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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
rnto? I think that is exactly the problem that I am frustrated at not being able to do something that I feel is actually helping, I can write things down on paper and get an A and that is great but I KNOW that this man would NOT take the fluids or food not matter what and that he was starting to have breakdown and that I can turn him but that he would not even allow me into his mouth to perform oral care. He just wants to die. I dont have any orders to give him medications to make him comfortable and he denies pain. The wife states that he hasnt had a good appetite for some time but she has been able to get him to eat something here and there, he is normally in a nursing home and is on an appetite stimulant which the hospital is not giving him. The wife doesnt seem to understand that he may have decided he is ready to die and to be perfectly honest, I have NO IDEA how to bring that up. Worse thing is that I have actually had my own child die....I have discussed death and dying with other clients, I do homecare with pediatric patients and I have a few that are hospice, I use my own experience quite often as a reference point - I have clients that know that my son died and will ask me questions about things and I honestly dont have a problem sharing this, I feel that this is why I am a nurse now and that if I can help these people with this process, there has been some good from what loss I have had in my life. But for some reason when I looked in this older womans face, I dont think she knew it was coming and perhaps that is what struck me....I cant be the one to TELL her that he is probably dying, that is NOT my job or is it? but if it was then I would think it would be in a care conference, not just at the bedside as a casual conversation. And why hasnt the doctor? The doctor came in, looked at him briefly, and left and never saw the wife that I knew of so I dont know what interaction they had.
or how to incorporate that into a care plan....she seemed totally oblivious to the situation although she was very sweet and seemed alert and responsive and intelligent I just think that she had been married to him a long time and perhaps was not ready to face the situation. Although this is where I dont like the student situation, ( I found this out in another case) sometimes the drs have these conversations with the clients and will not tell you or pass it on even to the nurses or note it in the chart, and the client will continue to deny but my job might be to talk about options and support the family yet I have no idea that this conversation has occurred and since the client finds it so hard to talk about it she will not bring it up and I dont want to be the one to raise it if the doctor has not.
I know exactly what you are saying as far as the tube feedings. The client is a DNR but I often see clients with a DNR still recieving tube feedings in the nursing home and this age I would simply have said dont do it. There was no order for NG feedings despite his not eating for several days and as I said the dr even started to turn down the IV fluids.
I guess what I was looking for as I said was thinks that I could actually DO for this gentleman without a drs order. I can put give fluids offer small amounts often etc....but I KNOW he wont take them so I was frustrated at putting things I knew were just the normal things. I wanted to actually have things I can do for this gentleman. And it turns out I guess some feedback on perhaps the conversation to have with the wife...or if that is even appropriate.
thanks for the help.
anangelsmommy
I honestly wouldn't have felt comfortable bringing up death/dying as a student nurse, but as a staff nurse, sometimes you have to say what no one else will. Doctors, IME, are not interested or not good at having this conversation. I've initiated it as a nurse. It's hard to tell people what they don't want to hear, but that's part of our job sometimes.
rnto?
122 Posts
Are you asking what else you can do for him or frustrated because you feel like you have to do something even though he seems to have made up his mind? What is the history on this gentleman? Was he previously walking to bingo and this is a sudden change, or has he been declining for a long time? What is the family's expectations? If it is a sudden change you would want to assess for any medical conditions that might be causing it, or perhaps the antibiotics are upsetting his stomach? Also, many elderly can refuse to eat/take medications if they are actively fighting an infection-perhaps it will resolve on its own once the infection clears, and you just need to provide supportive measures. IV fluids, as mentioned previously, can cause many more problems than they fix, based on research and IME. Also, if he's getting IVF, he's not going to feel thirsty, thus compounding the problem.
If this is something that has been coming for a long time, your interventions would be focused on keeping him comfortable, obviously. As you know, when the body begins the dying process, one does not feel hunger or thirst. Alot of your interventions will be focused on preparing the family, educating them, and supporting thier decisions. Alot of people think they need to put in a feeding tube and continue IVF until the cows come home so their loved one isn't suffering-nurses can educate the families about the realities of the dying process. Honestly, though, sometimes you can educate until you're blue in the face but families will still insist on feeding tubes, etc. For me, the hardest part of working with the elderly is this phenomena-when you KNOW that these interventions are causing the patient more harm than good (bedsores from lack of protein and hypervolemia, all the sequelae that comes along with tube feeding, etc) but the family refuses to let go. Sometimes, you are able to assist families, and that is very rewarding. We focus on helping people live, but sometimes we need to help them die.