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.
