Failure to Thrive (FTT) SKINNY Reasoning- CERTIFIED

Failure to Thrive (FTT) SKINNY Reasoning Ben Potter, 4 months old Primary Concept Nutrition Interrelated Concepts (In order of emphasis) • Fluid and Electrolyte Balance • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23%  • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity • Basic Care and Comfort 6-12%  • Pharmacological and Parenteral Therapies 12-18%  • Reduction of Risk Potential 9-15%  • Physiological Adaptation 11-17%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Ben Potter is a 4-month-old male presented to the pediatrician's office for a routine well-child exam. Ben is accompanied by his mother, Pamela, a 19-year-old single mother. Pamela appears visibly tired and reports that Ben has been getting up more frequently in the night, crying but refusing to eat. Pamela reports that over the past three weeks, Ben often refuses his formula feedings and reports episodes of gagging, arching his back, and frequent crying during and immediately following formula feedings. Pamela reports that she has interpreted this behavior as a sign that she is overfeeding Ben and has started watering down his Similac. According to his chart, Pamela has never breastfed Ben. In addition, the following growth measurements are noted: Date: Weight: Length: Head Circumference: April 22 (birth) 8 lbs 1 oz (3.7kg) 19 inches (48.3 cm) 35.5 cm May 2 7 lbs 9 oz (3.4 kg) 19 inches (48.3 cm) 36 cm June 19 10 lbs 8 oz (4.8 kg) 20.5 inches (52.1 cm) 38.8 cm August 20 (current) 12 lbs 4 oz (5.6 kg) 22 inches (55.9 cm) 42.3 cm Using the CDC chart, what percentile is Ben with weight and length? • Weight: o 10th percentile • Length o <5th percentile Important FYI: There is no consensus of a definition of FTT in literature (Kirkland et al 2015)but these authors define as when weight is less than 2nd percentile for gestation corrected age and sex when plotted out on growth chart Some sources describe when WT less than 5% Ben is thin and pale in appearance. Skin folds noted around his buttocks. No respiratory or neurological concerns noted. Reflexes and muscle tone within normal limits. Ben is alert, minimally interactive, and does not make eye contact with his mother. Ben's anterior fontanel is flat and open. Pamela leaves the room during the assessment to make a telephone call and smoke a cigarette. Ben's pediatrician makes the decision to transport Ben to the local Children's Hospital to admit him for observation. You are the nurse assigned to care for Ben. What would be reasons for a hospital admission based on data collected to this point? Personal/Social History: Ben lives with his 19-year-old mother (Pamela) and maternal grandmother (Susan) in Susan's small two-bedroom mobile home. Susan is 45 years old, is obese, and suffers from poorly controlled type 2 diabetes, hypertension, and smokes 2 packs per day. Susan watches Ben during the day while Pamela works part-time at a local gas station. Susan also cares for Ben three or four nights per week while Pamela spends her nights drinking and socializing with men and other adults at the local bar. Pamela became pregnant with Ben following a brief relationship with a 52-year-old man named Ryan. Ryan is not involved in Ben or Pamela's life and is currently in prison for assault. Past Medical History (PMH): • Pamela gave birth to Ben via spontaneous vaginal delivery at 37 weeks. • Prenatal care received after 12 weeks due to lack of insurance. • Maternal alcohol use during pregnancy – quantity unknown. • Maternal blood alcohol level negative at delivery. • Paternal history unknown • NKDA What data from the histories is important and RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Episodes of gagging, arching back, and frequent crying during and immediately following formula feedings. Mother's report of watering down formula. Anthropometric measures/Thin, pale appearance. Presence of skin folds around buttocks. Does not make eye contact with his mother There are many signs which may point toward a diagnosis of reflux in an infant, including episodes of spitting up, irritability, and recurrent back arching (Neu, Corwin, Lareau, & Marcheggiani-Howard, 2012). The nurse should document this finding and observe the infant before, during and after feeds in addition to close collaboration with the interdisciplinary team; including the registered dietician and physician. This is an alarming admission and must be addressed. Diluting formula can lead to water intoxication with resultant hyponatremia, deprivation of vital nutrients and minerals, and significant growth and developmental delays. In addition, diluting formula can lead to a deficiency in iron, which can lead to anemia. While growth measurements alone may not be useful, they may aid in problem identification and a holistic approach to care. The nurse must carefully plot Ben's growth values on age and sex specific growth charts established by the Centers for Disease Control (CDC) (Mahmood, 2015). Ben's thin, pale appearance must be recognized as an important clinical finding and should be investigated further. Ben's pallor may be a result of an underlying illness, such as a virus or anemia. This assessment data indicates that Ben is not getting enough calories to foster proper growth. These findings should be recognized by the nurse as clinical RED FLAGS! According to Hockenberry & Wilson (2015), clinical manifestations of failure to thrive include the avoidance of eye contact, withdrawn behavior, growth disturbances, developmental delays, and a stiff or flaccid response. The nurse must recognize that a 4-month-old infant typically enjoys social interactions, makes eye contact, and “talks” quite a bit when spoken to. RELEVANT Data from Social History: Clinical Significance: Susan watches Ben during the day while Pamela works part-time at a local gas station. Susan also cares for Ben three to four nights per week while Pamela spends her nights drinking and meeting men at the bar. Ryan is not involved in Ben or Pamela's life and is currently in prison for assault. Infants' developmental stage, according to Erickson. include developing a sense of trust versus mistrust. Infants “trust” that their comfort, feeding, and various needs will be met. The critical element for the achievement of this developmental task is the quality of both the relationship between the caregiver and child and the care the infant receives. In Ben's case, Pamela's age and immaturity in addition to financial and environmental concerns, combined with Susan's health status, places Ben at an increased risk for attachment issues, neglect and/or abuse, mistrust, and adverse health outcomes. The nurse must recognize these social factors as significant contributors to Ben's overall health and wellness. Patient Care Begins: Current VS: Pain Assessment – FLACC scale (0-2 points) T: 96.8°F (36.0 C) Face: 0 P: 150 Legs: 0 R: 34 Activity: 0 BP: 75/50 Cry: 0 O2 sat: 97% room air Consolability: 2 0 1 2 Face Relaxed or smile Occasional grimace, frown, withdrawn Frequent frown, clenched jaw, quivering chin Legs Relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, moves easily Squirming, tense Arched, rigid, or jerking Cry No cry (awake or asleep) Moans, whimpers. Occasional complaints Crying, sobs, screams, frequent complaints Consolability Content or relaxed Easy to console, distractible Difficult to console or comfort Each of the five categories is scored from 0-2, resulting in a total of 0-10 Current Assessment: GENERAL APPEARANCE: Ben is lying in his crib, eyes closed. Becomes irritable during assessment, difficult to console. Mom is not at bedside. RESP: No respiratory distress noted. Lungs sound clear throughout. CARDIAC: Apical pulse regular NEURO: Pupils round, reactive. More alert as assessment continues, remains very difficult to console. GI: Bowel sounds audible x4. Last BM unknown. GU: Diaper changed during assessment, no bruising or skin issues noted around peri area. SKIN: Pale, no open wounds or additional skin concerns noted. What assessment data is RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Becomes irritable during assessment, difficult to console. Mom is not at bedside. GU: Diaper changed during assessment, no bruising or skin issues noted around peri area. SKIN: Pale Ben's irritability and inconsolability must be recognized as significant by the nurse. Ben may be experiencing persistent irritability related to many possible causes, including a general mistrust of those around him, hunger, water intoxication, and possible underlying comorbidities, including possible thyroid or metabolic illnesses. Because of the initial concern about neglect and abuse that were identified at the beginning of this scenario, the absence of the mother is clinically significant. She may have gone out for a break, so the frequency and time of absence must be noted and documented. In addition the INTERACTION or lack of it between Ben and her mother must be noted and documented. The nurse must not pre-judge that the absence is out of not caring… sometimes when asked, parents report it is just too difficult to see their baby sick and/or parents may have other kids at home (not in this case), lack of money for gas or job that they have to be at or just plain lack of understanding of importance of being present. Ben is at risk for neglect and abuse. Because this finding is normal, it is clinically significant and confirms no outward signs of physical abuse. Why is Ben pale? Based on the data collected so far, anemia secondary to malnutrition is the most likely cause. Diagnostic Results: Basic Metabolic Panel (BMP) Na K Cl Gluc. Creat. Current: 127 2.9 91 70 0.8 Most Recent: 129 2.8 92 72 0.9 Complete Blood Count (CBC) WBC HGB PLTs % Neuts Current: 9.6 12.8 311 68 Most Recent: 10.2 13.1 367 65 What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Diagnostic Data: Clinical Significance: TREND: Improve/Worsening/Stable: Even if normal, because of their physiologic significance, the following labs must be noted as ALWAYS relevant by the nurse. Sodium: 127 Potassium: 2.9 Chloride: 91 Glucose: 70 Sodium is an important electrolyte that helps control the amount of water that surrounds and enters the cells. Hyponatremia occurs when the sodium levels in the blood are abnormally low. When too much water is ingested, the sodium in the body becomes diluted. Subsequently, the intake of water exceeds the kidney's ability to eliminate the water, causing water levels to rise and the cells to swell. As cellular edema progresses, hyponatremic encephalopathy can result. This is especially concerning for pediatric patients, as their brain-to- skull-size ratio is larger, which limits the space available for the extra water (Joo & Kim, 2013). Potassium balance is necessary to maintain normal cellular function. Hypokalemia may result from poor intake, excessive losses (vomiting, diarrhea, etc.), DKA, diuretic therapy, hyperthyroidism, or hyperaldosteronism. Muscle weakness may be evident in a child with hypokalemia in addition to life- threatening cardiac arrhythmias and acute respiratory failure. As hypokalemia progresses, the nurse should monitor for significant bradycardia and associated cardiovascular failure. Chloride partners with other electrolytes in the body, such as potassium, CO2, and sodium to balance body fluids and maintain an appropriate acid-base balance. Hypochloremia may be caused by metabolic alkalosis, excessive sweating, dehydration, and vomiting. • Required fuel for metabolism for every cell in the human body, especially the brain • Relevant to history of diabetes or stress hyperglycemia due to illness Slight WORSENING Low but STABLE Low but STABLE STABLE Creatinine: 0.8 • Elevated levels post-op can increase the risk of infection/sepsis. • GOLD STANDARD for kidney function and adequacy of renal perfusion • The functioning of the renal system affects every body system; therefore, it is ALWAYS relevant! STABLE WBC: 9.6 Though the WBC, neutrophil %, Hgb, and platelets are None concerning. The Neutrophils: 68 Hgb: 12.8 Platelets: 311 always relevant and must be noted by the nurse, these labs are WNL. Therefore, the nurse can conclude that though this is a clinical picture of FTT, there are no infectious differences in the TRENDS are not clinically significant. diseases that may be contributing to his FTT. Anemia is often seen when a patient is malnourished. Though his Hgb is normal, it is low normal and malnutrition needs to be noted as a likely cause in this context. Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology in OWN Words: Failure to thrive - Caloric deprivation related to familial stress, lack of education, inconsistent caregiving Failure to thrive - caloric deprivation related to familial stress, lack of education, fatigue Failure to thrive (FTT) can be described as a weight-for-length measurement less than the fifth percentile, or a weight-for-age value below the third percentile (Grodner, Roth, & Walkingshaw, 2012). FTT can be classified as organic, caused by metabolic disorders, congenital heart disease, HIV, various chronic diseases, and conditions that affect digestion and absorption. FTT can also be classified as non-organic, often diagnosed if there are no recognizable medical reasons for poor growth. Psychosocial considerations also play a role in diagnosing non-organic FTT including neglect, poor mother-infant attachment, poverty, lack of education/knowledge, and abuse. A careful genetic history, family history, and biological variability must also be considered. The cause of FTT is often multifactorial, involving a combination of dysfunctional parenting behaviors, infant organic disease, undiagnosed neurological or behavioral problems, and altered parent-child interactions. However, the primary etiology of FTT is inadequate caloric intake, regardless of the cause (Hockenberry & Wilson, 2015). Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome: 1. Admit to Pediatric Med/Surg 2. Daily weight 3. Strict I & O 4. Calorie counts 5. Vital signs every 4 hours 6. Similac Advance – per dietary 7. Monitor feeding tolerance, patterns, and behaviors 8. Consult registered dietician for nutrition assessment 1. Requires admission to assess physiologic status, presence of any electrolyte imbalances and the safety of Ben in his current home situation 2. Need to establish baseline and TREND over time to help determine clinical improvement 3. Need to maintain adequate oral intake and need to accurately document to determine hydration status 4. Need to determine caloric needs and then ensure that physiologic needs are being met 5. Need to establish clinical TRENDS over time to gauge clinical improvement. This is also the essence of clinical reasoning. 6. Advance diet as quickly as possible to improve nutritional status in a timely manner. 1. Complete assessment of physiologic status and improvement in nutritional status 2. Gradual weight gain as nutritional status improves 3. Accurate documentation of I&O 4. Accurate documentation of caloric intake with weight gain over time 5. Identify clinical TRENDS that will identify improving status 7. Essential assessments to establish current baseline 8. Will require specialized nutritional assessment to ensure adequate and optimal nutritional status. 6. Able to advance diet in timely manner with resultant improvement in nutritional status 7. Baseline tolerance and pattern established 8. Identify severity of current malnutrition Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: • Correct nutritional deficiencies/fluid balance • Restore optimum body composition/achieve ideal weight for height/provide adequate calories for catch-up growth PRIORITY Nursing Interventions: Rationale: Expected Outcome: The nurse will closely monitor patient's vital signs and neurological status, monitoring for seizure activity and overall level of consciousness. Although Ben is alert and irritable, the progression from alert to drowsy to lethargic to unresponsive can be rapid, especially in an infant. FLACC score of 0, decreased irritability and fussiness, neurological status WNL. The nurse will contact physician regarding vital signs and admission assessment. The nurse must contact the physician upon admission and anticipate new orders related to Ben's condition. New orders will be received and implemented by the nurse. The nurse will contact unit social worker, registered dietician, occupational/physical therapist as well as developmental psychologist and child life specialist if available The admission assessment revealed that no one was present with Ben in the hospital. A family-centered, interdisciplinary approach is necessary to facilitate a positive outcome for Ben and his family. Ben's caregivers will return to the hospital to collaborate with the health care team in order to create a mutually beneficial plan of care. 4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: Use your lens of practice as an educator to determine how you would establish a plan of care for each of the psychosocial priorities identified above. I have some general recommendations below that can be used to initiate dialogue and discussion. PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Discuss the following principles to effectively engage and communicate caring by showing that the patient matters to the nurse: Emotional support BE PRESENT and AVAILABLE to your patient. When this is made intentional to your patient, it communicates caring (Swanson, 1991). Providing/offering hope Hope is related to meaning and purpose in life, but its emphasis is on having a future hope or expectation. This is closely related to spiritual care Will feel valued and comforted Physical comfort measures (Swanson, 1991). Nurse Engagement The nurse must remain clinically curious and responsive to the patient's story and situation. When distracted and not engaged, the nurse will be unable to invest the energy needed to recognize relevant and urgent clinical signs that may require intervention. When nurses are not engaged with the patient and their clinical problem, patient outcomes will suffer. Nurse Presence To be present means that the nurse is AVAILABLE and ACCESSIBLE and this is communicated to the patient. Presence can also be defined as “being with” and “being there” to meet their needs in a time of need. Other ways to define or explain presence include caring, nurturance, empathy, physical closeness, and physical touch. (Rex–Smith, 2007). Use of touch Touch is a fundamental human need and an appropriate intervention that nurses should integrate into their practice. Touch is a positive way to influence the patient's physical environment. It uses nature to influence the patient's well-being (Bush, 2001). Never underestimate the power of the “little things' that are done for your patients. I have observed that the little things such as basic hygiene, shave, back rub, or obtaining the patient's story, are the BIG things that communicate caring and also make them feel so much better! Will feel valued and comforted EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship: • Rapport • Trust • Respect • Genuineness • Empathy SPIRITUAL: • F-Faith or beliefs: What are your spiritual beliefs? Do you consider yourself spiritual? What things do you believe in that give meaning to life? • I-Importance and influence: Is faith important to you? How has These questions, if used in this scenario by the nurse, would naturally explore this patient's spirituality. It is always best if the nurse has some comfort in the exploration of spirituality. Patients can sense discomfort or anxiety in approaching this portion of the assessment. The FICA model offers some open-ended questions to make spiritual Faith/beliefs are supported your illness or hospitalization affected your belief practices? • C-Community: Are you connected to a faith center in the community? Does it provide support/comfort for you during times of stress? Is there a person/group who assists you in your spirituality? • A-Address: What can I do for you? What support can healthcare provide to support your spiritual beliefs/practices? assessment a natural part of the conversation. Use this spiritual assessment tool to make caring for the spirit an essential component of your nursing practice! CULTURAL Considerations (IF APPLICABLE) Since religious worldviews provide a window to the prevailing values and ethnic norms of any cultural group, knowledge, and understanding of the most dominant religions of ethnic groups in your community are essential and will facilitate cultural sensitivity. But remember that there will always be exceptions, so be careful not to make assumptions! Becoming knowledgeable about another cultural group and integrating this knowledge into your practice is the essence of becoming culturally competent. It means respecting each patient's cultural diversity and examining how their beliefs may affect their health care. When nursing care does not intersect with the patient's worldview or belief set, compliance with the proposed treatment plan will be less likely (Ward, 2012). Cultural beliefs are supported 5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance) It will be essential for the health care team to establish contact with Ben's mother and maternal grandmother. Once contact is made, the health care team can do a thorough family assessment and identify perceived and actual barriers to Ben's health and wellness. Following an assessment, the health care team can work on creating a discharge plan that includes education and support regarding appropriate feeding schedules and methods specific to Ben's developmental level and growth needs. The nurse must also coordinate care with the entire team in order to connect Ben's family with resources in the community that may be able to assist in providing financial and food assistance. It is important for the nurse to keep in mind that a referral for Child Protective Services is indicated for suspected abuse or neglect. Temporary placement in a foster home may aid in relieving family stress, protect the child, and give the child some stability if overwhelming obstacles are present that prevent appropriate family function. Author Elizabeth A. Dailey, MBA, HCM, MSN, RN, Nursing Faculty, Chamberlain College of Nursing, Cleveland, Ohio Reviewers • Linden Fraser, RN, MSN, Nursing Faculty, Nicolet College, Rhinelander, Wisconsin • Julie C. McIntosh, MSN, RN, Nursing Faculty, Mount Mercy University, Cedar Rapids, Iowa • Linda A. Strong, MSN, CPNP, CNE, Nursing Faculty, Cuyahoga Community College, Cleveland, Ohio References Crook, M. (2014). Refeeding syndrome: Problems with definition and management. Nutrition,30, . doi:10.1026/.2014.03.026 Grodner, M., Roth, S., & Walkingshaw, B. (2012). Nutritional Foundations and Clinical Applications: A Nursing Approach (5th ed.). St. Louis: Elsevier. Hockenberry, M.J. & Wilson, D. (2013). Wong's Essentials of Pediatric Nursing (9th ed.). St. Louis: Elsevier. 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