Susie is a 6-month-old female who was brought into the emergency department for diarrhea and vomiting over the past two days. She had two large loose stools the first day and now her mother reports that she has been less active, is not interested in playing, and has been sleepier today. She is unable to keep any feedings down today. She has had 5 loose, watery stools and emesis x4 this morning. She has not had a wet diaper since yesterday evening. Susie has not had any immunizations since birth. She is 26 inches in length and weighs 16 pounds, 4 ounces. She weighed 17 pounds, 2 ounces at her last office visit two weeks ago. Susieâ€™s mother is 21 years old, a single mother, and this is her first child. Susieâ€™s mom is not currently working and lives with her parents and she feels overwhelmed as a new mother.
- What patient history has clinical significance to the nurse and why?
The most recent vital signs were:
T: 102.2 F/39.0 C (oral)
P: 158 (reg)
R: 36 (reg)
O2 sat: 95% on room air
2.What patient vital signs have clinical significance to the nurse and why?
- GENERAL APPEARANCE: Irritable when awake, alternates with lethargy once quiet. When awake and crying, tears are not present
- RESP: Breath sounds clear with equal aeration bilaterally, non-labored
- CARDIAC: Skin is pale, cool to touch, cap refill 3â€“4 seconds in both hands, brachial pulses palpable bilaterally
- NEURO: Lethargic, does not maintain eye contact with mom or caregiver
- GI: Abdomen soft with hyperactive BS x4 quadrants, no apparent tenderness to palpation
- GU: 5 mL dark amber, cloudy urine noted in urine collection bag-sent to lab
- SKIN: Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry with no shiny saliva present, when skin over abdomen is pinched, remains tented for 2â€“3 seconds
- 3.What patient assessment findings have clinical significance to the nurse and why?
- 4.What is the nursing priority at this time?
- 5.What nursing interventions will the nurse initiate based on the priority at this time?