Nursing Diagnosis: Adult Failure to thrive with NANDA, NOC, NIC

Nursing Diagnosis: Adult Failure to thrive
Gail B. Ladwig

NANDA Definition: Progressive functional deterioration of a physical and cognitive nature with remarkably diminished ability to live with multisystem diseases, cope with ensuing problems, and manage care

Defining Characteristics: Anorexia-does not eat meals when offered; states does not have an appetite, is not hungry, or "I don't want to eat"; inadequate nutritional intake-eating less than body requirements; consumption of minimal to no food at most meals (i.e., consumes less than 75% of normal requirements); weight loss (from baseline weight)-5% unintentional weight loss in 1 month or 10% unintentional weight loss in 6 months; physical decline (decline in bodily function) — evidence of fatigue, dehydration, incontinence of bowel and bladder; frequent exacerbations of chronic health problems (e.g. pneumonia, urinary tract infections); cognitive decline (decline in mental processing) as evidenced by problems with responding appropriately to environmental stimuli, demonstrated difficulty in reasoning, decision making, judgment, memory, and concentration; decreased perception; decreased social skills; social withdrawal-noticeable decrease from usual past behavior in attempts to form or participate in cooperative and interdependent relationships (e.g., decreased verbal communication with staff, family, friends); decreased participation in ADLs that the older person once enjoyed; self-care deficit-no longer looks after or takes charge of physical cleanliness or appearance; difficulty performing simple self-care tasks; neglect of home environment and/or financial responsibilities; apathy as evidenced by lack of observable feeling or emotion in terms of normal ADLs and environment; altered mood state-expresses feelings of sadness, being low in spirit; expresses loss of interest in pleasurable outlets such as food, sex, work, friends, family, hobbies, or entertainment; verbalizes desire for death

Related Factors: Depression; apathy; fatigue

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Physical Aging Status

·         Psychosocial Adjustment: Life Change

·         Will to Live

Client Outcomes

·         Resumes highest level of functioning possible

·         Consumes adequate dietary intake for weight and height

·         Maintains usual weight

·         Has adequate fluid intake with no signs of dehydration

·         Participates in ADLs

·         Participates in social interactions

·         Maintains clean personal and home environment

·         Expresses feelings associated with losses

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Mood Management

·         Self-Care Assistance

Nursing Interventions and Rationales

·         Elderly clients who have failure to thrive (FTT) should be evaluated by review of the patient's ADLs, cognitive function, and mood; a targeted history and physical examination; and selected laboratory studies. Early recognition and management of FTT can reduce the risk of further functional deterioration, hospitalization, or nursing home placement (Palmer, Foley, 1990).

·         Assess possible causes for adult FTT and treat any underlying problems such as depression, malnutrition, and illnesses that are caused by physical and cognitive changes. The characteristics of FTT in the elderly are malnutrition (undernutrition), loss of physical and cognitive function, and depression (Groom, 1993). Malnutrition is a frequent condition, both widely represented in the geriatric population and underestimated in diagnostic and therapeutic work-up, and is known to affect health status and life expectancy of elderly people (Vetta et al, 1999). An initial clinical assessment that combines multiple and varied sources of information is recommended to evaluate patients with suspected dementia (U.S. Department of Health and Human Services, 1996).

·         Assess for signs of fatigue and sensory changes that may indicate an infection is present that may be related to undetected diabetes mellitus. Older adults may never exhibit the classic signs of polyuria, polydipsia, polyphagia, and weight loss; instead they may develop an infection and complain of fatigue and sensory changes (Faherty, 1994).

·         Assess for all etiologies including depression using a geriatric depression scale. Be alert for depression in clients newly admitted to nursing homes. The geriatric depressions scale is recommended to determine the presence of depression (Jamison, 1997). Depression in newly admitted nursing home residents is a frequently overlooked area of nursing concern (Ryden et al, 1998). New depression may be the first sign of impending cognitive dysfunction (Sarkisian, Lachs, 1996).

·         Note if the client is irritable and is blaming others. Recent findings in nursing research support the presence of these behaviors as symptomatic of depression (Proffitt, Augspurger, Byrne, 1996).

·         Provide cognitive therapy for clients who are identified as depressed. Reinforce their value as a person and provide reality as to "who they really are." Clients who are depressed can be helped by examining "who they are" as compared to "who they believe they are" (Drake, Price, Drake, 1996).

·         Instill hope and encourage the expression of positive thoughts. The findings from this study of 1002 older disabled women suggest that positive emotions can protect older persons against adverse health outcomes. Of the women studied, 351 were described as emotionally vital, and among the women without a specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking 1/4 mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression because protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed (Pennix et al, 2000).

·         Monitor elderly client's weight and note any unexplained weight loss. The FTT of an elderly client is usually accompanied by weight loss that occurs without immediate explanation (Palmer, Foley, 1993).

·         Play soothing music during mealtimes to increase the amount of food eaten. One study suggested that dinner music, particularly soothing music, can reduce irritability, fear, panic, and depressed mood and can stimulate the appetite of demented patients in a nursing home. In this study the patients were less irritable, anxious, and depressed during the periods when music was playing (Ragneskog et al, 1996).

·         Note changes in the elderly client's appetite and assess for depression. Depression can lead to FTT by two routes: a direct path of decreased appetite as a symptom of depression and an indirect path of increasing disability as an effect of depression (Katz, DiFilippo, 1997).

·         Offer comfort foods and happy hour: foods associated with bygone years, intended to trigger recollections of pleasant childhood experiences and feelings of caring and healing, and a "happy hour" beverage, presented in a social milieu. These are two approaches that have demonstrated effectiveness in stimulating oral intake in the FTT client (Wood, Vogen, 1998).

·         Provide appropriate nutrition for the client whose obesity may be affecting physical performance and thus has limited ability to perform ADLs, which leads to functional dependence. Malnutrition includes obesity (overnutrition); obesity among older persons is defined as being (30% above ideal body weight. Obesity may contribute to the previously mentioned problems (Still, Apovian, Jensen, 1997).

·         Encourage clients to reminiscence about past experiences. Reminiscing helps to foster social relatedness (Jamison, 1997). A standard reminiscence interview and one that focused on successfully met challenges reduced state anxiety and enhanced coping self-efficacy (Rybarczyk, Auerbach, 1990).

·         Encourage clients to pray if they wish. Various studies have discovered that various groups of people have used prayer for managing their symptoms of aging or illness (Meraviglia, 1999).

·         Encourage elderly clients to interact with others on a regular basis. Have them participate in activities for seniors in their community. FTT of an elderly client is usually accompanied by social withdrawal (Palmer, Foley, 1993).

·         Help clients to participate in activities by assessing motivation and helping them to identify reasons to participate such as better mobility, more independence, feelings of well-being. Motivation has been identified as an important factor in the older adult's ability to perform functional activities (Resnick, 1998).

·         Provide physical touch for clients. Touch their hand or arm when speaking with them; offer hugs with permission. Touch helps with integration and fosters social relatedness. Tactile stimulation benefits the older adult's psychological well-being (Jamison, 1997).

·         Administer therapeutic touch (TT). Results of this study of (n = 16) patients in the advanced stages of dementia of the Alzheimer's type (DAT), showed that discomfort levels decreased significantly after five therapeutic touch sessions, becoming significantly lower than levels in the control group (n = 10) (Giasson et al, 1999).

·         Refer to care plans for Imbalanced Nutrition: less than body requirements, Hopelessness, and Disturbed Energy field.

Multicultural

·         Assess for the influence of cultural beliefs, norms, and values on the family's or caregiver's understanding of FTT. What the family considers normal and abnormal health behavior may be based on cultural perceptions (Leininger, 1996).

·         Validate the family's feelings and concerns related to the FTT symptoms. Validation lets the family know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

·         Assess and track areas of decreased functioning resulting from failure to thrive. Ensure that all symptomatology is considered for necessary action. Clients may change response to stressors/needs with changes in environment or interventions.

·         Give permission for role activity changes. Negotiate and clarify role expectations and reevaluate as necessary. Failure to thrive may require an extended period of recovery. Chronic illness often requires role changes to preserve a functional unit. Comfort level with role activities supports continued recovery.

·         Provide support for family/caregivers. Support for caregivers decreases caregiver burden.

·         Refer to medical social services or mental health counseling and/or community support groups. If necessary, contract with client to attend sessions. Counseling support can increase coping ability; group participation provides support and offers new problem-solving strategies to the client.

·         Refer to home health aide services for assistance with ADLs throughout the duration of decreased participation. Maintaining ADLs and the integrity of the environment prevents further decline in status of those areas and decreases frustration as the client recovers and resumes responsibility for them.

Client/Family Teaching

·         If adult FTT is related to dementia, help the caregiver to understand the diagnosis and help to identify needs that the caregiver will have to assist client with, such as nutrition, maintenance of adequate fluid intake, toileting, self-care, and safety. When the etiology of adult FTT is dementia, the caregiver needs to be educated on how to handle (Jamison, 1997).

·         Instruct the family on the use of verbal cues to encourage eating, such as "Pick up your spoon; use the spoon to scoop up the pudding; now put the spoon with the pudding in your mouth." Verbal cueing is effective for improving nutritional status (Jamison, 1997).

·         Discuss the possibility with the physician of a drug holiday when the etiology is delirium. Delirium may resolve with a drug holiday (Jamison, 1997).

·         Provide referral for evaluation of hearing and appropriate hearing aids. This study of 60 subjects >65 years of age (mean age 79 years) living in nursing homes demonstrated that hearing loss affects the communication, sociability, and psychological aspects of quality of life (Tsuruoka et al, 2001).

·         Refer for psychotherapy and possible medication if the etiology is depression. Treatment of the etiology is necessary; the previously mentioned are treatments that may be used for depression (Jamison, 1997).