Question

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.

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.

Question 1

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

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

Question 2

What data from the histories is important and RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

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

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.

Question 3

What assessment data is RELEVANT that must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:

Diagnostic Results:
Basic Metabolic Panel (BMP)
Na 127 K 2.9 Cl 91 Gluc. 70 Creat. 0.8

Complete Blood Count (CBC)
WBC 9.6 HGB 12.8 PLTs 311 % Neuts 68

Question 4

What data must be interpreted as clinically significant by the nurse?

RELEVANT

Diagnostic Data:

Clinical Significance:

Hint does base these values on the ADULT values you have learned in class - look up infant lab values.

Answer 1

ANSWERS:-

1) Reasons for hospital admission -

* Ben Potter 4months old baby getting up more frequently at night, crying but refuses the formula feeding, episodes of gagging, arching his back, frequent crying during and immediately following formula feeding. It points that baby is having abdominal discomfort, gas formation and pain due to the formula feed.He is pale, thin and skin folds are present around buttocks.

2) Relevant and important data from history and its clinical significance to nurse :-

a) Relevant data from present problems and clinical significance :-

* Gagging due to regurgitation of gastric content, may be due to indigestion or due to presence of excessive gas.

* Arching of back- showing discomfort and method used to comfort self during abdominal pain.

* Getting up more frequently at night- due to hunger, baby is not fed properly.

* Frequent crying during and immediately following formula feeding- baby doesn't want formula feed due to some irritation or discomfort during and after feeding.

* Baby has pain 0-2 points assessed by FLACC scale( face, leg, activity, cry and consolability scal- used to assess children between 2months to 7years) - indicating indigestion or intolerance to feed.

b) Relevant data from social history and clinical significance :-

* Single mother and working during day time (part time job)and go for night drinking and socializing with men 3-4 days per week, unwanted pregnancy.He is looked after by grand mother when his mother is away from house.This affects the bonding and psychosocial development of the baby - baby is not maintaining eye contact with mother and unable to console while crying.*Mother is alcoholic and smoker which affects baby's health, growth and development.

3) Relevant assessment data and clinical significance:-

* Skin is pale due to less hemoglobin due to poor feeding and nutrition.

* Irritable, not able to console and eyes closed - shows poor social interaction.

*Weight gain is not appropriate - indicate poor feeding.

4) Relevant diagnostic data and clinical significance:-

* Sodium is less 127, normal is 135-145 meq/l

* pottassium is less 2.9, normal is 3.5 to 5 meq /l. Electrolyte imbalance can cause irritability

Hemoglobin is also just borderline resulting pallor.

** BABY NEEDS PROPER ASSESSMENT AND PLANNING FOR NUTRITION INCLUDING FEEDING FORMULA WHICH IS COMFORTABLE AND SUITABLE FOR THIS BABY.