Danny is a 4-month-old male in the emergency department accompanied by his mother, Sarah, a 19-year-old single mother. Sarah appears visibly tired and reports that Danny has been getting up more frequently in the night, crying but refusing to eat his formula feedings and reports episodes of gagging, arching his back, and frequent crying during and immediately following formula feedings. Sarah reports that she has interpreted this behavior as a sign that she is overfeeding Danny and has started watering down his Similac. The following growth measurements are provided: 12 lbs 4 oz (5.6 kg), 22 inches (55.9 cm). Using the CDC chart, he is below the 5th percentile for his weight and length. Danny lives with his 19-year-old mom and maternal grandmother in a small two-bedroom mobile home. Dannyâ€™s grandmother is 56 years old, is obese, and suffers from poorly controlled type 2 diabetes, hypertension, and smokes 2 packs per day. Grandmother watches Danny during the day while mom works part-time at a local fast food restaurant. Three or four nights per week, grandmother watches Danny while Sarah spends her nights drinking and socializing with men and other adults at the local bar. Sarah became pregnant with Danny following a brief relationship with a 48-year-old man. Father is not involved in Dannyâ€™s life and is currently in prison.
- What patient history has clinical significance to the nurse and why?
The most recent vital signs were:
T: 96.8 F/36.0 C (axillary)
P: 150 (reg)
R: 34 (reg)
O2 sat: 97% on room air
2.What patient vital signs have clinical significance to the nurse and why?
- Danny 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. Danny is alert, minimally interactive, and does not make eye contact with his mother. Dannyâ€™s anterior fontanel is flat and open. Sarah leaves the room during the assessment to make a telephone call and smoke a cigarette.
- GENERAL APPEARANCE: Danny 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.
- GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Liver non-palpable, PEG tube in place with expected healing around tube/site
- GU: Voiding without difficulty, urine clear/yellow
- SKIN: Skin integrity intact, skin turgor elastic, no tenting present
- 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?