Mid-brain cavernoma

[Melinurse]

So I took care of a patient with a mid-brain cavernoma this past week and only medical doctors were on the case ( no neuro consult ). So my patient has a change of condition, has increased headache with dizziness which is new. Did a focused neuro assessment called doctor. No new orders. To quote the doctor " just keep an eye on the patient". Next day, I have same pt. and I see on the I&O sheet that on night shift the patient had oral intake of 8100 . Output for nights was 3000. This is not including IV intake of 600. So I talk to pt who is complaining of increased thirst and how irritated he/she is to be having to void so much, but can't stop drinking water. I called the MD again. New orders to cap IV?

So my question now is : What the *#@*^? I was thinking the docs would order labs, maybe a stat CT or MRI, come check on patient, order a neuro consult, check for developing SIADH or DI or water intoxication? Something? Am I completely wrong? Ok, done venting. What do you think?

[Daytonite, BSN, RN]

It is not unusual for patients with increased ICP to be thirsty and crave and drink huge amounts of fluids. We often had them on fluid restrictions and shut off the water to their rooms. I would assume that if the doc was concerned he'd have the patient on fluuid restriction and in ICU and on ICP monitoring.

Did you read what was in the doctor's progress notes to see what the medical treatment thinking on this is? This condition cannot always be repaired.

• http://www.avmsurgeon.com/cavernoma/deepcavernomas.html
  
• http://www.medi-fax.com/atlas/brainaneurysms/case29.html
  
• http://www.brainavm.uhnres.utoronto.ca/case_examples/case_Cavernomas_ST.html

[Melinurse]

Doctors just wrote patient improving will continue to watch and wait. Even after my calls. My preceptor was concerned about this too. She wrote to our CNS about it. I'm just not 100% on " what the right thing to do is"? I'm new to this and even though my preceptor said I was doing all the right things as a nurse for the patient I feel like I should have done more.

[Daytonite, BSN, RN]

I got it. We aren't the doctors though. They are the captain of the ship and often know the patient and what the plan of treatment is. Sometimes they don't disclose it in the chart. All we can do is notify them of our concerns and document that we did so. After that, it's up to karma. I would have started daily weights on this person to monitor the fluid status more closely since I&O on these people isn't always accurate or the patients aren't thinking normally or following directions. Our neuro patients were very creative in how they got their fluid (they would drink mouth wash and the water in flower vases) and how they got rid of it (they pee'd in trash cans, cups and any other kind of container they could find).

[Melinurse]

I got it. We aren't the doctors though. They are the captain of the ship and often know the patient and what the plan of treatment is. Sometimes they don't disclose it in the chart. All we can do is notify them of our concerns and document that we did so. After that, it's up to karma. I would have started daily weights on this person to monitor the fluid status more closely since I&O on these people isn't always accurate or the patients aren't thinking normally or following directions. Our neuro patients were very creative in how they got their fluid (they would drink mouth wash and the water in flower vases) and how they got rid of it (they pee'd in trash cans, cups and any other kind of container they could find).

Thanks. I guess I just found it odd that the doctors "did not seem "concerned about a change of condition. I'm sure they were, I was just suprised by what seemed a lack of concern. You have made me feel a bit better though. Thank you.

[Daytonite, BSN, RN]

one of the hardest lessons i had to learn over the years was that the doctors don't save everyone. sometimes not every patient is savable. not every patient wants to have every medical treatment done to them that can possibly be done. one of my doctors told me recently when i reminded him again that my advanced directives were in my chart and i wanted the plug pulled if i coded that he wanted to be a smoking spot in the bed when he finally died, meaning he wanted everything possible done to keep him alive, and i couldn't stop laughing for days over that. you had to be there to get the humor in it because he's an oncologist and he was quite cheerful when he said this. anyway, the goals of treatment fall into 3 categories, two of which people often forget about:

• improvement of the patient's condition/cure
  
• stabilization of the patient's condition
  
• support for the deterioration of the patient's condition
  

everyone is rooting for a cure, but the fact is that stabilization and deteriorization happen a lot and they are sometimes hard for people to deal with. nursing homes and cancer centers are not popular places to work because of this. end of life care is very different to tolerant emotionally for many people.

[Melinurse]

Thank you Daytonite. That is what I neglected to think about throughout the whole thing. I never stopped to think that maybe the patient had expressed to the doctors what she wanted. She had advanced directives and was a full code, but maybe she had mentioned something to the doctors about possibly changing them? Thank you for reminding me that not every patient has the same goals/outcomes.

:urck: :tku: