Please Help. Need super fast advice for a serious matter

[knhebert]

Hi all. I accidently posted this in the General Nursing Discussion forum, so here it is again for a more applicable audience

"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. "

I got a reply pretty quickly stating that the PEG tube goes into the abdomen and therefore risk for aspiration isn't even close, but I disagreed because that is why we turn off the tube feeding before we lay patients down to do any care....it can back up the espohagus into the trachea. So there is a risk for aspiration, especially since this client always managed to wiggle down in bed to lay almost flat