Failure to Thrive (FTT)
Ben Potter, 4 months old
Primary Concept
Nutrition
Interrelated Concepts (In order of emphasis)
1. Fluid and
... [Show More] Electrolyte Balance
2. Clinical Judgment
3. Patient Education
4. Communication
5. Collaboration
UNFOLDING Reasoning Case Study: STUDENT
Failure to Thrive (FTT)
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: 25%
□ Length: <5%
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.
• 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:
• 25% weight and <5% length according to CDC growth chart
• Mother is a smoker
• Refusing to eat
• Mother reports watering down formula
• Minimally interactive and does not make eye contact with mother
• Thin and pale
• Delayed prenatal care d/t lack of insurance
• Maternal alcohol use during pregnancy Baby is not meeting growth expectations. Mother is knowledge deficient about how to properly feed baby, missing hunger cues and is watering down feedings meaning baby is not receiving appropriate nutrients and may become hyponatremic. Bond between mother and baby is not healthy as evidenced by the baby won’t make eye contact with mother and baby is minimally interactive. Mother is a smoker and puts baby at risk for several disorders including FTT, SIDS and RSV. Maternal alcohol use may indicate fetal alcohol syndrome.
RELEVANT Data from Social History: Clinical Significance:
• Lives with mother and grandmother who both smoke
• Lives in small home
• Pamela is a drinker who spends 3-4 nights a week partying with random
guys
• FOB not in life, in prison for assault
• Grandmother in poor health:
obesity, DMII, HTN Baby is at increased risk for several disorders including FTT, SIDS and RSV d/t mother and grandmother are smokers. Baby’s grandmother is in poor health to be taking care of him and baby’s mother is being irresponsible by her choice in drinking heavily and partying with older random men. FOB is not involved d/t being in prison for assault, a bad influence for baby. Baby is not being taken care of properly at home.
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:
• Irritable during assessment
• Difficult to console
• Mom not at bedside
• Last BM unknown
• Pale Baby is without support system (mother) during assessment and may be experiencing some anxiety. Baby is difficult to console and irritable, may indicate being in pain – 2 on FLACC scale. Pale skin may be an indication of anemia. Bowel sounds are audible, not enough information to determine if
baby is constipated or not with last BM unknown.
Lab Results:
Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:
WBC (4.5–11.0 mm 3) 9.6 WNL 10.2
Neutrophil % (42–72) 68 WNL 65
Hgb (12–16 g/dL) 12.8 WNL 13.1
Platelets (150-450 x103/µl) 311 WNL 367
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
All current labs WNL. Hgb on low side of normal, all other lab results appear unremarkable. Labs are worsening from previous draw, but still currently WNL.
Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:
Sodium (135–145 mEq/L) 127 Low 129
Potassium (3.5–5.0 mEq/L) 2.9 Low 2.8
Chloride (95–105 mEq/L) 91 Low 92
Glucose (70–110 mg/dL) 70 WNL 72
BUN (7–25 mg/dl) 14 WNL 19
Creatinine (0.6–1.2 mg/dL) 0.8 WNL 0.9
What lab results are RELEVANT that must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
• Sodium 127 Labs indicate that baby is dehydrated and • Worsening
• Potassium 2.9 borderline hypoglycemic. • Improving
• Chloride 91 • Worsening
• Glucose 70 • Stable
Urine Analysis (UA:) Current: WNL/Abnormal?
Color (yellow) Clear WNL
Clarity (clear) Clear WNL
Specific Gravity (1.015-1.030) 1.003 Low
Protein (neg) Neg WNL
Glucose (neg) Neg WNL
Ketones (neg) Neg WNL
Bilirubin (neg) Neg WNL
Blood (neg) Neg WNL
Nitrite (neg) Neg WNL
LET (Leukocyte Esterase) (neg) Neg WNL
MICRO:
RBC’s (<5) 0 WNL
WBC’s (<5) 0 WNL
Bacteria (neg) Neg WNL
Epithelial (neg) Neg WNL
What lab results are RELEVANT that must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
Specific gravity In infants the specific gravity is less because their kidneys are still immature and unable to concentrate the urine as efficiently. Otherwise unremarkable urine results, no s/s of UTI.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
135-145 Hyponatremia causes • Monitor strict I&O’s
Sodium irritability,
encephalopathy and GI • Monitor VS
Value: 127 Critical Value:
< 135 disturbances.
May be caused d/t
mother diluting formula • Weigh daily at same time
• Nutrition/fluid replacement
with water. • Repeat labs as indicated
Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:
3.5-5
Critical Value:
<3.5 Hypokalemia can lead • EKG to monitor for cardiac dysrhythmia
Potassium to dysrhythmias. May
be caused d/t
• Give supplemental potassium as needed
Value: 2.9 dehydration.
• Monitor VS
• Repeat labs as indicated
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with? Inorganic failure to thrive
2. What is the underlying cause/pathophysiology of this concern? Psychosocial considerations, neglect, inadequate nutrition.
Collaborative Care: Medical Management
Care Provider Orders: 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. Assess for FTT or neglect
2. Monitor fluids and weight gain/loss
3. Monitor for fluid imbalances
4. Ensure proper nutritional intake
5. To assess for changes from baseline
6. To supplement nutrients
7. Assess for inability to latch, suck, swallow, etc.
8. Specialists are able to aid in ensuring adequate nutrition is being obtained 1. To determine the cause for inadequate nutrition
2. Plan of care is effective AEB weight gain
3. No s/s of fluid overload or deficit
4. Gaining adequate weight
5. Vital signs improve or WNL
6. Baby takes in adequate nutrients to gain weight
7. Tolerates feedings and no feeding issues noted
8. Identify patients nutritional needs
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders: Order of Priority: Rationale:
• Daily weight
• Strict I & O
• Vital signs every 4 hours
• Similac Advance – per dietary
• Consult registered dietician for nutrition assessment 1. Vital signs
2. Daily weight
3. Strict I&O
4. Dietician
5. Similac 1. To establish a baseline
2. To establish a baseline
3. To monitor for fluid imbalances
4. To determine supplements required for proper growth and health maintenance
5. To supplement as indicated by dietician
Food for Thought:
1. What are Ben’s estimated energy needs? 103 kilocalories/kg/day
2. What are Ben’s estimated protein needs? 2.2g/kg/day
3. Are IV fluids indicated?
Yes, baby appears malnourished and dehydrated upon admission.
4. What is refeeding syndrome and is this a problem to anticipate in this scenario?
Shifts in fluids and electrolytes that occur in malnourished or dehydrated patients. This could potentially be a problem.
Collaborative Care: Nursing
3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)
Correction of electrolyte imbalances, adequate nutritional intake, maternal education.
4. What interventions will you initiate based on this priority?
Nursing Interventions: Rationale: Expected Outcome:
• Initiate IV fluids as ordered
• Monitor I&O’s
• Daily weight
• Monitor VS
• Educate mother on how to prepare feedings • For treatment of hyponatremia
• To ensure baby is not retaining fluid
• To ensure baby is not retaining fluid
• To ensure there are no changes from baseline
• For nutrition improvement in baby • Labs WNL, baby is well hydrated
• Input and output will be
approximately equal
• Baby will not retain fluids
• VS WNL
• Baby gains weight appropriately
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
Cardiac d/t hypokalemia and neurologic f/t hyponatremia
6. What is the worst possible/most likely complication to anticipate?
Cardiac arrest, seizures, arrythmias and refeeding syndrome
7. What nursing assessments will identify this complication EARLY if it develops?
Monitor neuro status Q hour, monitor for bulging or for sunken fontanelles, monitor cardiac rhythm, VS Q hour, monitor for increased irritability
8. What nursing interventions will you initiate if this complication develops?
Seizures: have suction and oxygen at bedside, padding in the cribs for safety, administer medications as ordered Refeeding syndrome: stop IV fluids and administer diuretics as indicated by physician
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Patient will need child protective services involved d/t neglect. Mother will need some assistance with her substance abuse and unhealthy lifestyle choices.
10. How can the nurse address these psychosocial needs?
Get social worker and CPS involved for baby, refer mother to AA and group therapy.
Evaluation: Three hours after admission…
All orders have been implemented and consults have been called.
Ben’s mother arrives at the hospital. Pamela is slurring her speech, and her eyes appear glazed. Pamela admits to the nurse that she stopped and had a single glass of wine prior to coming to the hospital. Ben becomes agitated and inconsolable when his mother attempts to pick him up. The nurse calls hospital security and a cab is called for Pamela.
Current VS: Most Recent VS: Pain Assessment – FLACC scale (0-2 points)
T: 97.2°F (36.2 C) T: 96.8°F (36.0 C) Face: 0
P: 141 P: 150 Legs: 0
R: 32 R: 34 Activity: 0
BP: 82/40 BP: 75/50 Cry: 0
O2 sat: 98% on room air O2 sat: 97% room air Consolability
: 2
Current Assessment:
GENERAL APPEARANCE: Ben is awake and alert, respirations regular and unlabored.
RESP: No respiratory distress noted. Lungs clear throughout.
CARDIAC: Apical pulse regular, no murmurs or abnormal sounds noted.
NEURO: Pupils round, reactive. Volunteer present in Ben’s room, holding him in a rocker. Resting calmly.
GI: Bowel sounds audible x4. Last BM still unknown.
GU: Voiding without difficulty
SKIN: No open wounds or skin concerns noted.
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance:
Vitals are unremarkable. Baby is stable.
RELEVANT Assessment Data: Clinical Significance:
• Baby assessment is
unremarkable.
• Mother appears to hospital with slurred speech and eyes glazed over.
• Baby irritable and cries when
mother tries to pick him up. Mother is under the influence of alcohol and is incapable of caring for baby at this time. Baby irritability when mother hold him indicates fear or mistrust of mother.
2. Has the status improved or not as expected to this point?
Infants vitals and assessment have showed improvement from initial admission.
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Plan of care needs to include more teaching and education for mother. It also needs to include more safety care for baby including CPS and social worker involvement.
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Priority would be to ensure a safe environment for the baby to return to upon discharge, whether it be a foster home or back with mother. Services need to be provided for mother to assist in alcohol and substance abuse cessation.
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact Ben’s care. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:
Situation:
Name/age: Ben Potter, 4 months old.
BRIEF summary of primary problem: Admit from doctors office for suspected FTT r/t malnutrition and caregiver neglect.
Background:
Primary problem/diagnosis: Inorganic failure to thrive
RELEVANT past medical history: Mother used alcohol during pregnancy. Prenatal care was not obtained until 12 weeks gestation.
RELEVANT background data: FOB not involved d/t being in prison. Baby lives in small home with
heavy smokers. Mother abuses alcohol and parties with random men multiple nights a week. Mother arrived to hospital today intoxicated and had to be sent home.
Assessment:
Most recent vital signs: temp 97.2 pulse 141 resp 32 BP 82/40 O2 98%RA
RELEVANT body system nursing assessment data: Irritable and difficult to console. Last BM unknown. No apparent bruising or injury noted. Low growth and weight for age.
RELEVANT lab values: Sodium (127) Potassium (2.9) Chloride (127) Specific Gravity (1.003) INTERPRETATION of current clinical status (stable/unstable/worsening): Baby is stable.
Recommendation:
Suggestions to advance plan of care: Get social services and CPS involved with baby case to ensure when baby is ready for discharge, he will have a safe environment to return to.
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem?
Ensure mother knows the importance of feeding baby based on hunger cues. Remind mother to mix formula exactly as directed and to not dilute formula. Mother needs to be educated on cessation of smoking and use of substances.
Grandmother also needs education on smoking cessation. Set up home visits to ensure baby is being taken care of properly after returning home.
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching?
Have mother teach back what she has been taught: hunger cues, how to hold baby and bond with baby, how to mix a bottle, etc. Have mother demonstrate mixing a bottle for baby and show nurse how she would hold baby to feed. Have mother demonstrate ways to aid in smoking cessation: patches, gum, etc.
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
Baby is probably experiencing fear and anxiety when around his caregivers. He is unable to care for himself and has to rely on those around him. His caregivers are neglecting to provide appropriate love and affection as well as nutrition for baby.
2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person?
As the nurse I would hold baby and show him reassurance that there are people who love him. I would use a calming voice when speaking to baby and soothe him.
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
Failure to thrive happens unintentionally in most cases due to the improper care given to baby by their caregiver.
Proper education is the key to preventing inorganic failure to thrive. Had mother known diluting the formula would affect her baby the way it did then baby would not have had such inadequate nutrition.
2. How can I use what has been learned from this scenario to improve patient care in the future?
I can use the information I have learned about failure to thrive in my care for infants and for geriatric patients as well. Recognizing early warning signs will allow me to start early intervention and lessen the likelihood of severe complications. [Show Less]