Hi all. First of all, let me say my name is Krista, and I have posted here once or twice before, but that was a long time ago.
I am actually in my senior year of nursing school, originally due to graduate in just two weeks, but my last clinical instructor had a personal issue with me and ended up unsatting me for the whole rotation on the last day of clinical, with no warnings whatsoever. I am currently fighting this unsat, and am actually do to meet with the Dean, Clinical Coordinator, and clinical instructor at 3pm today, but I have a question about one thing that she wasn't happy with but I cannot figure out an alternative.
On my nursing care plan, we had to fill out a nutritional assessment, and if the patient had a score of less than 11, we had to incorporate a nutrition related diagnosis into the careplan. The only problem was my patient was quite an conundrum. She was an elderly lady that came in with frank red GI bleed (probably hemmorhoids) but was not actively bleeding anymore. She was, however, pretty immobile and had a PEG tube infusing 60cc/hr of Glucerna. The nutrition form they gave us to fill out did not apply to this lady at all (it asked questions such as how many meals did they eat a day, did they snack, blah blah). So of course my lady scored low. However, this lady was a 4'11" lady who weighed 200 lbs (made her BMI 44.4). That is severely obese according to the BMI scale. So I looked into the Less than and More Than body requirements diagnoses, but they did not fit her in the least. After figuring out the nutrition she was actually receiving (every single little element) and comparing it to the DRI for this woman, along with an ICU nutrition sheet utilizing BEE and TEE, I discovered this lady was only receiving about 100 calories less than her TEE. So less than didn't qualify because interventions focus on feeding her more, and more than didn't seem to qualify because all of the interventions focused on losing weight (which in her case would have been a great diagnosis, but not for that particular moment). I say that because her H&H and RBC's were still pretty low and I reasoned that we didn't want to reduce her feeding any because she needed the nutrition to build her blood back up. In the end, I went with a Risk for Aspiration r/t tube feeding. I figured that was slightly nutrition related and seemed to fit.
Of course she didn't agree and says I out right "disobeyed" her instructions. When trying to explain my rationales to the clinical coordinator, she comes back with things like "we don't know for sure she is getting that amount" "what about residuals" (of which she had none, or "what if they turn it off when she goes off the floor?" (which she never went off the floor because they did no diagnostic tests for her. Anyway, I don't know what I am missing here, and since I am trying to fight this unsat for the rotation, I am trying to fix the care map so it shows a more "nutrition related" diagnosis, but I still can't bring myself to use any of these diagnoses in the Nursing Diagnosis Handbook from Ackley, 7th ed. Are there other nutrition diagnoses I am missing? Could I use a "potential" r/t her high BMI that would be good to work on after her H&H is back up? I am so confused.
Anyway, thank you in advance for any help you can give me. It will be greatly appreciated.
First of all, thank you for all of the quick replies. The woman had a low H&H and RBC's, as well as diabetes. Her blood sugars were pretty well controlled however. The problem with this poor lady was that she had dementia and a DNR order, with no family and little information from the nursing home. I did say in my rationales I gave later to the school that it might be good to try and get her to feed orally again, but that would take a lot of time because we would have to figure out why she was placed on the feeding to begin with. Either way, I think I may have focused on the here and now. I did speak with the dean this afternoon. She said she wanted me to concentrate on my studying to get through the final, then she wants me to rewrite how I think I have progressed with each objective. I asked her about my presidency (I am the president of the class), because the pinning is coming up and our associate dean is asking me to write a speach, but she wants to print the programs and put my VP as the new president. Anyway, the dean said to go ahead and go on like I am still the president, and to not worry about the pinning because they can make the programs the day before if need be. So some friends and my mother are optimistic about that, because they say if she had plans on not reversing the unsat, she would not be telling me to go on like I am. I, however, and not convinced, but I will try my best. I am not sure if I have to redo the care map or not, but I may anyway when I get bored of studying and need a break (heehee, some break).
I took a look at those websites you posted, and they look great. I did see there that PEG feeding has as much of a risk for aspiration as NG tube, which is a good thing to know, because the responses raised the question in my mind. I also may go with the diabetic diagnosis, because I guess that is nutrition related since you said it was listed in the nutrition section. Anyway, thank you so much again. You all came very quickly to my aid even though you don't know much about me. I really appreciate it.
Specializes in med/surg, telemetry, IV therapy, mgmt.
Let me suggest something else as well. Call the DON at this nursing home and ask if you can come back during the day to see this patient's care plan. Every nursing home has a care plan for these patient's (it's required by federal law). Many times they are kept either at the nursing station or in the MDS (Minimum Data Set) nurses office. If the MDS nurse is really helpful, she might even let you look at the last MDS report that was filed with Medicare on this patient (they are filed every 90 days) which will have the patient's comprehensive ADL assessment on it as well as a nutritional report of some type by the dietician. These care plans are usually quite extensive. I guarantee it will address her nutritional problems and will probably have input from the dietician. Take a look at what their facility care plan is for this patient as it will give you a better idea of what is going on with her. It will give you a chance to see what a real working care plan looks like as well as what someone else has already diagnosed this patient with. This care plan will be about as correct for her situation as it can be or else the facility will be in big doo-doo with the state department of health. While you are there you might also want to go back into her chart and look to see what the dietician had to say in her notes as I am almost 100% sure their facility dietician has had input--it's another federal requirement. It will be buried somewhere in the back of the patient's chart. (I worked in a number of nursing homes over the years--I know this.) Good luck!
I hope in the end it all works out for you. It sounds like you are trying to fix whatever the "problem" may be and learn from it instead of focusing on the negative aspects of your situation. Make sure you let us know what happens.
I do see your point where there may be a slight risk for aspiration, but.... that's not really nutrition related. Not sure what you should pick. Leaning towards More than body requirements etc. My instructors don't really like to see risk diagnosis that much. They want to see actual diagnosis.
Yeah, I think the risk for aspiration is more of a safety or airway issue. I would put the daggone impaired nutrition less than body requirements as the diagnosis. It seems like her issue with it is that, in her opinion, you "ignored" it. So make her happy. It seems to me that even if you address it incorrectly, addressing it at all is what she's looking for.
Sometimes instructors are insane. For those you have to take a minute and figure out how to please them and dispense with all common sense and reason. I don't care how scientifically sound your reasoning is, how many references you can show them, how organized and detailed your work is they want it THEIR WAY. And since they have the power to fail you, do it their way and move on. If you know what's right and can take that away from the experience, you can give them whatever BS they're asking for a still live with yourself.
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knhebert
5 Posts
First of all, thank you for all of the quick replies. The woman had a low H&H and RBC's, as well as diabetes. Her blood sugars were pretty well controlled however. The problem with this poor lady was that she had dementia and a DNR order, with no family and little information from the nursing home. I did say in my rationales I gave later to the school that it might be good to try and get her to feed orally again, but that would take a lot of time because we would have to figure out why she was placed on the feeding to begin with. Either way, I think I may have focused on the here and now. I did speak with the dean this afternoon. She said she wanted me to concentrate on my studying to get through the final, then she wants me to rewrite how I think I have progressed with each objective. I asked her about my presidency (I am the president of the class), because the pinning is coming up and our associate dean is asking me to write a speach, but she wants to print the programs and put my VP as the new president. Anyway, the dean said to go ahead and go on like I am still the president, and to not worry about the pinning because they can make the programs the day before if need be. So some friends and my mother are optimistic about that, because they say if she had plans on not reversing the unsat, she would not be telling me to go on like I am. I, however, and not convinced, but I will try my best. I am not sure if I have to redo the care map or not, but I may anyway when I get bored of studying and need a break (heehee, some break).
I took a look at those websites you posted, and they look great. I did see there that PEG feeding has as much of a risk for aspiration as NG tube, which is a good thing to know, because the responses raised the question in my mind. I also may go with the diabetic diagnosis, because I guess that is nutrition related since you said it was listed in the nutrition section. Anyway, thank you so much again. You all came very quickly to my aid even though you don't know much about me. I really appreciate it.
Good night!