NURSING PROCESS:THE PATIENT WITH GASTRIC CANCER
The nurse elicits a dietary history from the patient, focusing on recent nutritional intake and status. Has the patient lost weight? If so, how much and over what period of time? Can the patient tolerate a full diet? If not, what foods can he or she eat? What other changes in eating habits have occurred? Does the patient have an appetite? Is the patient in pain? Do foods, antacids, or medications relieve the pain, make no difference, or worsen the pain? Is there a history of infection with H. pylori bacteria? Other health information to obtain includes the patient’s smoking and alcohol history and the family history (any first- or second-degree relatives with gastric or other cancer). A psychosocial assessment, including questions about social support, individual and family coping skills, and financial resources, will help the nurse plan for care in acute and community settings.
After the interview, the nurse performs a complete physical ex-amination, carefully assesses the patient’s abdomen for tenderness or masses, and also palpates and percusses to detect ascites.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
• Anxiety related to the disease and anticipated treatment
• Imbalanced nutrition, less than body requirements, related to anorexia
• Pain related to tumor mass
• Anticipatory grieving related to the diagnosis of cancer
• Deficient knowledge regarding self-care activities
The major goals for the patient may include reduced anxiety, op-timal nutrition, relief of pain, and adjustment to the diagnosis and anticipated lifestyle changes.
A relaxed, nonthreatening atmosphere is provided so that patient can express fears, concerns, and possibly anger about the diagno-sis and prognosis. The nurse encourages the family in their efforts to support the patient, offering reassurance and supporting pos-itive coping measures. The nurse advises the patient about any procedures and treatments so that the patient knows what to ex-pect. The nurse also may suggest talking with a support person (eg, spiritual advisor), if the patient desires.
The nurse encourages the patient to eat small, frequent portions of nonirritating foods to decrease gastric irritation. Food supplements should be high in calories, as well as vitamins A and C and iron, to enhance tissue repair. If the patient is unable to eat adequately to meet nutritional requirements, parenteral nutrition may be neces-sary. Because the patient may develop dumping syndrome when enteral feeding resumes after gastric resection, the nurse explains ways to prevent and manage it (six small feedings daily that are low in carbohydrates and sugar; fluids between meals rather than with meals) and informs the patient that symptoms often resolve after several months. If a total gastrectomy is performed, parenteral vitamin B12 will be required indefinitely, because dietary vitamin B12 is absorbed in the stomach. The nurse monitors the IV therapy and nutritional status and records intake, output, and daily weights to ensure that the patient is maintaining or gaining weight. The nurse assesses for signs of dehydration (thirst, dry mucous mem-branes, poor skin turgor, tachycardia, decreased urine output) and reviews the results of daily laboratory studies to note any metabolic abnormalities (sodium, potassium, glucose, blood urea nitrogen). Antiemetics are administered as prescribed.
The nurse administers analgesics as prescribed. A continuous in-fusion of an opioid may be necessary for severe pain. The nurse assesses the frequency, intensity, and duration of the pain to de-termine the effectiveness of the analgesic being administered. The nurse works with the patient to manage pain by suggesting non-pharmacologic methods for pain relief, such as position changes, imagery, distraction, relaxation exercises (using relaxation audio-tapes), backrubs, massage, and periods of rest and relaxation.
The nurse helps the patient express fears, concerns, and grief about the diagnosis. It is important to answer the patient’s questions hon-estly and to encourage the patient to participate in treatment deci-sions. Some patients mourn the loss of a body part and perceive their surgery as a type of mutilation. Some express disbelief and need time and support to accept the diagnosis.
The nurse offers emotional support and involves family mem-bers and significant others whenever possible. This includes rec-ognizing mood swings and defense mechanisms (eg, denial, rationalization, displacement, regression) and reassuring the pa-tient and family members that emotional responses are normal and expected. The services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists are made available, if needed. The nurse projects an empathetic at-titude and spends time with the patient. Most patients will begin to participate in self-care activities after they have acknowledged their loss.
Self-care activities will depend on the mode of treatment used— surgery, chemotherapy, radiation, or palliative care. Patient and family teaching will include information about diet and nutri-tion, treatment regimens, activity and lifestyle changes, pain management, and possible complications (Chart 37-3). Consul tation with a dietitian is essential to determine how the patient’s nutritional needs can best be met at home. The nurse teaches the patient or care provider about administration of enteral or pa-renteral nutrition. If chemotherapy or radiation is prescribed, the nurse provides explanations to the patient and family about what to expect, including the length of treatments, the expected side effects (eg, nausea, vomiting, anorexia, fatigue, neutropenia), and the need for transportation to appointments for treatment. Psy-chological counseling may also be helpful.
The need for ongoing care in the home will depend on the patient’s condition and treatment. The home care nurse reinforces nutri-tional counseling and supervises the administration of any enteral or parenteral feedings; the patient or family member must become skillful in administering the feedings and in detecting and pre-venting untoward effects or complications related to the feedings. The nurse teaches the patient or a family member to record the patient’s daily intake, output, and weight and explains strategies to manage pain, nausea, vomiting, or other symptoms. The nurse also teaches the patient or caregiver to recognize and report signs and symptoms of complications that require medical attention, such as bleeding, obstruction, perforation, or any symp-toms that become progressively worse. It is important to explain the chemotherapy or radiation therapy regimen. The patient and family need to know about the care that will be needed during and after treatments. Because the prognosis for gastric cancer is so poor, the nurse may need to assist the patient and family with decisions regarding end-of-life care. Referral to hospice may be warranted.
Expected patient outcomes may include the following:
1) Reports less anxiety
a. Expresses fears and concerns about surgery
b. Seeks emotional support
2) Attains optimal nutrition
a. Eats small, frequent meals high in calories, iron, and vitamins A and C
b. Complies with enteral or parenteral nutrition as needed
3) Has less pain
4) Performs self-care activities and adjusts to lifestyle changes
a. Resumes normal activities within 3 months
b. Alternates periods of rest and activity
c. Manages tube feedings