ineffective ? care plan for 93 yo with dyhydration....but why???

[anangelsmommy, ADN, BSN, RN]

ok, I am an lpn that is a student rn in the last month for my ADN-RN, I have a pt is 93 ys old and stops eating and drinking and I have to do a care plan, so the dx is dehydration, nursing diagnosis is deficient fluid volume related to inadequate fluid intake and I need to do interventions.....i guess the issue I have is that he is refusing to eat and drink....reality is that this person is most likely readying to die. So the interventions that I listed are things like offer liquids and pureed foods every hour, but pt absolutely refuses....I can only list so many things and I need to list a certain amount. realistically I wonder about the reality of this all....but then again in real life...a lot of times they would start tube feedings unless the family decides they dont want to go down this road. pt is getting iv fluids, but then doc actually cut the iv fluids down??? So any other ideas what I can do for interventions other than to offer fluids and pureed foods, determine preferences and offer these first, oral care 4x per day, iv fluids as ordered, assess for diarhea/fever and correct as soon as possible to prevent further dehydration. But I guess I wonder about the reality of it since the patient has totally refused all liquids and it just doesnt seem that he will at any time decide to take any, he is also being treated for an infection, so perhaps this is having an effect on his appetite but his spouse said that he normally gets something to increase his appetite and even then it is difficult to get him to eat at times. patient is also blind so you have to feed him. Any ideas for interventions? It just seems to me that when a patient refuses to eat and they are a dnr, and there is not much wrong and they are 93, what can you do? but you HAVE to do a care plan???? help?

angelsmommy

[Virgo_RN, BSN, RN]

You should post this in the "Students" section.

[netglow, ASN, RN]

You know we can't do this homework for you, but here is a hint:

You say you cannot do much more for him medically, what else can you do for him?

If you were his family, what would you hope people were doing for him when you were not at his bedside? Also, what can you do for the family?

[anangelsmommy, ADN, BSN, RN]

no I dont want you to do my homework, If you notice I already listed the interventions I would put, I would want him made comfortable. I guess that is exactly what made me think about this, if it was my family member, I would not want him to suffer and at some point I would have to wonder if being without fluids would make him start to suffer, although he is getting iv fluids. I cannot give him any medication without a doctors order. of course I am doing more for him unrelated to this nursing diagnosis - turn every 2 hrs to prevent skin breakdown etc etc but what I was focused on was that I never had a patient that I couldnt actually help before. That the interventions I had, were refused...the only thing that seems to be working is the iv fluids, he has no prn medication - no pain meds although he denies pain at all times and I have assessed him for pain every hour.... I am sort of stuck? am I not seeing the forest for the trees? or perhaps sometimes you just have interventions that aren't effective and need reevaluation. in this case I dont think that they will do any good and I guess that is what has me stumped....what good is an intervention if you KNOW it will do no good?

[luvschoolnursing, LPN]

Providing frequent oral care comes to mind.

[mauxtav8r]

Hey, this is a great question.

I think you have the wrong nursing dx, though. I'd go with adult failure to thrive (is that in the NANDA list? or is is a medical dx?). The point is, dehydration is a symptom of the dying which has already begun.

Do look up the consequences of hydrating dying patients. Not the comfort intervention that you seek.

Turns, yes. Social-type interventions such as offering spiritual counseling, therapeutic communication, stress-relief measures come to mind also.

Good luck.

[mauxtav8r]

Altered Health Maintenance might be a good choice.

[loriangel14, RN]

You have looked at nursing interventions and physical tasks such as turning and oral care but what about emotional?

[txspadequeenRN, BSN, RN]

look up care plans for hospice....look at comfort care careplans, pain management skin care.....spiritual , death and dying ....so many can fit this situation....

[anangelsmommy, ADN, BSN, RN]

well the patient was combative and not able to communicate beyond telling me his name....He was a dnr but his wife didnt seem to understand the possibility that this could be his decision and he was not as yet exhibiting agonal breathing or any direct indications of imminent death but more I felt that this may be an indication that he had more or less made that choice. In the nursing homes, it seems that many pts refuse to eat and then soon after they die.

Altered health maintenance / adult Failure to Thrive - I cant find but I can find Ineffective health maintenance but for this it seems that the patient seems to need to be able to be teachable? This patient is definately NOT teachable, he is asleep all the time, blind and combative when he is disturbed. The Medical diagnosis is chosen for me and I can't change that. The nursing diagnosis I cant choose. I was just trying to make some sense of how you care for a patient that refuses most of your care.

I spoke to the spouse and she was very willing to be involved but he was uncooperative for her as well. I found information on Vitamin A deficiency altering smell and taste in the elderly but if there is not an order for either a vitamin or foods with vitamin A that he will eat, I can't get him to eat the vitamin A in hopes it might help him in finding food more appealing- if this could be in any way associated.

I know...grasping at straws here.

oral care was already included in my plan 4 times per day - does that seem enough if he is not eating at all? perhaps swabs more often in between?

[In_Chantress]

Have you tried food with different textures or temp. I one a patient that was refusing to eat or drink... but when we offered him ice cream or popsicles, he ate it all and asked for more. Another patient refused anything, but would take ice chips... or anything that had salsa on it (she was hispanic).

[anangelsmommy, ADN, BSN, RN]

He can only have pureed foods so it does limit but I have offered chocolate and vanilla, and banana pudding, cream of wheat cereal and I cant even get him to open his mouth to even try. I tried to reason with him to get him to take medication telling him he needs to feel better but to no avail. My instructor came in and tried also ( I dont think she believed that i had really tried LOL) but he refused also for her and she saw that I really did offer more than one thing and that he really wanted NOTHING and in fact he said " leave me the hell alone" and then went back to sleep. I wish I could try popsicles but he can only have thickened liquids. I tried orange juice with thick it, thinking that perhaps the juice would spur his taste buds but also a no..... but I did write in my plan to determine food preferences and temperature preferences and to also try to get family involved in feeding. The spouse said that sometimes he would eat for her but today he wouldnt have anything to do with food and he seems to be on a downward spiral.