Nursing Protocol

Nutritional Insufficiency, Pediatric Units

PURPOSE

To direct nursing care of pediatric patients with Nutritional Insufficiency on the medical units at the Cleveland Clinic.

SUPPORTIVE DATA

Pediatric patients with nutritional insufficiency often require care on the inpatient pediatric units. Being underweight and poorly nourished is a severe health risk. These risks include but are not limited to: bradycardia, arrhythmias, orthostatic vital signs, and electrolyte imbalances. Nutritional Insufficiency also interferes with an individual’s ability to think clearly. For these reasons, the primary goals of hospitalization include: improvement of patient’s nutritional status, restoration of weight, stabilization of vital signs, and resolution of acute medical issues. These goals are attained by eating three meals a day and drinking an adequate amount of fluids. Once medically stable, the patient will be transferred or discharged to the appropriate level of care for their nutritional insufficiency.

There are two approaches to the dietary management of this patient population. The

Exchange Method, where the patient is involved in the dietary choices with the nutritionist, is primarily used for patients 18 years of age and older. The Maudsley Method, used for patients under 18 years of age, is an evidence based method found to be very effective in the treatment of eating disorders in adolescent patients. This method is based on the premise that eating disorder patients are unable, by the nature of their illness, to select meals that will best meet their nutritional requirements and will thus temporarily require parental selection of their meals. Consistent with this method, menus for patients on the Maudsley track will be selected daily with guidance by the nutritionist and input from a parent or guardian in order to ensure that adequate nutritional needs are met. Patients will not be included in the selection of their meals. Nutrition education is available for patients that demonstrate readiness to learn. Meal plans will be adjusted as nutritional requirements change. These meal plan selections are extremely important because food is the "medicine" that will repair vital organs and assist in your patient’s recovery.

POLICY

  1. The nutritional insufficiency protocol may be initiated by any RN together with a physician who believes the patient exhibits this behavior.
  1. Patients admitted with nutritional insufficiency may be referred to the behavioral medicine and/or psychiatric service to assist in their care.
  1. Physicians and nursing staff will determine a patient’s safety risk. A physician is responsible for performing a thorough physical exam including searching for any unsafe items.
  1. Concerns about suicidality or homicidality will prompt immediate psychiatric consultation todetermine a patient’s safety risk.
  1. The dietary treatment method will be ordered by the physician (either Exchange or MaudsleyMethod).
  1. Our goal is to have the patient, the nurse, and the physician sign the Patient Care Plan onadmission to the unit. However, the protocol is in effect regardless of whether or not it issigned by the patient.

CONTENT

ASSESSMENT /
  1. Assess the patient on admission including:
  2. Orthostatic vital signs are done at 0600, 1400, 2200.
  3. Daily weight at 0600 (before breakfast) in hospital gown ONLY, after void. Patient is to stand with back facing the display on scale. Do not communicate weight to patient.
  4. Patient will be dressed in a hospital gown and underpants only. When patient is to be weighed, undergarments and lead wires must be removed.
  5. Patients are expected to gain 0.2 kg per day. A nutritionist will graph expected weight changes and it will be kept in the chart. All changes to diet and use of supplements will be determined daily by the nutritionist.
  6. Assess the room and environment for unsafe objects every shift.
  7. Assess parent/guardian understanding of the nutritional insufficiency protocol.

PATIENT SURVEILLANCE /
  1. All patients hospitalized for nutritional insufficiency require constant observation. Constant observation means a health care provider (PCNA, CT, patient companion, nurse, physician, therapist) will stay with the patient at all times. When patient is using the bathroom, the door should be held slightly ajar by the nursing staff member so that observation can be maintained. Patients MAY NOT be left alone in the bathroom with the door closed. In the event that the patient has an opposite sex companion, a same sex person should be offered to observe bathing and toileting. Patient family members or friends may never substitute for nursing constant observation. Any concerns must be communicated immediately to the RN by the personnel providing the constant observation.
  2. Medical supplies, instruments and plastic bags should be removed from storage areas in the patient’s bed space and bathroom (EXCLUDING EMERGENCY EQUIPMENT).
  3. It is not recommended that patients being treated for nutritional insufficiency share a room.
  4. One nursing staff person provides surveillance for one specific patient only. Appropriate roommate selection is important and based on discretion of the nurse manager or designee.
  5. Medication administration should be supervised to ensure patient compliance.
  6. All meals will be supervised especially closely. Patients will be given 30 minutes to eat each meal and 20 minutes to eat each snack, or per physician order for time allotted. Each meal is to be eaten in its entirety. Patients are not permitted to use the bathroom until one hour post completion of a meal or snack.
  7. If 100% of the meal is not eaten, supplements will be given.
  8. Supplements are regarded as medicine and are given under health care provider supervision and are NOT negotiable.
  9. If supplements are not taken orally within 20 minutes, notify the nutritionist and house officer.

SAFETY & PRIVILEGES /
  1. On admission, or when protocol is implemented, the nurse and patient companion will remove personal belongings from the patient. The patient will be permitted to keep ESSENTIAL ITEMS (i.e. toiletries, make-up) in a plastic bag with the companion during the stay. No items are to be kept in bed with the patient. All other non-essential items will be sent home, including all medications.
  2. The use of the bathroom and showering will be determined based on the patient’s clinical status, which will be assessed daily by the medical team and ordered.
  3. Nutritionally insufficient patients will not be denied privileges (i.e. TV, etc.) unless deemed necessary by the health care team in discussion with the staff physician. The use of the hospital phone will be allowed. Cell phone use will be permitted on day two, but use may be limited/prohibited if used inappropriately. Activities such as light reading, school work, computer use, and activities in bed may be allowed.
  4. It will be determined by the healthcare team if any privileges need to be revoked based on behaviors or influences.
  5. All visitors must check with the RN before visiting. Visitors are restricted to family members only. A sign should be placed outside the door for visitors.

OFF THE UNIT /
  1. Nutritionally insufficient patients may only travel off the unit for medical purposes (i.e., scheduled tests) or if privilege are ordered and must be accompanied by a nursing staff member (RN, LPN, PCNA, patient companion).

PATIENT AND PARENT/GUARDIAN EDUCATION /
  1. Instruct patient and family on management guidelines.
  2. Instructpatient and family on purpose of these precautions.
  3. Instruct patient and family to notify nursing staff member of any changes in mealtime behaviors and any exercising.

REPORTABLE CONDITIONS /
  1. Notify primary physician and behavioral health service (if necessary) of any changes in patient’s behavior (i.e. increased agitation or withdrawal, attempt to leave the hospital, unauthorized visitors, etc.).

DOCUMENTATION /
  1. Document patient’s behavior in medical record every change in caregiver.
  2. Document presence of patient companion or nursing staff member providing constant observation every change in caregiver.
  3. Document patient’s behavior in the appropriate section of the electronic medical record every 30 minutes by patient companion.
  4. Document safety of room/environment every change in caregiver.
  5. Document preventative skin care measures (i.e. turning every 2 hours).

ADDENDUMS INCLUDE:

  1. NUTRITIONAL INSUFFICIENCY: PATIENT CARE PLAN
  2. CHILDREN’S HOSPITAL NURTITIONAL INSUFFICIENT PROTOCOL DO’S ANDDON’TS

REFERENCES

Lock, J., Le Grange, D., Agras, W. S., C. Dare. 2001. Treatment manual for anorexia nervosa: A family-based approach. New York: Guildford Publications, Inc.