Please Help. Need super fast advice for a serious matter

Nursing Students General Students

Published

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.

Up Vote Up Vote ×

The PEG tube goes directly into the abdomen. "Risk for aspiration r/t tube feeding" isn't even close.

Up Vote Up Vote ×

It is a risk for aspiration because the contents in the stomach can come up the esophagus into the trachea. Mainly if they are not upright, that is. Hence why you always turn off the tube feeding before you lay them down to bathe or turn or whatever else it is you need them flat to do.

Up Vote Up Vote ×

BTW, I think I may have posted this in the wrong forum. I was scrolling through the forum list because I could have sworn there was a nursing student forum, but I didn't see it. I saw it though just now when I replied as a link at the bottom of the page. Sorry.

Up Vote Up Vote ×
Specializes in Education, FP, LNC, Forensics, ED, OB.

Thread moved to General Nursing Student forum.

Up Vote Up Vote ×
It is a risk for aspiration because the contents in the stomach can come up the esophagus into the trachea. Mainly if they are not upright, that is. Hence why you always turn off the tube feeding before you lay them down to bathe or turn or whatever else it is you need them flat to do.

NG tube would be more risk for aspiration in my opinion. Maybe risk for impaired skin integrity?

Up Vote Up Vote ×

Hi. I am so sorry you got such a rigid clinical instructor. I have not done down and dirty nsg dx in years, but how bout looking at the fact that with and H & H so low, we could have increased her foods high in iron to contribute, but with her peg tube feeds, not an option. That is certainly an alteration in.... d/t inability to tol. po feeds.

Since your alleged poor performance was paperwork related, ask for a chance to resubmit. Also, explain your rationale to them like you did here. Inform them of all the steps, work and thinking you put into it, just like you told us. Your instructor has power/control issues which you can't fix and unfortunately CAN NOT allude to in your meeting. Don't personally attack her. Be calm, matter of fact and confident. Maybe while stating your case on how you did not blatantly ignore the assignment requirements, just approached it from another angle, both of these professionals you will meet with today will be willing to learn something themself.

Also, I TOTALLY agree with the pot for aspiration-- anyone not taking food by mouth and having any sort of tf (peg, gt,og,ng) will be pot at risk for aspiration. I concur that it can be considered nutritional related.

good luck and let us know how it goes.;)

Up Vote Up Vote ×
Specializes in Cardiac Telemetry, ED.

I agree an NG tube would generally present a greater aspiration risk, since the tube itself goes through the cardiac sphincter, which could allow stomach contents to seep through in a retrograde fashion. However, what if the person with the PEG tube has delayed gastric emptying or reflux? Then they, too, are at risk for aspiration.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry, ED.

I can see your dilemma. What I might have done, had I been in your shoes, and it may be too late to go back and do it this way, was to fill out the nutrition sheet according to her dietary habits prior to this hospitalization and PEG placement. She obviously fits the defining characteristics of "More Than", so I would have gone with that. Interventions then would have been focused on managing her dietary intake, which is what is happening with her PEG tube feedings.

Up Vote Up Vote ×
Specializes in Family Nurse Practitioner.

Based on the information you have listed I also would have gone with the "more than" diganosis. Keep in mind that it really is about what the professors want you to focus on even if you don't agree with their rationale. Just my two cents because I haven't seen any good come from bucking the system no matter how correct you may be. I'd suck it up and give them exactly what they asked for.

Good luck, Jules

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

I'm looking at the Domains, Classes and Diagnoses table of the NANDA taxonomy in my copy of NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 and these are the nursing diagnoses they list under nutrition

Class 1 Ingestion
Taking food or nutrients into the body

Ineffective infant feeding pattern

Impaired swallowing

Imbalanced Nutrition: less than body requirements

Imbalanced Nutrition: more than body requirements

Risk for imbalanced nutrition: More than body requirements
[you could also make a diagnosis of Risk for imbalanced nutrition: less than body requirements as well]

Class 4 Metabolism
The chemical and physical processes occurring in living organisms and cells for the development and use of protoplasm, production of waste and energy, with the release of energy for all vital processes

Risk for impaired liver function

Risk for unstable blood glucose level

Class 5 Hydration
The taking in and absorption of fluids and electrolytes

Deficient fluid volume

Risk for deficient fluid volume

Excess fluid volume

Risk for imbalanced fluid volume

Readiness for enhanced fluid volume

Because I didn't understand half of the information you provided, mainly because you used abbreviations that I don't know or understand, I would strongly recommend that you do a couple of things:

  1. Go back and review the physical assessment you made of this patient--labwork, information from the chart, your physical assessment
  2. Do the best you can to extract abnormal information from the nutritional assessment you were required to do because the abnormal information becomes the symptoms that you need to determine nursing diagnoses
  3. Follow the nursing process in determining a nursing diagnosis. . .in other words make a list of your patient's abnormal symptoms (defining characteristics) and then start comparing them with potential nursing diagnoses

  4. Look first at the nursing diagnoses I've listed above. Read their definitions to see if they seem to fit your patient's circumstances. You only need one or two defining characteristics for a nursing diagnosis to fit the patient's problem
  5. Ask yourself why this patient is on tube feedings in the first place. What's going on that this patient can't eat orally? What was the last set of electrolytes looking like? Did this patient have any symptoms of any vitamin or mineral deficiencies that are likely to develop in patients on tube feedings? What about any GI problems such as diarrhea as a complication of the tube feeding? My memory may be going bad here, but isn't Glucerna given to diabetics? Diabetes can be a nutritional problem. What are this lady's blood sugars running? What are her Intake and Outputs looking like?

What instructions of the instructor did you disobey? You didn't make that clear.

Up Vote Up Vote ×
Specializes in med/surg, telemetry, IV therapy, mgmt.

after doing a quick search i found these websites on assessing the (patient) receiving tube feedings which you might want to use as a guideline and reference them in your care plan:

by the way, did you include nursing interventions for the care of the gastric tube?

Up Vote Up Vote ×
+ Add a Comment