Policy



Authors:Morgan Chojnacki, DNP, RN, Lindsay Ragsdale, MDCategory:ClinicalTitle: Disordered Eating GuidelineKeywords:Eating Disorder, bulimia, anorexiaDate of last update:12/18/2015Purpose:To provide a systematic guideline for inpatient medical care of pediatric patients with anorexia, bulimia, and/or other eating disorders. File Type:docxUniversity of Kentucky / UK HealthCareNursing Care GuidelineGuideline # FORMTEXT gNU-79 Title/Description: Disordered Eating Guideline at the Kentucky Children’s Hospital Purpose: To provide a systematic guideline for inpatient medical care of pediatric patients with anorexia, bulimia, and/or other eating disorders. TOC \o "1-2" \n \h \z \u PolicyProcedureAdmissionDaily WeightLabsNutritionMedicationBehavioral HealthAdjunctive TherapyInternet, Electronics Access, and Privilege SystemPhysical ActivitySocial ServicesPatient Safety Companions (Sitters)VisitationCare ConferencesTransfersEducationPersons and Sites AffectedPolicies ReplacedEffective DateReview/Revision DatesAppendix AServices that are providedServices that can be earned as incentivesPolicyThe purpose of this guideline is to provide the patient care team with a standard procedure for the admission, care, and transfer of minor patients with eating disordersProcedureAdmission Any patients for which there is a concern for an eating disorder shall be referred from outside hospitals or physician offices for inpatient medical management and medical stabilization and management if:BMI is ? 13 kg/m2 > 1kg loss in one weekBMI below 2nd percentile for age and genderWeight ? 85 percent of ideal body weightAcute food refusalConsuming ? 500 calories per dayBlood pressure less than 90/60Marked orthostatic hypotensionHypothermia (?34.5 degrees Celsius)Electrolyte abnormalities such hypokalemia, hypomagnesemia, hypophosphatemia such as ho Glucose ?60End organ compromise such as renal or liver failure such as renal failure, liver failure evidenced by laboratory dataDehydration Cardiac arrhythmia/abnormality such as severe bradycardia with HR <40/min, Prolonged QTc, or other EKG abnormalities such as p or b with HR SyncopeSeizureHematemesis or esophageal tearPancreatitis Each patient referred from non-UK providers are evaluated in the emergency department before admission to the PICU or PCU. EKG and electrolyte are obtained before direct admission from UK ambulatory clinics. Admission to a telemetry unit for the first 10 days of treatment is necessary to monitor for EKG changes associated with refeeding syndrome. The patient is admitted to PICU if the ANY of the following are present:Circulatory failure due to ventricular fibrillationComa or altered mental statusEpileptic seizureRespiratory failure (secondary to aspiration from purging)EKG changes of SVT, ST elevation, Inverted T-wave past lead V3, RHR?40bpmPotassium ?2.5mmol/LPhosphate ?0.5mmol/LSodium >150 OR ?125Magnesium <1.0mg/dLRenal failureThe patient shall be evaluated by the pediatric hospitalist or intensivist on call as soon as possible. The Disordered Eating Order Set is entered on admission. Pediatric cardiology is consulted if ANY of the following are present:Prolonged QTc (manually calculated)Arrhythmia Muffled heart sounds (pericardial effusions common)Inverted T-wave over lead 3ST elevationDaily Weight1. Weight is obtained daily at 0800 after voiding and before any PO intake. The patient shall wear only a gown and undergarments and shall step onto the scale backwards so that he or she cannot see the readings and are not made aware of their weight metrics. 2. Neither the parents nor any nor any visitor are permitted to see the patient’s weight nor is it reported to them except for care planning purposes.Labs Days 1-3: BID (First draw is on admission)Magnesium levelPhosphorus levelCMPThiamine (Vitamin B1) onceDaily UATSH onceCBC onceUrine pregnancy test upon admission Days 4-10: Daily Magnesium level RFP (Includes phosphorus level)CMP instead of RFP only if previous liver abnormalities Day 10 on: Every MondayMagnesium levelb) RFPc) CMP instead of RFP only if previous liver abnormalities4. Other labs as necessary as determined by as determined by providers. Lab holidays can be taken at the provider’s discretion if the lab value has remained stable.Nutrition Ideal body weight is calculated on admission. The ideal body weight calculator can be found here. If the patient is ? 70% ideal body weight or severe uncontrolled purging is present, the following diet is strongly recommended along with consulting inpatient dietician regarding NG formula and rate of NG feeds :Day 1: 1200 calorie PO diet during day and continuous NG feeds at night totaling 600 caloriesDay 2: 1200 calorie PO during day and continuous NG feeds at night totaling 800 caloriesDay 3: 1200 calorie PO during day and continuous NG feeds at night totaling 1000 caloriesDay 4: 1200 calorie PO during day and continuous NG feeds at night totaling 1200 caloriesDays 5+: Increase PO as tolerated and decrease NG by 20ml/hr every day as PO intake increasesIf weight is >70 % ideal body weight, start diet at 1200 calories per day. Increase calories by 200 calories every two (2) days until goal of one (1) kg per week weight gain is achieved. 1200, 1400, 1600, 1800, 2000, 2200, and 2400 calorie biweekly rotation diet menus shall be established by dietary and ordered for the patient by the dietician. These menus are posted on the patient’s unit by the dietician so that nurses can verify accuracy to food present on tray.No food from home is permitted in the room or consumed by patient. NO EXCEPTIONS are made.Sign that states “Please deliver all food trays to nursing station” is placed on door. The patient’s nurse shall check tray with menu provided by the dietician.Dietary services shall not contact the patient or family member regarding meal preferences. Family members may have guest trays delivered to room.The patient shall not have advance knowledge of the foods that he or she will be consuming.The patient is not permitted to substitute or eliminate any foods from his or her diet FOR ANY REASON except severe food allergy that is documented by a physician or religious belief (ex: no pork). Vegetarian diets are considered if that is the patient’s preference. Patients MAY NOT eat a vegan, gluten-free, lactose-free, egg-free, etc diet except previously stated reasons.Each patient is accompanied by a patient safety companion, nursing care tech, or registered nurse during meal times, including for one (1) hour after meal times (1.5 hours total). This is to model therapeutic meal support to the parents and patient, to provide intake of all food and beverages, and to verify safety of the patient.The patient shall have 30 minutes to complete each meal or snack. He or she may not go to the bathroom or leave the room during meal time.The patient shall eat meals sitting in non-recliner chair with tray on the patient bedside table to avoid intentional food loss in bedding, chair, clothing, etc. The patient may not use the bathroom for one (1) hour after each meal or snack. Neither the patient nor the parent shall take food out of room after it has been delivered.The patient shall eat 100% of all meals. If refused, percentage of the meal not eaten is replaced with that percentage of volume of 250ml can of Boost. Example: If the patient eats 75% of meal, patient must drink 63ml (25%) Boost. If Boost is refused, the nurse shall insert NG and give boost over 30-60 minutes.Free water intake is limited to 2000ml daily including IV fluid to avoid water loading.A calorie count is documented after each snack and meal. MedicationThiamine: Thiamine 100mgIV minibag is given STAT before patient’s first meal to prevent Wernicke’s encephalopathyThiamine 100mg PO daily after loading dosePhosphorusIf phosphorus level is ?2mg/dl, administer potassium phosphorus PhosNaK contains 250mg phosphorus, 160mg sodium, and 280 mg (7.2 mEq) potassium Electrolyte replacement as neededBehavioral Health A Behavioral Health representative shall evaluate patient as close to admission as possible.The role of the behavioral health representative is to establish rapport with the patient so that there is a smooth transition to outpatient therapy. The behavioral health representative shall provide support and act as a representative of the mental health system; when the brain is acutely undernourished, patients cannot begin to form the new connections/associations necessary to be effective in therapy. Behavioral health shall be available for care conference meetings with the medical teamBehavioral health shall be present during discharge teaching with the nurse. Nurse shall page representative at least one (1) hour prior to the initiation of discharge teaching to coordinate.Antipsychotics and antidepressants are managed by the psychiatrist if needed.Adjunctive TherapyThe patient is encouraged to participate in alternative therapies offered by the hospital to provide diversion for distracting thoughts about eating and food (see appendix A).Internet, Electronics Access, and Privilege System Patients may access their own electronic devices and the hospital television and phone. Access may be limited by nursing staff if it is interfering with POC goals (for example, accessing pro-anorexia sites on phone). If this is necessary, personal electronic devices should be given to parents for safekeeping. Privileges for different activities/experiences may be earned based on compliance with plan of care goals (see Appendix A). The child life specialist shall screen books, magazines, and movies, prior to patient use.Physical Activity1. Physical activity is limited on admission and may be earned based on adherence to plan of care goals and stability of labs and hemodynamics.2. Showers are limited to 15 minutes and the door must be cracked to permit observation and intervention in the event of water loading.Social ServicesThe pediatric social worker shall be consulted on admission.If the patient’s family indicates intent to leave against medical advice, the patient may be placed on a 72 hour hold, pending filing a petition for involuntary hospitalization.Patient Safety Companions (Sitters)The patient shall have a patient safety companion (PSC) at all times. There is strong evidence to support the positive correlation of eating disorders and suicidal ideation, suicide attempts, and self-harm.The nurse shall inform the DCN for the need of a PSC.The DCN shall communicate with central staffing to verify that a PSC is available.PSCs shall be briefed on the patient by the nurse prior to entering the room. Visitation Visiting hours are the same as the hospital with the exception that only parents can stay overnight with the patient.Parents may be asked to leave if they are detrimental to the patient’s progress toward goalsParents should not be present during patient meals in the first 2 days of admission. After that, parents are encouraged to be present during mealsCare ConferencesCare conferences shall be held 1-2 days after admission, as needed, and prior to transition periods (example, prior to transfer to inpatient psych facility)The hospitalist/resident shall coordinate care conferences as needed.Transfers When patient’s labs are stable and weight gain is occurring, plans for transfer to home with outpatient therapy or to inpatient resident facility should be initiated. Family preference and patient needs, insurance type, and residential facility intake requirements should be assessed prior to discussing transfer with the patient.Education Parents, patients, and care providers can be educated about meal support during hospitalization at:Kelty Mental Health Meal Support: Kelty Mental Health Post-Meal SupportPersons and Sites Affected FORMCHECKBOX Enterprise FORMCHECKBOX Chandler FORMCHECKBOX Good Samaritan FORMCHECKBOX Kentucky Children’s FORMCHECKBOX Ambulatory FORMCHECKBOX Department FORMTEXT ?????Policies Replaced FORMCHECKBOX Chandler HP FORMTEXT ????? FORMCHECKBOX Good Samaritan FORMTEXT ????? FORMCHECKBOX Kentucky Children’s CH FORMTEXT ????? FORMCHECKBOX Ambulatory KC FORMTEXT ????? FORMCHECKBOX Other FORMTEXT ?????Effective Date: FORMTEXT 12/18/2015Review/Revision Dates: FORMTEXT 12/18/2015Authored and Approved by:Morgan E. Chojnacki, RN, Pediatric Progressive Care, Kentucky Children’s HospitalKristin Six, Chair, Nursing Professional Practice CouncilAppendix AServices that are providedVisits from Therapy Dogs as scheduled Music Therapy Music therapy groups as scheduledJarrett’s Joy CartSpecial guests and visitors as scheduledMoviesBooks and magazinesServices that can be earned as incentivesMassage and Yoga as permitted by KCH managementSelf-guided activity binder with selection of activitiesMandalasWord searchesSudokuCross-words puzzlesJournal/sketch pad of patient selection Wheel Chair rides with staff as approved by doctorTime in the adolescent room as approved by doctorCraft activity with Child Life Staff/volunteerCollagingBeadsScrapbookingMasksCanvas paintingsJig saw puzzlesSyringe painting ................
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