What Diagnosis would you say this patient is?

[CANRN, MSN, RN]

I was sent to do an admission in a LTC facility. The patient was having respiratory distress with stridor. HORRIBLE stridor!

Past history included Alzheimer's disease with dementia and Psychosis. The patient was treated twice in the last three months in a hospital for respiratiory failiure. The last discharge was on 4/29 and orders were for palliative care. Primary diagnosis was respiratory failure secondary to Alzheimer's Disease, dementia and pscychosis.

He had been evaluated at that time and deamed by the evaluating nurse that he was NOT hospice appropriate, The patient was on Prednisone in tapering doses. He finished the last dose over the weekend. Yesterday, he started with the resp distress and stridor, unresponsive, no eye opening response, no moaning, he did have a withdrawal response when you attempted to move his arms for a B/P, could not swallow, and had copious amount of secretions coming out of his mouth. I did not hear any rhonchi, although difficult to auscultate due to the stridor, but nevertheless, his lung sounds were what I called diminished but clear. Do to the drooling, I surmised the patient could not swallow or he would have swallowed the secretions. I admitted under general debility based on the rapid decline in condition and level of consciousness. He also had a HX of CAD and HTN. His B/P for me was a systolic below 90 and is diastolic was in the 40's. Heart rate was 100, respirations were 28.

Our clinical manager, who has not been in the field forever I might add, said to put him on inpatient level of care, which I felt he did not qualify, we had him under control before I left, with levisin (which the facility all ready had ordered) and one dose of Roxanol quieted his breathing. He was comfortable.

The medical director, agreed with me when I told him my findings, that Debility was teh best DX to use.

Now, I am being told he does not qualify for this DX because we do not have a BMI at 22 or below!! I thought that was for failure to thrive?

I understand nutrition is a big part of Debility, but with this rapid decline in LOC and his respiratory distress, wouldn't that be an appropriate DX? ALso, H&P's from the last two hosiptalizations for this visit the MD's all DX with Respiratory Failure.

I also felt that was the appropriate DX for him, Respiratory Failure, based on the DX from the hospital docs and it was on his community referral form. But was told NO, because there is no HISTORY of COPD????

I am not a new hospice nurse, but I am new with this company. Was I taught wrong? All of my "cheat sheets" and criteria information I used does not say a BMI has to be a deciding factor in a debility DX. BUt, nutrition is a factor, this man could no longer swallow! I did put that in my summary note as well. I put all my findings in my summary note to support the DX.

Can you help me out here? It would help me to understand this. I am totally baffled.

Thanks,

Cindy

[doodlemom]

I would use respiratory failure as a diagnosis

[CANRN, MSN, RN]

I would use respiratory failure as a diagnosis

I tried that and was shot down. As I pointed out on the CRF and the H&P, he was hospitalized twice in two monts for Respiratory Failure. THe documentation clearly supports it. I was told, "there is no history of COPD" I was thinking to myself "WHAT THE????

WHere I worked before we had several Respiratory failure patients and I know one of them was never diagnosed with COPD.

I'm telling ya, I think this place is weird. Not one of these nurses has a year in hospice care yet! (I have four as a hospice case manager, did my community based nursing in hospice care, )The CPM has not been in the field in forever. They do not attend seminars to keep updated on the latest rules and symptom managment options. THey rely entirely on the corporate office to update them. You can't work in a bubble and keep on top of changes.

I take my CHPN in June, after that, I think I am going to look for another agency. This one seems almost comical to me. They make everything so dang hard and it's not.

[saribeth]

What about Failure to Thrive or Total Body System Failure???? I know Medicare doesn't love those but heck, it is what it is!!!!

[CANRN, MSN, RN]

What about Failure to Thrive or Total Body System Failure???? I know Medicare doesn't love those but heck, it is what it is!!!!

He does not fit failure to thrive, his BMI is too high and he has not had progressive weight loss. This all just started in March. And all the documentation from the hospital supports respiratory failure. It will be interesting to see what she decides tomorrow. If "her" diagnosis is not supported by the documentation from the doctors who cared for him, I will be expected to sign the cert. I won't do it if I do not feel comfortable with it and there is not documentation to suport it. Am I wrong there?

[nlion87]

My first guest would be impaired gas exchange or ineffective airway clearance but I could be wrong.. It seems to me you are providing a medical diagnos with COPD rather than a nanda diagnosis

[morte, LPN, LVN]

hmm maybe he has had co wt loss r/t prednisone?///

also, perhaps this isnt a patient care issue at all, but the fact that you are "not doing what your are told"?......

[aimeee, BSN, RN]

You need the low BMI to support Failure to Thrive but you don't need it for debility. Although I have used failure to thrive when the pattern of loss was correct but they were not quite there yet because they started out with such large fat stores. I would probably have chosen debility too but I hate having to use it. Its unclear here what is driving the respiratory failure.

[CANRN, MSN, RN]

My first guest would be impaired gas exchange or ineffective airway clearance but I could be wrong.. It seems to me you are providing a medical diagnos with COPD rather than a nanda diagnosis

THis is the medical diagnosis. It is the admitting diagnosis for hospice. THe documentation and assessment support Respiratory failure for admitting hospice diagnosis (the H&P from the DOCTORS determined his DX). My supervisor does not want it to be what the doctor has, she wants to change it saying he does not fit the criteria for respiratory! My entire assessment and admission summary relate entirely to his repspiratory status and LOC.

[CANRN, MSN, RN]

perhaps this isnt a patient care issue at all, but the fact that you are "not doing what your are told"?......

BINGO! I agree, and I wouldn't mind if the admission diagnosis was supported with the doctor's documentation and presenting symptoms were appropriate.

We'll see how this goes today.

[CANRN, MSN, RN]

--------------------------------------------------------------------------------

You need the low BMI to support Failure to Thrive but you don't need it for debility

THANK YOU!!! I have argued that point with her on several patients, she INSISTS you need the BMI for both and will not accept a diagnosis for either with out the low BMI.

Thank God! I'm NOT crazy!!!!:chuckle

[aimeee, BSN, RN]

Do you know which fiscal intermediary you are under? I could help you find the link to the latest guidelines online and then you can print it out and give it to her with the appropriate sections highlited.