Question

Background Information:
Alison is a 12 month old who has been vomiting for the past 12 hours. Since waking at 6 AM she has "not held anything down." It is now 5:30 PM and Alison's mother is becoming concerned. She calls the primary care office and the nurse recommends that Alison be brought into the office for evaluation. On initial assessment, Alison is lethargic and very quiet. Her lips and skin are dry. She is crying at times, but does not produce tears. Her diaper is dry; her mother says that she has not needed to change her diaper since 7 AM.

What are the nurse's primary concerns based on these findings? why?

1.  
2.  
3.  
4.  
5.  

Alison lies very quietly on the examination table. Her vital signs are:
Temperature: 101O F
Apical Rate: 150 bpm
Respiratory Rate: 40 breaths per minute
Blood pressure 90/48
Birth weight: 8 lbs
Current weight: 21 lbs 6 oz
Weight at 12 month visit 2 weeks ago: 24 lbs 2 oz

What is the nurse concerned with now? Why?

1.  
2.     
3.     
4.  

Answer 1

Answer

Finding : vomitings past 12 hours

Not held any thing down up to 5.30 pm

Lethargic and very quiet

Lips and skin dry

No tears while crying

Dry diapers since 7 am (anuria or urine output 10.30 min)

primary concerns:

1.check vital signs .and administer oxygen if needed.

2.Anti emitics to reduce vomiting.

3.Correct dehydration by if baby can take orally oral rehydration solution or intravenous fluids. And breast feeding.

4. Physical assessment for bladder if it is full empty by catheterization. and maintain intake and out put chart.

5. Keep neat and tidy, warmpthness for baby, comfortable position and apply moisturizer on lips.

Nursing concerns:

1. History collection regarding any common cold and cough since how many days because which may cause for weight reduction by poor eating pattern.

2. Administration of oxygen with nasal prongs @ 2 l/mt.

3. Cold application for fever. Ex: ice cap or sponge bath.

4. Administration of antipyretics. Ex .paracetamol Injection or syrup. According to doctor proscription.

5. Preparation of wearing diet plan accordingly to calories requirement of baby and likely food.