Question

Pedro Gomez, a 5-year-old Hispanic male, was admitted Friday afternoon for an open reduction and internal fixation of a left forearm compound fracture. Following an uneventful surgery, cast placement was planned for the following day. Overnight, Pedro developed early signs and symptoms of varicella that went undetected by the night nurse. Pedro speaks adequate English, but neither of his parents do. A postoperative IV antibiotic is due right after report.

1.)As the nurse caring for this client, what are the two focused assessments that should be completed throughout the shift and what should be assessed during the focused assessments?

T = 101.4 F (38.6 C) BP = 98/60 P = 100 RR = 24 Oz Sat = 99% (room air)

Heart sounds: Normal
T = 101.4 F (38.6 C) BP = 98/60 P = 100 RR = 24 Oz Sat = 99% (room air)

Lung sounds: Clear

Abdominal sounds: Present

Pulses: Strong

Patient's speech: Clear

Patient states, "I'm not hungry. I feel yucky.

I feel hot."

2.) What vital signs and assessments are abnormal?

3.) What, if any, interventions should be completed?

Answer 1

1) The two focused assessments that should be completed by the nurse throughout the shift are :-

• Assessment of Vital signs : Body temperature, pulse rate, respiratory rate, blood pressure and oxygen saturation of the patient should be regularly monitored throughout the shift.
• Assessment of heart sounds, breathing sounds, and abdominal sounds of the patient : These sounds should also be regularly monitored by the nurse

2) Normal values for the vital signs of a 5 - year child are :-

• Pulse rate / heart rate : 70 to 115 beats / min
• Respiratory rate : 20 to 25 per min
• Blood pressure : 95 to 110 / 60 to 75 mm of Hg
• Body temperature : 98.6 to 99.0 ^oF or 37.0 to 37.2 ^oC
• Oxygen saturation : 95 to 100%

​​​​​​​Therefore, the only abnormal vital sign is body temperature of the patient which is 101.4^oF or 38.6^oC.

The patient also states that he feels yucky ( unpleasant or uncomfortable) and hot. This is also a matter of concern.

3) Since the body temperature of the patient is high. Therefore he suffers from fever. This is why he feels unpleasant (uncomfortable) and hot.

Therefore, appropriate measures to bring down the body temperature should be applied such as cold compresses, etc. Antipyretic medicine such as paracetamol, etc could be given to the patient to bring down the raised body temperature.

Regular monitoring of the body temperature should be focused by the nurse.

These are some interventions which should be completed.