatment and how to deal with their feelings. The presence of family, friends, a spiritual advisor, and health professionals may be supportive. Support groups such as the Brain Tumor Support Group may provide a feeling of sup-port and strength.
Spending time with patients allows them time to talk and to communicate their fears and concerns. Open communication and acknowledging fears are often therapeutic. Touch is also a form of communication. These patients need reassurance that continuing care will be provided and that they will not be aban-doned. The situation becomes more endurable when others share in the experience of dying. If a patient’s emotional reactions are very intense or prolonged, additional help from a spiritual advi-sor, social worker, or mental health professional may be indicated.
The family needs to be reassured that their loved one is receiving optimal care and that attention will be paid to the patient’s changing symptoms and to their concerns. When the patient can no longer carry out self-care, the family, additional support sys-tems (social worker, home health aid, home care nurse, hospice nurse) may be needed. A nursing goal is to keep anxiety at a man-ageable level.
The patient and family often have major responsibility for care at home. Therefore, teaching includes strategies of pain manage-ment, prevention of complications related to treatment strate-gies, and methods to ensure adequate fluid and food intake (Chart 65-2). Teaching needs of the patient and family regarding care priorities are likely to change as the disease progresses. It is important to assess the changing needs of the patient and the family and to inform them about resources and services early to assist them to deal with changes in the patient’s condition.
Home care nursing and hospice services are valuable resources that should be made available to the patient and the family early in the course of a terminal illness. Anticipating needs before they occur can assist in smooth initiation of services. Home care needs and interventions focus on four major areas: palliation of symp-toms and pain control, assistance in self-care, control of treatment complications, and administration of specific forms of treatment, such as parenteral nutrition. The home care nurse assesses pain management, respiratory status, complications of the disorder and its treatment, and the patient’s cognitive and emotional sta-tus. Additionally, the nurse assesses the family’s ability to perform necessary care and notifies the physician about changing needs or complications if indicated.
The patient and family who elect to care for the patient at home as the disease progresses benefit from the care and support provided through hospice services. Steps to initiate hospice care, including discussion of hospice care as an option, should not be postponed until death is imminent. Exploration of hospice care as an option should be initiated at a time when hospice care can provide support and care to the patient and family consistent with their end-of-life decisions and assist in allowing death with dignity.
Expected patient outcomes may include:
1) Engages in self-care activities as long as possible
a) Uses assistive devices or accepts assistance as needed
b) Schedules periodic rest periods to permit maximal par-ticipation in self-care
2) Maintains as optimal a nutritional status as possible
a) Eats and accepts food within limits of condition and preferences
b) Accepts alternative methods of providing nutrition if indicated
3) Reports being less anxious
a) Is less restless and is sleeping better
b) Verbalizes concerns and fears about death
c) Participates in activities of personal importance as long as feasible
4) Family members seek help as needed
a) Demonstrate ability to bathe, feed, and care for the pa-tient and participate in pain management and preven-tion of complications
b) Express feelings and concerns to appropriate health professionals
c) Discuss and seek hospice care as an option
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